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Cardiology > Cardiology for Finals > Flashcards

Cardiology for Finals Flashcards

1
Q

List some symptoms and signs of left sided heart failure

A 
Dyspnoea
Paroxysmal nocturnal dyspnoea
Orthopnoea
Cool peripheries
Frothy cough
Poor exercise tolerance
Bibasal crackles
Atrial fibrillaion
3rd and 4th heart sounds
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2
Q

List some symptoms and signs of right sided heart failure

A 
Peripheral and sacral oedema
Raised JVP
Hepatomegaly
Ascites
Premature satiety
Pleural effusion
Pericardial effusion
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3
Q

How is heart failure classified?

A

According to the New York Heart Failure Classification:
I = Heart disease present, but no undue SOB from ordinary activity
II = Comfortable at rest, SOB on ordinary activity
III = Less than ordinary activity causes SOB which is limiting. Comfortable only at rest
IV = SOB at rest, all activities cause discomfort

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4
Q

What is the mechanism of paroxysmal nocturnal dyspnoea?

A

BP drops when asleep, and the diastolic pressure drops relatively more during the systolic. Heart fills during diastole, so if there is lower pressure whilst asleep, there will be less filling and reduced cardiac output. In a heart with already low output, this will cause PND as the tissues feel hypoxic.

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5
Q

What criteria is used to describe the presence of congestive cardiac failure?

A

Framingham criteria

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6
Q

True / False: Verapamil is used in the treatment of heart failure

A

False - Verapamil is a calcium channel blocker which acts as a negative inotrope so it worsens heart failure

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7
Q

What drugs give symptomatic benefit in heart failure?

A

Diuretics i.e. furosemide, bumetanide

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8
Q

What drugs give prognostic benefit in heart failure?

A

ACE-Inhibitors
Beta-blockers (Metoprolol, carvedilol, bisprolol)
Spironolactone
Vasodilators e.g. hydralazine

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9
Q

What is the first line medical treatment for chronic treatment of heart failure?

A

ACE-Inhibitor

Beta-blocker

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10
Q

What is metolazone and when is it indicated for use in heart failure?

A

Thiazide-like diuretic, indicated if patient is still symptomatic despite maximum dose of other medications

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11
Q

Which electrolyte disturbance is a poor prognostic indicator in heart failure?

A

Hyponatraemia

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12
Q

What is the management of acute heart failure?

A 
DR ABCDE approach:
- Sit the patient up
- High flow oxygen
- IV furosemide
- GTN infusion
- Diamorphine
- Catheterise for monitoring urine output
- Daily weights
Patients with acute-on-chronic heart failure can continue their normal meds unless they have other complications e.g. renal impairment
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13
Q

What is the chararistic finding of Wolf-Parkinson-White on ECG?

A

Delta wave (slurre upstroke leading to the QRS complex)

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14
Q

In which condition is a ‘delta wave’ seen on ECG?

A

Wolff-Parkinson-White

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15
Q

ST elevation in leads II, III, aVF indicate infarction of which territory and artery?

A

Inferior MI

Artery = Right coronary artery

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16
Q

ST elevation in leads V1 - V6 indicates infarction of which territory and artery?

A

Anterior MI

Artery = Left anterior descending

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17
Q

ST elevation in leads V1-V4 indicates infarction of which territory and artery?

A

Septal MI

Artery = Left anterior descending

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18
Q

ST elevation in leads I, aVL and V5-6 indicates infarction of which territory and artery?

A

Lateral MI

Artery = Circumflex

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19
Q

True / False: A rise in troponin is seen in unstable angina

A

False

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20
Q

What is the acute management of acute coronary syndrome with a STEMI?

A
  • DR ABCDE and MONAC
  • High flow oxygen
  • IV access, bloods including troponin
  • Morphine
  • IV GTN infusion
  • Aspirin 300mg
  • Clopidogrel 300mg (or ticagrelor 180mg)
  • Anti-emetic (Metoclopramide)
  • Anticoagulation
  • Primary PCI is gold standard, or thrombolysis alternatively
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21
Q

What is the acute management of acute coronary syndrome with an N-STEMI?

A
  • DR ABCDE and MONAC
  • High flow oxygen
  • IV access, bloods including troponin
  • Morphine
  • IV GTN infusion
  • Aspirin 300mg
  • Clopidogrel 300mg (or ticagrelor 180mg)
  • Anti-emetic (Metoclopramide)
  • Anticoagulation with LMWH (Fondaparinux)
  • Establish risk using GRACE score
  • High risk need coronary angiography ± stent
  • Low risk need exercise ECHO and angiography if this is positive
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22
Q

What is the secondary prevention of acute coronary syndrome?

A 
Aspirin 75mg daily life-long
Clopidogrel 75mg daily for 12 months
ACE-Inhibitor e.g. Ramipril
Beta-blocker e.g. Bisoprolol
Stating e.g. Atorvastatin 80mg
Cardiac rehabilitation
Lifestyle modification e.g. stop smoking
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23
Q

What is the time-window for primary PCI in patients with a STEMI?

A

Symptom to needle time less than 120 mins

Door to needle time less than 90 mins

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24
Q

List some presenting features of aortic dissection

A

Sudden tearing chest pain, radiating to the back
Unequal arm pulses and pressures (do bilateral BPs)
Focal neurology if carotid branch affected
Ischaemia of limbs
Risk of STEMI if ascending aorta affected as this supplies coronaries

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25
Q

What does chest x-ray show in aortic dissection?

A

Widened mediastinum

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26
Q

What is the management of aortic dissection

A 
DR ABCDE approach
Cross-match 10 units of blood
CT angiogram
IV labetolol
IV GTN
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27
Q

What is the first-line treatment for hypertension in a Caucasian patient under the age of 55?

A

ACE-Inhibitor

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28
Q

What is the first-line treatment for hypertension in an Afro-Caribbean patient or Caucasian patient over the age of 55?

A

Calcium channel blocker

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29
Q

What is the second line drug in the treatment for hypertension?

A

If already on ACE-Inhibitor = Add calcium channel blocker

If already on calcium channel blocker = Add ACE-Inhibitor

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30
Q

What is the third-line treatment regime for hypertension?

A

ACE-Inhibitor PLUS calcium channel blocker PLUS thiazide diuretic

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31
Q

What are the side effects of ACE-Inhibitors?

A 
Cough
Hyperkalaemia
Raised creatinine with renal artery stenosis
Hypotension with 1st dose
Angioedema
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32
Q

What are the side effects of angiotensin receptor blockers?

A

Hyperkalaemia
Renal impairment
Pruritis, urticaria
Vertigo

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33
Q

What is the key side effect of calcium channel blockers?

A

Ankle swelling

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34
Q

Give some side effects of thiazide diuretics

A

Hyponatraemia
Hypokalaemia
Dehydration

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35
Q

Give some side effects of spinolactone

A

Hyperkalaemia

Gynaecomastia

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36
Q

How is the diagnosis of hypertension made?

A

If clinic BP reading high, it must be confirmed by ambulatory BP monitoring (result more than 135/85 indicates HTN)

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37
Q

What are the stages of hypertensive retinopathy?

A

Stage 1: Tortuous vessels with thickened, shiny walls (silver wiring)
Stage 2: Plus arterio-venous nipping
Stage 3: Plus cotton wool spots and flame haemorrhages
Stage 4: Plus papilloedema

38
Q

What is the treatment for malignant hypertension?

A

Admission
Phenoxybenzamine THEN beta-blocker
Other anti-hypertensives: Bendroflumethiazide, amlodipine, nifedipine
Decrease BP slowly over 48 hours so not to reduce cerebral blood flow
Look for underlying cause e.g. phaeochromocytoma

39
Q

What does histology show in malignant hypertension?

A

Fibrinoid necrosis

40
Q

Give some infections associated with acute pericarditis

A

Viruses: Coxackie, echovirus, EBV, HIV, varicella, mumps
Bacterial: TB, pneumonia, rheumatic fever

41
Q

Give some non-infective causes of acute pericarditis

A

Dressler’s syndrome
Drugs: Cocaine
Uraemia
SLE

42
Q

What might be seen on ECG of a patient with pericarditis?

A

Saddle-shaped ST elevation

PR depression

43
Q

What is the treatment for acute pericarditis?

A

NSAIDs

Treat the underlying cause

44
Q

What is Kussmaul’s sign? When is it seen?

A

JVP rises on inspiration

See in constrictive pericarditis or cardiac tamponade

45
Q

What might x-ray show in constrictive pericarditis?

A

Calcification of the pericardium

46
Q

What is the treatment of constrictive pericarditis?

A

Surgical excision of the pericardium

47
Q

What is Beck’s Triad? What is it a sign of?

A

Falling BP, rising JVP, muffled heart sounds

Sign of cardiac tamponade

48
Q

What is pulsus paradoxus?

A

Exaggerated fall in systolic BP on inspiration. Sign of cardiac tamponade.

49
Q

What might an ECG show in cardiac tamponade and pericardial effusion?

A

Electrical alternans

50
Q

List some causes of dilated cardiomyopathy

A 
Alcohol
Vitamin deficiencies, especially thiamine
Thyrotoxicosis
Hypertension
Genetic predisposition in 30%
51
Q

List some signs of dilated cardiomyopathy

A

Symptoms of LV failure: Orthopnoea, PND, dyspnoea, ankle swelling
Arrhythmia
Tachycardia
Mitral regurgitation (which potentiates the dilatation)

52
Q

What is the inheritance pattern of hypertrophic obstructive cardiomyopathy?

A

Autosomal dominant

53
Q

What are the features of hypertrophic obstructive cardiomyopathy on ECHO?

A

Systolic anterior motion of the anterior mitral valve leaflet
Asymmetrical septal hypertrophy
Mitral regurgitation

54
Q

What is the management of hypertrophic obstructive cardiomyopathy?

A 
Symptomatic:
- Beta blockers and calcium channel blockers (verapamil) reduce cardiac contractility
- Anticoagulation for AF
- Amiodarone for arrhythmias
Septal myomectomy
Alcohol septal ablation
Implantable defibrillator
55
Q

Give 8 reversible causes of cardiac arrest

A 
Hypovolaemia
Hyper/hypo-kalaemia + other metabolic abnormalities
Hypothermia
Hypoxia
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade (cardiac)
Toxins
56
Q

How many joules is given in a shock during cardiac arrest in a shockable rhythm?

A

150J

57
Q

How much adrenaline is given in cardiac arrest in a shockable rhythm?

A

1mg IV every 3-5 minutes, starting after the 3rd shock

58
Q

Which cardiac arrest rhythms are suitable to be given amiodarone?

A

VF

Pulseless VT

59
Q

How much amiodarone is given in cardiac arrest with a shockable rhythm?

A

300mg IV after 3rd shock

150mg IV after 5th shock

60
Q

When is the first dose of adrenaline given in a cardiac arrest with a shockable rhythm?

A

In the 2 minute period of CPR after the 3rd shock

61
Q

When is the first dose of amiodarone given in a cardiac arrest with a shockable rhythm?

A

In the 2 minute period of CPR after the 3rd shock

62
Q

If a patient has a witnessed and monitored pVT / VF arrest what is the management?

A

Give up to 3 (‘stacked’) shocks immediately, and commence CPR and ALS algoryhthm if these unsuccessful

63
Q

What are the 2 non-shockable rhythms?

A

Pulseless electrical activity

Asystole

64
Q

When should adrenaline be given in a pulseless cardiac arrest?

A

As soon as IV access is secured, then every 3-5 minutes if pulseless activity continues

65
Q

What is the management of a pulseless cardiac arrest?

A
  • Commence CPR
  • Adrenaline 1mg IV to be given as soon as IV access obtained, then every 3-5 minutes if pulseless activity continues
  • Find and treat the cause!
66
Q

What is paroxysmal AF?

A

AF which lasts usually less than 48 hours and always less than 7 days and terminates spontaneously

67
Q

What is persistent AF?

A

AF which lasts more than 7 days, terminated by intervention

68
Q

What is permanent AF?

A

Arrhythmia which cannot be terminated with intervention (medication or cardioversion), or where AF has lasted more than 1 year without cardioversion being attempted

69
Q

Give some causes of AF

A 
Ischaemic heart disease
Rheumatic heart disease
Thyrotoxicosis
Alcohol
Sepsis
PE
Trauma
ETC!
70
Q

What is the management for acute AF?

A
  • Treat any known underlying cause e.g. sepsis
  • Haemodynamically unstable: Synchronised DC cardioversion
  • Haemodynamically stable and symptoms less than 48 hours: Cardioversion with amiodarone or flecainide
  • Haemodynamically stable and symptoms more than 48 hours: Rate control with calcium channel blocker or beta-blocker, then anticoagulate and attempt cardioversion after 3/52
71
Q

What is the drug of choice for medical cardioversion in patients with underlying structural heart disease?

A

Amiodarone

72
Q

What is the drug of choice for medical cardioversion in patients with no underlying structural heart disease?

A

Flecainide

73
Q

How do you decide which drug to use in medical cardioversion of AF?

A

Underlying structural heart disease = Amiodarone

No underlying structural heart disease = Flecainide

74
Q

Why is sotalol not used for rate control of AF?

A

Prolongs the QT interval, increasing risk of Torsade de Pointes

75
Q

What are the drugs of choice for rate control in chronic AF?

A

1st line = Beta blocker e.g. metoprolol, bisoprolol (NOT sotalol)
2nd line = Calcium channel blocker e.g. verapamil, diltiazem
3rd line = Digoxin

76
Q

Give some side effects of digoxin

A

Visual disturbances - Yellow vision
Toxicity: GI symptoms (nausea, vomiting)
Arrhythmias: Bradycardia, heart block
Gynaecomastia

77
Q

Give some side effects of beta-blockers

A

Bronchospasm
Bradycardia
Negative inotrope

78
Q

List some side effects of amiodarone

A 
Deranged LFTs - Liver fibrosis
Hypo- and hyper-thyroidism
Lung fibrosis
Arrhythmias: Tachycardias including VT, VF, AF
Photosensitivity
79
Q

Which tool can be used to determine a patient’s need for anticoagulation in atrial fibrillation?

A

CHA2DS2-VASc Score

80
Q

What is the CHA2DS2-VASc Score?

A 
Congestive heart failure
Hypertension
Age over 75 (x2 points)
Diabetes
Stroke (x2 points)
Vascular disease
Age 65-75
Sex Category = Female
81
Q

Which tool can be used to assess a patient’s risk of bleeding on warfarin?

A

HASBLED score

82
Q

What are the parameters in the HASBLED score?

A 
Hypertension
Age over 65
Abnormal LFTs
Abnormal U+Es
Stroke or TIA
Bleeding risk (previous bleed or predisposition)
Labile INRs
EtOH excess
Drugs predisposing to bleeding e.g. Aspirin, NSAIDs
83
Q

What is the management of supraventricular tachycardia in a patient who is haemodynamicaly stable?

A

Vagal manoeuvres: Valsalva manouvre, carotid sinus massage

Adenosine 6mg, 12mg, 12mg

84
Q

Which patients are contraindicated in the use of adenosine?

A

Asthmatic patients - Adenosine causes bronchospasm

85
Q

What is 1st degree heart block?

A

Elongation of the PR interval but no dropped beats

86
Q

What is 2nd degree heart block, Mobitz Type 1?

A

Progressive elongation of the PR interval until 1 atrial contraction does not translate into ventricular contraction

87
Q

What is 2nd degree heart block, Mobitz Type 2?

A

Elongation of the PR interval by the same amount each time, with dropped ventricular beats

88
Q

What is 3rd degree heart block?

A

No association between atrial and ventricular contractions i.e. P waves and QRS complexes

89
Q

What is Wenckebach?

A

Mobitz Type 1

90
Q

What is the treatment for Mobitz Type 1?

A

Generally nothing if asymptomatic as inconsequential

91
Q

What is the treatment for Mobitz Type 2 heart block?

A

Pacemaker

92
Q

What is the management of complete heart block?

A

Atropine
Isoprenaline
Pacemaker

Cardiology (4 decks)

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