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Cardiovascular Flashcards

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1
Q

What three conditions come under Acute Coronary Syndrome?

A

STEMI
NSTEMI
Unstable angina

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2
Q

How does an STEMI present on an ECG?

A

St elevation
New left bundle branch block

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3
Q

What are the symptoms of ACS?

A

Chest pain: central, crushing
Pain radiating down left arm
Dyspnoea
Nausea
Dizziness
Vomiting
Palpitations
Epigastric pain
Syncope
Confusion

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4
Q

What are the modifiable risk factors for ACS?

A

Smoking
Obesity
Diet
Hyperlipidemia
Sedentary Lifestyle

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5
Q

Is MI more common in males or females?

A

Males
60-70

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6
Q

How do you differentiate between NSTEMI and unstable angina?

A

Both show inverted t waves and st depression
NSTEMI: will have raised Troponin due to myocardial infarction

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7
Q

How do you diagnose ACS, and differentiate between the types?

A

ECG
CxR
Troponin
Echocardiagram
lipid profile
U&E
Glucose
FBC

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8
Q

What is the initials management for suspected ACS?

A

Aspirin: 300mg orally
Morphine: 5mg IV
Nitrates: GTN
Oxygen: If says below 94%

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9
Q

What is the criteria for PCI treatment in STEMI? What drugs are used?

A

Criteria:
- within 12 hrs of symptom onset
- can be given within 120minutes of thrombolysis
- >12 hrs if ongoing ischaemia

Drugs:
- prasegral once PCI confirmed: no anticoagulant
- clopidogrel if on anticoagulant.

Radial access: unfractioned heparin + GPI
Femoral access: bivalirudin + GPI

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10
Q

If PCI cannot be given within 120 minutes what treatment is given for a STEMI?

A

Thrombolysis + antithrombin
Then ticagrelor

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11
Q

How is NSTEMI/ unstable angina treated?

A

Initial management + fondaparinux (2.5mg)
Use Grace scoring:
- >3% angiography + PCI (prasegral)
-<3% offer ticagrelor

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12
Q

What is the secondary management for ACS?

A

ACE inhibitor: Indefinitely
Dual Antiplatelet therapy: for 12 months
Then single Aspirin: indefinitely
Beta blocker: up to 12 months
Statin: indefinitely

Lifestyle:
Diet
Exercise
Smoking cessation
Alcohol consumption

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13
Q

Is infective endocarditis more common in males or females?

A

Males

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14
Q

What are the risk factors for infective endocarditis?

A

Cardiac:
- Structural heart disease
- valvular disease
- hypertrophic cardiomyopathy
- prosthetic valve and cardiac devise

General,
- Male
- IV drug use
- immunocompromised
- Previous IE
- dental procedure/ surgery
- Haemodialysis

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15
Q

What are the most common bacteria causing IE?

A
  • staph aureus
  • streptococcus Viridian
  • Enterococci
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16
Q

What are the symptoms of IE?

A

Fever
Fatigue
Weight loss
Anaemia
Night sweats
Malaise
Breathlessness
Haematuria
Abdominal pain

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17
Q

What are the clinical signs of IE?

A

Heart murmur
Splinter haemorrhages
Jane way lesions
Osler nodes
Roth spots
Clubbing
Petechiae
Bibasal lung Crepitations
Glomerular nephritis

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18
Q

What investigations are done for IE?

A

Blood cultures
FBC
CRP/ESR
Urea + Electrolytes
Transthoracic echocardiogram
Transoesophageal echocardiogram
CxR
CT

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19
Q

Which type of echocardiogram is performed first line for IE?

A

Transthoracic
Transoesophageal performed if trans thoracic is negative but clinical signs point towards IE

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20
Q

Describe the bacterial culture process for IE?

A

3 cultures must be taken within 30 mins of each other, from 3 different sites, before commencing antibiotics at the peak of fever

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21
Q

What is the dukes criteria?

A

Dukes criteria is used for diagnosis of Infective endocarditis
IE definite if :
- positive pathological criteria
- 2 major criteria
- 1 major + 3 minor
- 5 minor criteria

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22
Q

What are the major criteria for IE?

A

Positive blood cultures:
- 2 separate cultures positive for microorganisms causing IE
- persistent positive cultures of microorganism typical of aiE
- single positive culture for coxiella Burnetti
- High IgG antibody titre 1:800

Endocardial damage:
- new dehiscence (breakdown of sutures attaching valve)
- new valvular regurgitation
-abscess

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23
Q

What are the minor criteria for IE?

A
  • fever >38c
  • present risk factors for IE
  • vascular phenomena: Jane way lesions, septic emboli (PE)
  • immunological phenomena: glomerulonephritis, Osler nodes, roth spots
  • positive microorganisms/ blood culture
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24
Q

What is the empirical treatment for suspected IE?

A

Native: Amoxicillin + gentamicin
PA allergy: vancomycin + gentamicin
prosthetic: vancomycin + rifampicin + gentamicin

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25
What is the antibiotic of choice for Staph aureus causing IE in both native and prosthetic IE?
Native: - fluoxacillin Penicillin allergy: vancomycin + rifampicin Prosthetic: - fluoxacillin + rifampicin + low dose gentamicin PA: vancomycin + rifampicin + low dose gentamicin
26
What are the indications for surgery in IE?
- heart failure - persistent/ uncontrolled infection - abscess - recurrent systemic emboli
27
What is acute heart failure?
New onset of or worsening of signs and symptoms of heart failure
28
What is decompensated acute heart failure?
Decompensated heart failure is worsening of symptoms in a patient with a background of heart failure
29
What is the leading cause of acute heart failure?
Myocardial infarction
30
What are the symptoms of acute hearts failure?
Dyspnoea Ankle oedema Fatigue Pink frothy sputum Orthoptera Reduced exercise tolerance Paroxysmal nocturnal dyspnoea Wheezing Weight gain
31
What are the signs of heart failure?
Bibasal crackles Hypoxia Tachypnoea Raised JVP Cyanosis Dull lung bases
32
How is heart failure diagnosed?
BNP NT-ProBNP CxR Echocardiogram Troponin fBC ABG ECG
33
When do you urgently refer a patient with suspected Acute heart failure for an echo?
If the NT-proBNP is greater than 2000ng/L
34
If a patient has a pro BNP between 400-2000ng/L what should you do?
Refer them for specialist assessment and transthoracic echocardiogram within 6 weeks
35
What can a chest x ray show in acute heart failure?
Alveolar oedema (batwing opacification, perihilar) Kerley b line (IO) Cardiomegaly Dilated upper lobe vessels Effusion
36
How is acute heart failure initially managed?
Oxygen if patient is hypoxic Loop diuretic: furosemide 40mg Nitrates: In patients with myocardial Ischemia and hypertension, not in patients with systolic below 90mmHg
37
What can reduce cardiac output?
Reduced heart rate Reduced preload Reduced contractility Increased preload
38
When patient is on an ACE inhibitor what routine checks need to be done?
Serum sodium Serum potassium Renal function
39
What specialist treatment is available for chronic heart failure?
Ivabradine Digoxin Sacubitril Valsartan
40
What lifestyle changes are recommended in heart failure patients?
Smoking cessation Reduced alcohol consumption Exercise Diet Vaccinations Cardiac rehabilitation
41
What is the order of treatment in chronic heart failure?
1: ACE/ARB 2: Beta blocker 3: aldosterone antagonist (MRA) 4: SGLT2 inhibitor
42
What is the most common cause of right sided heart failure?
Left sided heart failure
43
What is the most commonly involved artery in an MI?
Left anterior descending artery
44
Which leads show st elevation in inferior MI? Which artery is affected?
Lead 2 Lead 3 avF Right coronary artery
45
Which leads show st elevation in anteroseptal MI? Which artery is affected?
V1-V4 Left anterior descending artery
46
Which leads show st elevation in lateral MI? Which artery is affected?
Lead 1 AVL V5-V6 Left circumflex artery
47
What is required to make a diagnosis of postural hypotension?
Standing/ lying blood pressure. Get patient to lie on the bed for 5 minutes, then take blood pressure. Get patient to then stand for a minute then take blood pressure again. Make diagnosis if: Systolic Bp falls by 20mmHg or more Diastolic BP falls by 10mmHg or more
48
What is the difference between primary and secondary hypertension?
Primary hypertension makes up around 90% of cases and is hypertension with no underlying cause. Secondary hypertension is high blood pressure caused secondary to another condition.
49
What is classed as stage 1 hypertension?
Clinic BP of 140/80 mmHg or more ABPM/HBPM 135/85mmHg or more
50
Describe step 1 management of hypertension in stage 2 and 3 hypertension?
Offer ACE/ARB in: - patients who are type 2 diabetic - patients who are <55 and are not of black African/ African-Caribbean origin Offer calcium channel blocker in: - patients >= 55 and don’t have type 2 diabetes - are of black African or African- Caribbean descent and don’t have diabetes
51
What is step 2 management of hypertension?
If step 1 not successful, first check adherence and review Add: - thiazide like diuretic (indapamide) - calcium channel blocker Those already on CCB: - offer ACE or ARB - offer thiazide like diuretic ARB preferred in black Africans and African- caribbeans
52
What treatment is offered in step 3 for hypertension?
Check doses at optimal and adherence Offer all 3: - ACE/ARB - thiazide like diuretic - CCBn
53
What is the mechanism of action of rivaroxaban? Side effects?
It is a factor Xa antagonist It competitively inhibits factor Xa which prevents activation of prothrombin (factor 2) to thrombin (factor 2a). This then prevents activation of fibrinogen to fibrin. Side effects: menorrhagia, dizziness, GI discomfort, headache, oedema, diarrhoea
54
What is the reversal agent for factor Xa antagonists?
Adexanet alfa
55
Which murmurs are systolic?
Aortic stenosis Pulmonary stenosis Mitral regurgitation Tricuspid regurgitation
56
What produces an ejection systolic murmur?
Aortic stenosis Pulmonary stenosis Atrial septal defect HOCM
57
What murmur produces a diastolic murmur?
Mitral stenosis Tricuspid stenosis Aortic regurgitation Pulmonary regurgitation
58
When in diastole does the s4 and s3 sounds occur?
S4: End diastole S3: Early diastole
59
What produces a mid to late systolic murmur?
Mitral valve prolapse
60
Why is the S4 sound produced?
Pressure overload Thickened left ventricle resulting in increased pressure which the atrium has to pump blood against ( non compliant ventricle)
61
What causes a S4 heart sound?
Left ventricular hypertrophy Hypertrophic cardiomyopathy Systemic hypertension
62
Do you listen for s3 and s4 with the bell or diaphragm?
Bell: low pitched sounds
63
What type of murmur is produced by aortic regurgitation?
Early diastolic murmur
64
What is aortic stenosis?
Narrowing of the aortic valve
65
What are the main symptoms of aortic stenosis?
Exertional dyspnoea Exertional angina Exertional syncope
66
What are the clinical signs found in aortic stenosis?
Ejection systolic murmur Radiation to carotids Slow rising pulse Split s2 on expiration S4 heart sound
67
What are the causes of aortic stenosis?
Idiopathic age related calcification Bicuspid valve Unicuspid valve Rheumatic fever Familial hyper cholesterolemia Chest radiation therapy
68
What is galvardins phenomenon?
It is when a pansystolic murmur is heard at the apex due to aortic stenosis mimicking mitral regurgitation
69
What are other symptoms of aortic stenosis?
Heyde syndrome Heart failure symptoms: oedema, Orthopnoea AF
70
How do you determine the severity of aortic stenosis?
Jet velocity Mean transvulvular pressure gradient Aortic valve area
71
Which symptom most often presents first in aortic stenosis?
Dyspnoea
72
What is Heyde syndrome?
It is a triad of aortic stenosis, GI bleeding and acquired Von Willebrand syndrome It is GI bleeding from Angiodysplasia in the presence of aortic stenosis due to increased shear stress on the blood flowing through the aortic valve
73
How do you distinguish between gallavardin phenomenon and mitral regurgitation?
Hand grip exercise and transient arterial occlusion
74
Describe the mechanism behind syncope in aortic stenosis?
During exercise the peripheral blood vessels dilate to increase blood flow to muscles, this results in reduced total peripheral resistance. In aortic stenosis the valve is narrowed and therefore the cardiac output cannot increase enough to meet this demand as a result the mean arterial blood pressure drops and blood flow to the brain is reduced. Resulting in syncope.
75
Describe the mechanism behind angina in aortic stenosis?
In aortic stenosis, the left ventricle needs to pumps against a greater pressure in order to pump blood around the body. In order to overcome this, the left ventricle becomes thicker (hypertrophies) overtime as aortic stenosis worsens. However, the ventricle at one point is unable to hypertrophic anymore but the aortic stenosis continues to worsen. The left ventricle requires more blood as it needs to work harder, the blood supply to the heart is unable to meet this demand resulting in myocardial ischaemia. During exercise there is a mismatch in supply and demand.
76
Why is the intensity of an aortic stenosis murmur not a good indicator of severity?
Initially as aortic stenosis becomes worse the murmur gets loader. However, once the patient develops heart failure the cardiac output reduces and the murmur becomes softer
77
How is symptomatic AS treated?
SAVR or TAVI
78
When do you offer surgical treatment for AS if patient is asymptomatic?
- left ventricular ejection fraction below 50% - undergoing other cardiac surgery - rapid progression
79
What is the most common cause of aortic stenosis in those aged under 70?
Bicuspid aortic valve
80
What investigation is done for aortic stenosis with reduced ejection fraction?
Dobutamine stress echocardiogram
81
What 2 things can cause an irregularly irregular pulse?
AF Ventricular ectopics
82
What is Atrial Fibrillation?
AF is when the electrical activity of the atria become disorganised. Each individual myocyte of the heart has the ability to contract independently resulting in unsynchronised contraction of the atria.
83
What symptoms are seen in AF?
Asymptomatic Palpitations Dizziness Fatigue Dyspnoea Stroke Tachycardia Tachypnoea HF
84
What are the risk factors/ causes for AF?
Cardiac: IHD, structural heart disease, HTN, DM, obesity Respiratory: pneumonia, PE Thyrotoxicosis Chronic kidney disease Caffeine Alcohol excess Age Male
85
What investigations are done for suspected AF?
ECG Radial pulse examination 24hr ECG Underlying cause: FBC U&Es TFTs Blood glucose Echo radiogram
86
What are the 2 types of AF?
Paroxysmal: recurrent episodes of AF terminating within 7 days Persistent: AF lasting more than 7 days
87
What is the first line treatment for AF? What are the contraindications?
Rate control Contraindications include: Reversible cause of AF Haemodynamically unstable New onset AF HF caused by AF
88
What are the indications for immediate cardioversion?
New onset AF within 48hrs of onset Haemodynamically unstable
89
What medication is used for pharmacological cardioversion?
Flecainide Amiodarone: if IHD or SHD
90
When should delayed cardioversion be done? Procedure?
Patient presents after 48 hrs with symptoms/ unsure of onset. Anticoagulant must be started 3 weeks before cardioversion. Cardioversion must be electrical guided by trans oesophageal echocardiography.
91
What medications are used for long term rhythm control after successful cardioversion?
First line: beta blocker Second line: dronedarone Third line: amiodarone
92
W(at are the requirement# for dronedarone use?
No HF or left ventricular systolic function plus one of the following: Hypertension Diabetes Age 70 or above Previous stroke/ TIA
93
What is the “pill in pocket” approach?
This is used for patients with paroxysmal AF, who meet the following criteria: Infrequent episodes No IHD, SHD Systolic Bp above 100 HR above 70 Flecainide is given to be taken when experiencing an episode of AF
94
What anticoagulation medication is given for patients with new onset AF? When can it be discontinued?
Heparin Discontinue if patient is successfully returned to sinus rhythm after cardioversion Low risk of reacurrence
95
If rate is not controlled in Afib my mono therapy what can be done?
Dual therapy with 2 of the following: Beta blocker Diltiazem Digoxin
96
Which calcium channel blockers are rate limiting?
Diltiazem Verapamil

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