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Flashcards in Cardiovascular Deck (109):
1

Signs of subendocardial ischaemia on ECG?

ST depression
T wave inversion

2

Signs of transmural ischemia on ECG?

ST elevation

3

Definition of STEMI?

>1mm STE in 2 adjacent limb leads
>2mm STE in at least 2 precordial leads
New LBBB

4

Investigations for stable angina?

ECG, Exercise ECG
CT angiogram, Invasive angiogram
Functional imaging

5

Management of stable angina?

Lifestyle
Aspirin + Statin (secondary CVD prevention)
GTN spray
BB (atenolol) +/or CCB (verapamil) (nifedipine if in combo)
Consider: Long acting nitrates (isosorbide mononitrate), ivabradine, nicorandil, PCI, CABG

6

What drugs are CI with GTN and why?

Phosphodiesterase-5-inhibitors (sildenafil)
Can cause drastic decrease in BP

7

Why is verapamil avoided with BBs?

High risk of heart block

8

How to differentiate between UA and NSTEMI?

Cardiac enzymes are released in NSTEMI

9

What are the three ACS and distinguishing features?

UA: ST depression, T wave inversion, no cardiac enzymes
NSTEMI: ST depression, T wave inversion, cardiac enzymes
STEMI: STE, cardiac enzymes

10

What are the two useful cardiac enzymes and why is one of them useful for detecting a second MI within close timing of the first?

Troponin (levels take up to 7 days to return to normal)
CK-MB (levels decrease back to normal within 72 hours)

11

Management of STEMI?

Morphine (IV 10mg titrated to effect with metoclopramide 10mg IV over 3mins)
Oxygen
Nitrates (GTN 3 puffs sub lingually every 5 mins)
Aspirin (300mg orally)
Clopidogrel (second antiplatelet can be helpful)
<120 mins PCI
>120 mins thrombolysis

12

Management of NSTEMI/UA?

Morphine (10mg IV titrated to effect with metoclopramide 10mg IV over 3 mins)
Oxygen
Nitrates (GTN 3 puffs sub lingually every 5 mins)
Aspirin (300mg orally)
Clopidogrel
Urgent coronary angiography

13

Secondary prevention post ACS?

Aspirin + Clopidogrel
BBlocker
ACEi
Statin

14

Anterior MI?

V1-V6 (LCA)

15

Inferior MI?

II, III, aVF (RCA)
Reciprocal I, aVL

16

Anteriolateral MI?

I, aVL, V5, V6 (circumflex)
Reciprocal II, III, aVF

17

Anterioseptal MI?

V1-4 (LAD)

18

Posterior MI?

ST depression in V1-3 (RCA)

19

Complications post MI?

Arrythmias (VF common)
Left ventricular aneurysm and LVF
Dresslers (pericarditis 6 weeks post MI)
HF

20

Signs of old MI on ECG?

Pathological Q waves
Inverted T waves
LBBB
LVH

21

ECG signs of hyperkalemia?

Tall tented T waves globally

22

Signs in right sided heart failure?

Raised JVP, peripheral odema, hepatosplenomegaly, ascites

23

Signs in left sided heart failure?

Pulmonary oedema (crackles, pleural effusion, pink frothy sputum)
Breathlessness, orthopnea

24

When is ACEi CI?

Bilateral renal artery stenosis

25

Management of HF?

ACEi (lisinopril) + BB (bisoprolol)
Spironolactone or ARB (candesartan) or Hydralazine with nitrate
Digoxin or cardiac resynchronisation therapy
Furosemide at any stage if fluid over loaded

26

What are the two vessels going into and away from the glomerulus?

Afferent to
Efferent exit

27

Summarise RAAS?

Low blood pressure detected by kidneys stimulates production of renin that converts angiotensinogen to angiotensin 1. A1 converted to A2 by ACE. A2 acts as vasoconstrictor and stimulates release of aldosterone from the adrenals. Aldosterone increases reabsorption of Na.

28

Hypertension staging?

1- >140/90
2- >160/100
3- >180 or >110
Clinical readings AMBP/HBPM have separate values

29

How do you treat stage 1 hypertension and what are the exceptions?

Lifestyle
Treat is end organ damage, 10year risk >10%, CVS or renal disease, diabetes

30

Management of hypertension?

<55 or all diabetics: A (lisinopril, losartan if cough from ACE)
>55/black: C (amlodipine) (verapamil SE ankle swelling)
A + C
A + C + D (indapamide SE gout, bendroflumethazide)
A + C + D + further diuretic (K <4.5 spironolactone) (K>4.5 higher dose thiazide)
Or alpha blocker (tamulosin) or BB

31

How do you determine the ECG axis?

I+ aVF+ normal
I- aVF+ RAD
I+ aVF- LAD

32

What anti hypertensives should be avoided in pregnancy and what should be used instead?

ACEi use BBs instead

33

What are 5 main secondary causes of hypertension to be aware of?

Renal artery stenosis
Cushing's syndrome
Hyperaldosterism
Phaechromocytoma
Coartcation of the aorta

34

End organ damage seen in hypertensives?

Retinopathy, nephropathy, HF, IHD

35

Definition of a STEMI?

>1mm STE in 2 adjacent limb leads
>2mm STE in at least 2 precordial leads
New onset LBB

36

Main causes of RHF?

IHD including old MI, HTN, cardiomyopathies (dilated, hypertrophic, restrictive), valvular disease

37

Why are ACEi key in heart failure management?

Decreased perfusion of kidneys due to poorer heart function activates the RAAS that results in vasoconstriction, Na reabsorption and ultimately hypertension which exacerbates the HF issue as heart attempts to pump into higher pressures. Blocking A1 to A2 reduces this vicious cycle.

38

What are the main causes of LHF?

RHF, septal defects, chronic lung disease

39

What are the key investigations in HF?

ECG, CXR (heart changes, pulmonary odema)
BNP measurement (<100 unlikely, >100 likely)
ECHO

40

HF management?

ACEi (lisinpopril) + BB (bisoprolol)
Spironolactone, ARB (candesartan) or hydralazine with a nitrate
Digoxin or cardiac resynchronization therapy
Furosemide if fluid overloaded

41

JONES criteria for rheumatic fever?

Joint (migratory polyarthritis)
O (pancarditis)
Nodules (sub cut)
Erythema margentum
Syndehams chorea
+ evidence of strep infection

42

What is rheumatic fever and when does it occur?

An inflammatory disease affecting heart, joints, skin and brain
Can occur after strep throat when ABs to GAS cross react with self tissue (molecular mimicry/T2HS)

43

What kind of haemolysis does GAS undergo?

Beta/complete

44

Describe the key features of pancarditis in rheumatic fever?

Endo: Involves valves most commonly mitral causing regurgitation in the acute phase
Myo: most common cause of death due to inflamed tissue not being able to pump effectively
Epi: pain and friction rub

45

What happens with repeat episodes of acute rheumatic fever?

Chronic rheumatic heart disease with damage to most commonly mitral valve (mitral stenosis) can also affect aortic valve

46

What are the layers of the pericardium?

Serous (visceral and parietal)
Fibrous

47

Triad in pericarditis?

Chest pain
Friction rub
ECG changes

48

What are the ECG changes seen in pericarditis?

Saddle shaped STE
PR segment depression

49

Management of pericarditis?

Treat underlying cause
NSAIDS
pericardiocentesis (if pericardial effusion/cardiac tamponade)

50

Causes of pericarditis?

Idiopathic
Infection (viral coxsackie)
AI (rheumatic heart disease)
Dresslers (6 weeks post MI)
High urea

51

What is the most common cause of endocarditis?

Infection (infective endocarditis)

52

What are the key symptoms of infective endocarditis?

FROM JANE
fever, roth spots, osler nodes, murmur, janeway lesions, aneamia, nail bed haemorrhages, emboli

53

What are the big risk factors for infective endocarditis?

open wound/dental surgery
Rheumatic heart disease (damage to the valves predisposing to vegetations to grow)

54

Common organisms in infective endocarditis and the features of each?

Strep viridans (caused by subactue endocarditis)
S.aureas (IVDU)
S.epidermidis (prosthetic valves)
S.bovis (colorectal ca)

55

What is the criteria for infective endocarditis?

DUKES (includes 3 positive blood cultures 6 hours apart)

56

Major branches of the aorta?

Brachiocephalic (R subclavian, R Internal carotid)
L internal carotid, L subclavian

57

What is the ductus arteriosus?

Connection of PA to aorta in foetal circulation

58

What are the two main types of coarcation of the aorta and ?

Infantile (70%) and adult

59

How can the narrowing in aortic coarcation be classified and where do adult and infantile commonly arise?

Pre ductal (infantile), ductal and post ductal (adult) (meaning the ductus areteriousus)

60

What are some of the key symptoms in coarcation of the aorta?

Pulse defects (radio radial delay, radiofemoral delay - depending on where the narrowing is)
BP differences (upper>lower)
Claudication
Hypertension (resistant to treatment or in young due to activation of RAAS)

61

Complications of coarcation of the aorta?

Berry aneurysms
Aortic dilation and dissection
Rib notching on CXR

62

Investigations in coartcation of the aorta?

ECHO (narrowing and pressure gradient)
ECG (LVH)
CXR (Cardiomegaly, rib notching)

63

What is aortic dissection?

Separation in the walls of the aorta caused by damage to the intima allowing blood into a false lumen and separating it from the media

64

What are the layers of blood vessels?

Tunica intima, tunica media, tunica externa/adventitia

65

Where are the common sites of aortic tears?

Sinotubular junction on the ascending aorta
Distal to the L subclavian

66

What is the classification in aortic dissection?

Stanford: A- on ascending aorta, B- not on ascending aorta

67

What are the symptoms in aortic dissection?

Severe ripping pain substernally or intercapsular
Blood pressure differences and pulse deficits

68

What is an aortic aneurysm?

Dilation of the aorta greater than 1.5x in size

69

Where do the majority of aortic aneurysms arise?

Below the renal arteries

70

Descending aorta anatomy and branches?

Thoracic aorta above diaphragm has posterior intercostal arteries becomes abdominal aorta below the diaphram
Coeliac trunk (splits into hepatic and splenic artery)
SMA
2x renal arteries
2x gonadal arteries
IMA
Common iliac

71

Who gets screening for abdominal aortic aneurysms and how is it done?

Men >65 years, USS

72

What are the different results for AAA screening and the management of each?

Normal: discharge no repeat scan
Small (3 - 4.5): 12 month repeats
Medium (4.5 - 5.5): 3 month repeats
Large >5.5: Surgery

73

What are the symptoms of AAA?

Usually asymptomatic
Palpable expansile mass
Mild pain

74

What are the symptoms of ruptured AAA and management?

Sudden and sever abdominal pain
Haemodynamic instability
Resus and emergency surgery

75

What causes a heart murmur?

Turbulent flow across a valve

76

What is a thrill and how do you feel for them?

Palpable murmur
Palpate with flat of hand over all 4 valve areas

77

What is a parasternal heave and how do you identify one?

Visible pulsation of the chest wall (due to RVH)
Feel with heel of the hand over the left sternal edge

78

Key investigation in valve disease?

ECHO

79

Most common cause of aortic stenosis and the biggest RFs?

Wear and tear resulting in fibrosis and calcification
RFs: Bicuspid aortic valve, Chronic rheumatic heart disease (concurrent mitral stenosis), Age

80

What are the 4 key heart murmurs?

Aortic regurge, Aortic stenosis
Mitral regurge, Mitral stenosis

81

Aortic stenosis

Ejection click (stiff valve clicks open between S1 and S2)
Systolic crescendo decrescendo
Loudest at RSE (aortic area)
Radiates to carotid
Slow rising pulse

82

Main causes of aortic regurge?

Aortic root dilation (connective tissue disorders - marfans, ehlors danhos, hypertension)
Acute rheumatic heart disease (mitral valve affected too)
Infective endocarditis
Bicuspid aortic valve

83

What two valves are most commonly affected in infective endocarditis?

Tricuspid
Mitral and aortic

84

Valves most commonly affected in rheumatic heart disease?

Mitral then aortic

85

Key symptoms in aortic stenosis?

Asymptomatic for long period as LV can compensate
SOB, angina, syncope

86

Key symptoms in aortic regurgitation?

Often asymptomatic until LHF develops
SOB, fatigue, left sided heart failure symptoms
Hyperdynamic BP and widened pulse pressure

87

Aortic regurge?

Diastolic decrescendo
Loudest at erbs point 3rd ICS LSE
Collapsing pulse
Bounding pulse
Manoeuvre: Sit patient forward with diaphragm over erbs point, deep breath in and out and hold. Murmur louder on expiration

88

Treatment for aortic stenosis?

Valve replacement
If unstable balloon valvuplasty

89

Management of aortic regurgitation?

Reassurance if normal left ventricular function (ejection fraction >50%)
Replacement is left ventricular failure

90

What are the 2 diastolic murmurs?

Aortic regurge, mitral stenosis

91

What are the 2 systolic murmurs?

Aortic stenosis, mitral regurge

92

What is mitral valve prolapse and how can it be identified?

One or both of the mitral valve leaflets prolapse into the LA during systole
Mid diastolic click on examination
ECHO

93

What are the complications of mitral valve prolapse?

Mitral regurgitation, infective endocarditis, arrythmias

94

What are the RFs for mitral valve prolapse and thus mitral regurgitation?

Age (degeneration)
Connective tissue disease (marfans, ehler danlos)
MI (damage to the papillary muscles)
Rheumatic heart disease
Left sided HF (causes left ventricular dilation)

95

Management of mitral valve prolapse?

Reassurance unless comorbidities

96

Mitral regurge

Pan systolic
Radiates to axilla
Loudest at apex

97

What happens to the systolic click when sitting or standing in mitral valve prolapse?

Squatting: later (increased venous return, larger ventricle)
Standing: earlier (decreased venous return, smaller ventricle)

98

Symptoms of mitral regurge?

SOB, decreased exercise tolerance

99

Most common murmur associated with rheumatic heart disease?

Mitral stenosis

100

Mitral stenosis?

Opening snap
Diastolic rumble
Manoeuvre: roll onto left side with bell over 5th ICS mid clavic, deep breath in and out.

101

Management of mitral stenosis?

Symptomatic treatment
Valvotomy if severe

102

SAD mneumonic for aortic stenosis?

Syncope
Angina
Dyspnoea

103

4 ways to classify AF?

First episode
Paroxysmal (>1 episode and self terminating)
Persistent (not terminating)
Permanent (can't cardiovert)

104

What are the 2 key treatment options for AF and who gets what?

Rate control: 1st line approach
Rhythm control: 1st line if CHF, first onset AF, obvious reversible cause, <65years, symptomatic despite rate control

105

What are the drug options for rate control?

Bisoprolol or Diltiazem (rate limiting CCB)

106

When should you consider a pacemaker in AF?

For older patients with poor rate control

107

What are the options for rhythm control in AF?

Pharmacological cardioversion (Amioderone if structural heart disease, Flecainide if no structural heart disease)
Electrical cardioversion in unstable patients (synchronised DC shocks)

108

When must a patient be anticoagulated from if attempting cardioversion in AF?

3 weeks prior to cardioversion if symptoms have been present for >24hrs

109

How long must patients be anticoagulated for following AF cardioversion?

4 weeks