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Case 13 Flashcards

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1
Q

Ionic current responsible for phase 4 of myocyte action potential

A

Ik1 - Inwardly rectifying potassium channels

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2
Q

Ionic current responsible for phase 0 of myocyte action potential

A

INa - Influx of sodium into cell

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3
Q

Ionic current responsible for phase 1 of myocyte action potential

A

Ito - Transient outward movement of potassium ions

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4
Q

Ionic current responsible for phase 2 of myocyte action potential

A

ICa,L - longlasting, inward movement of calcium

Ikr and Iks - rapid and slow outward movement of K+

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5
Q

Ionic currents increased by B-adrenergic stimulation

A

Iks, Ik1 and ICa,L

Calcium to a lesser extent than potassium

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6
Q

Effect of B-adrenergic stimulation on myocyte action potential

A

Shortens phase 2

Greater activation of potassium channels than calcium. So phase 2 ends sooner

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7
Q

Ryanodine receptor (RyR2)

A

Release of calcium in sarcoplasmic reticulum into sarcoplasm

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8
Q

Calsequestrin

A

Binds Ca2+ in SR lumen

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9
Q

FKBP

A

Inhibits RyR2

Dissociates from RyR2 on B-adrenergic stimulation - no longer inhibiting it.

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10
Q

SERCA2a

A

Ca2+ ATPase
In SR
Transports 2x Ca2+ per ATP

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11
Q

PMCA

A

Ca2+ ATPase
In sarcolemma (plasma membrane)
Transports 1x Ca2+ per ATP

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12
Q

Phospholamban

A

Regulator of SERCA2a

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13
Q

Calmodulin

A

Regulator of PMCA

Causes removal of Ca2+ when activated

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14
Q

Effect of sympathetic stimulation on phospholamban

A

Phospholamban is phosphorylated by PKA

Becomes less inhibitory of SERCA2a

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15
Q

TnT

A

Troponin which binds tropomyosin

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16
Q

TnC

A

Troponin which binds calcium

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17
Q

Effect of Ca2+ binding to TnC

A

Myosin and actin are able to interact

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18
Q

When TnI is phosphorylated by PKA

A

Sensitivity of myofilaments to Ca2+ is decreased

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19
Q

HCN channels

A

Hyperpolarisation-activated Cyclic Nucleotide-gated

Cause there to be an unstable resting potential (funny current)

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20
Q

Ionic current responsible for phase 4 of pacemaker action potential

A

If

Inward movement of Na+ via HCN channels

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21
Q

Ionic current responsible for phase 0 of pacemaker action potential

A

ICa,L

Inward movement of Ca2+

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22
Q

Ionic current responsible for phase 3 of pacemaker action potential

A

Ikr and Iks

Outward movement of K+

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23
Q

What is happening in the SAN to bring about tachycardia?

A

Increased binding of cAMP to HCN4 channels.
Increased Na+ entry into SAN cells.
Increased steepness of pacemaker potential.

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24
Q

What is happening in SAN to bring about bradycardia?

A

Decreased binding of cAMP to HCN4 - flattening of pacemaker potential.

Increased KACh (outward K+ current) - hyperpolarisation, takes longer for membrane potential to reach threshold.

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25
I ncx (Ionic Current NCX)
Inward current via 3Na+(out)/Ca2+(in) exchange
26
I Ca,T (Ionic current Ca,T)
Inward T-type Ca2+ currents Activated at negative potentials Inactivated rapidly
27
I Kr (Ionic current Kr)
hERG channels | Associated with LQT2
28
I Ks (Ionic current Ks) channels are associated with...
LQT1
29
Dromotropic agents affect..
Conduction speed in AVN
30
High conductance connexins
Cx40 and Cx43
31
Low conductance connexins
Cx30 and Cx45
32
Connexins expressed by AVN
Cx30 and Cx45
33
Activated tropomyosin...
Blocks actin from binding to myosin
34
Troponin:Ca2+ complex...
Pulls tropomyosin away from actin's myosin binding site
35
In smooth muscle, calcium binds to...
Calmodulin
36
Calcium:Calmodulin complex in smooth muscle cells activates...
MLCK
37
Smooth muscle cross bridge activity is turned on by Ca2+-mediated changes in...
Thick filaments Myosin
38
Skeletal muscle cross bridge activity is turned on by Ca2+-mediated changes in...
Thin filaments Actin
39
Normal AVN delay
0.12-0.2s
40
On an ECG, AVN delay is represented by...
PR interval
41
Conduction velocity in Bundle of His
1m/s
42
Conduction velocity in Purkinje Fibres
5m/s
43
Why is conduction velocity higher in Purkinje Fibres than in Bundle of His?
Larger diameter
44
Mechanism for AVN reentry tachycardia
Activation enters AVN via slow pathway. Retrogradely activates atria via fast pathway.
45
AVRTs can be...
Orthodromic or Antidromic
46
AVRT result from....
An accessory pathway
47
ECG features of an orthodromic AVRT
200-300bpm P waves buried in QRS T wave inversion ST depression
48
ECG features of an antidromic AVRT
200-300bpm | Wide QRS
49
Bundle of Kent
Accessory pathway seen in Wolff-Parkinson White syndrome
50
Wolff-Parkinson-White Syndrome
AVRT resulting from a specific accessory pathway - the Bundle of Kent
51
ECG features seen in Wolff-Parkinson-White Syndrome
PR interval <120ms Delta wave QRS prolongation ST segment and T wave changes
52
Delta Wave
Slurring, slow rise of initial portion of QRS Seen in WPW Syndrome
53
Peri-infarct zone consists of...
Dense scar tissue dispersed between living, normal cells
54
How does scar tissue cause reentry tachycardia?
Flow of impulse perpendicular to line of muscle cells is much slower than usual. When excitation reaches the end of the muscle cells, it is able to stimulate them perpendicularly in the opposite direction (since it is not in ERP)
55
Triggered Activity
Impulse initiation in cardiac fibres that is dependent on after depolarisations
56
After-depolarsations
Oscillations in membrane potential that follow the upstroke of an action potential.
57
Causes of repolarisation abnormalities (3)
Drugs Genetic predisposition Electrolyte imbalance
58
Why do cardiac cells have automaticity?
They can generate spontaneous action potentials due to diastolic depolarisation. i.e. net inward current during phase 4 of action potential
59
Broad complex tachycardia
QRS complex >120ms
60
Narrow complex tachycardia
QRS complex <120ms
61
Causes of broad complex tachycardia
VT SVT + BBB Accessory pathway related
62
Causes of narrow complex tachycardia
``` Atrial fibrillation Atrial flutter Multifocal Atrial tachycardia AVNRT/AVRT (short PR) Sinus tachy/Atrial tachy (long PR) ```
63
Tachycardia
>100bpm
64
Sinus rhythm
P wave before every QRS complex Normal PR interval (120-200ms) Regular rhythm
65
Normal PR interval
120-200ms
66
Sinus Arrhythmia
Normal phenomenon in the young | Heart rate increases when a deep breath is taken in and out
67
Symptoms of arrhythmias
``` Palpitations Dyspnoea Presyncope (dizziness) Chest pain Sudden cardiac death ```
68
Since palpitations are a common symptom, you should also ask about (the palpitations)...
Duration Onset Associated symptoms
69
Why do arrhythmias cause dyspnoea?
Reduced cardiac output
70
Why do arrhythmias cause chest pain?
O2 demand exceeds supply. Demand may be high due to tachycardia Supply may be low due to low cardiac output
71
Why do arrhythmias cause presyncope?
Inadequate cerebral perfusion
72
Prevalence of sudden cardiac death
1/1000 per year
73
Arrhythmias causing sudden cardiac death
Ventricular fibrillation Polymorphic ventricular tachycardia Monomorphic ventricular tachycardia
74
Proportion of sudden cardiac deaths with structurally abnormal heart
2/3
75
Proportion of sudden cardiac deaths resulting from coronary artery disease
80%
76
On an ECG, Ventricular ectopic beats...
Broad QRS
77
On an ECG, Atrial ectopic beats...
Narrow QRS Inverted P waves Compensatory pause afterwards
78
Paroxysmal AF
Episodes last <48hrs
79
Persistent AF
Episodes last 48hrs-1 week
80
Permanent AF
Symptoms occurring at all times
81
Structural heart disease causing AF
Valvular, Ischaemic, Hypertensive and congenital heart disease Athletes heart Cardiomyopathies
82
Causes of AF with no structural heart disease
Metabolic e.g. hyperthyroidism Biochemical e.g. Hyperkalaemia Drugs e.g. caffeine, alcohol Severe infections
83
MOA of flecainide
VW Class Ic - Na+ channel blocker
84
MOA of Propafenone
VW Class Ic - Na+ channel blocker
85
MOA of amiodarone
VW Class III - K+ channel blocker
86
MOA of dronedarone
VW Class III - K+ channel blocker
87
First degree heart block
Prolonged PR interval (<200ms)
88
Second degree heart block
Occasionally a P wave does not elicit a QRS complex
89
Mobitz Type I Heart Block
PR interval gets longer until eventually, P wave fails to elicit a QRS complex
90
Mobitz Type II Heart Block
PR interval stays the same. | Occasionally, a P wave does not elicit a QRS complex
91
2:1 Heart Block
Every 2nd P wave does not elicit QRS
92
3:1 Heart Block
Every 3rd P wave does not elicit a QRS
93
Complete Heart block
Complete AV dissociation
94
Causes of Heart Block
``` Age-related Acute ischaemia Hyperkalaemia Hypothermia Hypothyroidism Drugs (AVN blockers) Congenital Raised ICP ```
95
Management of heart block
Permanent Pacemaker
96
Brugada syndrome
ECG shows ST elevation | Leading cause of sudden cardiac death in young males
97
As a cardioaccelerator, Noradrenaline acts principally on...
Sinoatrial Node
98
As a cardioinhibitor, Acetylcholine acts principally on...
Atrioventricular Node
99
Indication for VW Class I
SVT, AVNRT, WPW
100
VW Class I
Na+ channel blockers
101
VW Class IA
Moderate Na+ channel blockers Increase ERP
102
VW Class IB
Weak Na+ channel blockers Decrease ERP
103
VW Class IC
Strong Na+ channel blockers No effect on ERP
104
VW Class IA Example
Procainamide
105
VW Class IB Example
Lidocaine
106
VW Class IC Example
Flecainide
107
ADRs of Lidocaine in treatment of arrhythmias
Dizziness Paraesthesia Drowsiness Bradycardia
108
ADRs of Flecainide
``` Oedema Dyspnoea Dizziness Fever Visual Disturbance ```
109
Contraindications of Lidocaine
AV block | Myocardial depression
110
Contraindications of flecainide
Heart failure History of MI heart block
111
Indication for lidocaine (Class IB)
Ventricular tachycardias
112
Indication for flecainide (Class IC)
For life threatening SVT and VT
113
Indication for VW Class IA
AF A.Flutter SVT VT
114
VW Class II
Beta 1 Adrenoceptor Antagonists
115
MOA of Bisoprolol
Beta 1 Adrenoceptor Antagonist
116
Indication for bisoprolol
SVT
117
ADRs of bisoprolol
``` Hypotension Cardiac failure Bronchospasm Bradycardia Cold Extremities Loss of libido Sleep disturbance ```
118
Contraindications of Bisoprolol
``` COPD/Asthmatic In cardiogenic shock Bradycardia Cardiac failure AV block ```
119
Why should beta-blockers be used cautiously in patients with diabetes?
The drug will mask the warning sign (tachycardia) for insulin-induced hypoglycaemia
120
VW Class III
K+ channel blockers
121
VW Class III Example
Amiodarone
122
Indications for VW Class III
VT, AF, WPW, Atrial Flutter Tachyarrhythmias caused by reentry
123
ADRs of Amiodarone
``` Torsade de Pointes (esp. in those with LQT) Bradycardia AV Block Grey skin abnormalities Phototoxicity Liver failure Pulmonary fibrosis Sleep disorders Tremor Thyroid abnormalities ```
124
Indications for Amiodarone
VT, AF, WPW, Atrial Flutter Tachyarrhythmias caused by reentry
125
Contraindications of Amiodarone
Heart block SAN dysfunction Iodine sensitive Existing thyroid dysfunction
126
VW Class IV
Ca2+ channel blockers
127
VW Class IV Examples
Verapamil | Diltiazem
128
Indications for VW Class IV
Paroxysmal SVT AF (reduces ventricular rate) Hypertension
129
ADRs of verapamil
``` Dyspnoea Constipation Arrhythmia Tachycardia Hypotension Headache Ankle oedema ```
130
Contraindications of Verapamil
``` Hypotension Bradycardia AV Block (2nd and 3rd) Cardiogenic shock Heart failure WPW ```
131
VW Class V
Adenosine
132
Indication for Adenosine
AVNRT | WPW
133
MOA of Adenosine
``` Binds to A1 receptor Inhibits Adenylyl Cyclase Decreased cAMP Hyperpolarisation due to K+ traffic Inhibits Ca2+ entry ```
134
ADRs of adenosine
Flushing headache Rapid arterial hypotension AV Block
135
Contraindications of Adenosine
AV Block (2nd or 3rd)
136
Why is rate control usually trialled first?
Fewer ADRs | Safer for patients
137
CHADS2VASC
Congestive Heart Failure/LV dysfunction (1) Hypertension (1) Age > 75 (2) Diabetes Mellitus (1) Stroke/Thromboembolism (2) Vascular Disease (1) Age 64-75 (1) Sex (female) (1)
138
Administration of Warfarin
Oral
139
MOA of Warfarin
Vitamin K Carboxylase inhibitor
140
Clotting factor synthesis inhibited by Warfarin
VII, IX, X
141
Monitoring for warfarin
Regular measurement of Prothrombin Time to determine INR
142
Normal INR
<1.1
143
Target INR for those taking anticoagulants
2-3
144
Antedote for Warfarin
Vitamin K
145
Administration of Heparin
IV
146
MOA of heparin
Activates anti-thrombin III which inactivates thrombin and Factor Xa
147
MOA of Fondaparinux
LMWH | Inhibits Factor Xa only
148
Monitoring of Heparin
Regular measurement of prothrombin time against activated partial thromboplastin time (aPTT)
149
Antedote for Heparin
Protamine Sulphate
150
MOA of Dabigatran
Thrombin Inhibitor
151
MOA of Rivaroxaban
Factor X inhibitor
152
MOA of Apixaban
Factor X inhibitor
153
Synergism of warfarin and heparin causes...
Penile Necrosis
154
Fundoscopy for hypertensive crisis shows...
Cotton wool spots Flame haemorrhages Papilloedema
155
Urinalysis in hypertension shows..
Increased albumin:creatinine ratio | ACR
156
Important blood tests in investigating hypertension
``` Plasma glucose Electrolyes Creatinine Estimated GFR Serum total cholesterol HDL cholesterol ```
157
Prohypertensive proteins
Angiotensinogen | Renal epithelial Na+ channels
158
Adrenoceptors found on the surface of blood vessels
Alpha 1 and 2
159
Function of Renin
Converts Angiotensinogen to Angiotensin I
160
Function of ACE
Converts Angiotensin I to Angiotensin II
161
Who is offered treatment for hypertension?
``` Stage 1, >80yo with one or more of the following: Target organ damage Diabetes CVD Renal disease 10yr risk of CVD >20% ``` All patients with stage 2 hypertension
162
Initial treatment for patients under 55, not of African/Caribbean origin With Hypertension
1. ACE inhibitors If not tolerated: 2. ARB
163
Initial treatment for patients over 55, or of African/Caribbean origin with Hypertension
1. CCBs If CCB causes oedema or there is evidence of heart failure: 2. Thiazide-like diuretic
164
If step 1 is ineffective, step 2 anti-hypertensive treatment is...
CCB/Thiazide-like diuretic + ACE/ARB ARB>ACE for African/Caribbean origin
165
If step 2 is ineffective, step 3 anti-hypertensive treatment is...
ACE/ARB + CCB + Thiazide-like diuretic
166
If step 3 is ineffective, step 4 anti-hypertensive treatment is...
Addition of low dose spironolactone if K+<4.5mmol/L OR Increase dose of thiazide-like diuretic if K+>4.5mmol/L
167
MOA of Ramipril
ACE inhibitor
168
Method of BP reduction by ramipril
Blocks Na+ reuptake in kidneys (and therefore water reuptake) Limits LV remodelling Reduces vasomotor tone (since there is less angiotensin II)
169
Contraindications of ACE inhibitors
Hypersensitivity to ACE inhibitors | Renovascular disease
170
ADRs of ACE inhibitors
``` Hypotension Renal impairment Persistent dry cough angioedema Rash ```
171
Method of BP reduction by Losartan
Blocks Na+ reuptake in kidneys (and therefore water reuptake) Limits LV remodelling Reduces vasomotor tone (since there is less angiotensin II bound to its receptor)
172
MOA of Losartan
ARB
173
ARBs should be used with caution in patients with...
Renal artery stenosis | Aortic/Mitral valve stenosis
174
ADRs of ARBs
Hypotension - dizziness Hyperkalaemia (occasionally) Angioedema (rare)
175
Method of BP reduction by CCBs
Negative chronotrope and inotrope Prevents vascular smooth muscle cell contraction
176
MOA of Nifedipine
CCB
177
MOA of Isradipine
CCB
178
Contraindications of CCBs
Cardiogenic shock Aortic stenosis Recent MI (within 1 month) Acute/Unstable Angina
179
ADRs of CCBs
``` GI disturbance Oedema Palpitations Headache Lethargy Dizziness ```
180
MOA of Furosamide
Blocks Na/K/Cl reabsorption in loop of Henle Loop diuretic
181
Contraindications of Furosamide
Hypokalaemia Hyponatraemia Renal failure Comatose associated with liver cirrhosis
182
ADRs of furosamide
GI disturbance Increased serum cholesterol Electrolyte disturbance Hyperglycaemia
183
MOA of Bendroflumethiazide
Blocks Na/Cl absorption in DCT Thiazide diuretic
184
Contraindications of bendroflumethiazide
``` Hypokalaemia Hyponatraemia Hypocalcaemia Hyperuricaemia (high uric acid in blood) Addison's Disease ```
185
ADRs of bendroflumethiazide
GI disturbance Electrolyte disturbance Hyperglycaemia
186
MOA of Spironolactone
Blocks aldosterone receptor in collecting duct. Blocking Na+ reabsorption but K+ sparing.
187
Contraindications of spironolactone
Hyperkalaemia Anuria Addison's Disease
188
ADRs of Spironolactone
``` GI disturbance Gynaecomastia Breast pain Menstrual disturbance Drowsiness/Dizziness Hyperkalaemia Hyponatraemia ```
189
Advantages of ARBs over ACE inhibitors?
ARBs do not prevent production of angiotensin II altogether So angiotensin II can still exert its effects in other areas of the body. ARB does not cause cough.
190
Method of BP reduction by bisoprolol
Inhibition of renin release | Negative chronotrope and inotrope
191
Method of BP reduction by GTN spray
Releases NO causing vasodilation
192
How does NO cause vasodilation?
``` Activation of guanylyl cyclase. Increased cGMP Causing: Increased K+ efflux Decreased Ca2+ influx Increased MLC phosphatase ```
193
Rhythm Strip
Prolonged reading from a single lead (usually lead II) | Useful for analysis of heart rate and rhythm
194
aVR is predominantly...
Negative
195
T wave inversion is normal in...
aVR and V1 Children
196
Sinus Rhythm
Regular rhythm P waves followed by QRS complexes Normal PR interval (120-200ms)
197
Enlargement of Right Atrium ECG shows...
Tall pointed P waves
198
Enlarged left atrium ECG shows...
Bifid P waves
199
P-mitrale
Bifid P waves due to enlarged Left Atrium
200
Right ventricular hypertrophy ECG shows...
Taller R waves in V1 (R:S >1) | Deeper S waves in V5 or V6 (R:S <1)
201
Deep, broad Q waves indicate...
Permanent myocardial damage from MI
202
Permanent myocardial damage from an inferior MI ECG shows...
Deep, broad Q waves in II, III and aVF
203
Right bundle branch block ECG shows...
Prolonged QRS (>120ms) Tall R wave in V1 (M) Wide, slurred S wave in V6 (W) MaRRoW
204
Left bundle branch block ECG shows...
Prolonged QRS (>120ms) Dominant S wave in V1 (W) Notched R wave in V6 (M) WiLLiaM
205
Cardiac ischaemia ECG shows...
ST depression in associated leads
206
Anterior Myocardial Infarction ECG shows...
ST elevation in V1-V6
207
Septal MI ECG shows...
ST elevation in V1-V4
208
Lateral MI ECG shows...
ST elevation in I, aVL, V5 and V6
209
Inferior MI ECG shows...
St elevation in II, III and aVF
210
Anterior MI is due to infarction in which coronary artery?
LAD
211
Septal MI is due to infarction in which coronary artery?
LAD
212
Lateral MI is due to infarction in which coronary artery?
Left circumflex
213
Inferior MI is due to infarction in which coronary artery?
``` RCA (80%) Left Circumflex (20%) ```
214
Hyperkalaemia ECG shows...
Tall T waves
215
Pathological inverted T waves:
``` Raised ICP BBB Ventricular HTN PE Hypertrophic Cardiomyopathy MI or ischaemia ```
216
Normal PR interal
120-200ms
217
Normal QRS complex
80-100ms
218
Normal RR interval
0.6-1.2s
219
ECG - 1 square =
0.04s/0.1mV
220
Management of MI
Primary Percutaneous Intervention
221
Heart rhythm abnormalities associated with MI
Atrial fibrillation Complete heart block VT VF (Arrest)
222
Long QT syndrome ECG shows...
T wave flattening Prominent U waves Long QT interval due to fusion of T and U waves
223
Rhythm abnormality associated with LQT syndrome
Torsade de Pointes (Polymorphic VT)
224
Main causes of LQT syndrome (3)
Drugs Myocardial Ischaemia Electrolyte imbalance (esp. Hypokalaemia)
225
Wolff Parkinson White Syndrome ECG shows...
Delta waves Short PR interval Broad QRS complex
226
Rhythm abnormalities associated with WPW
AF Narrow complex tachycardia VF
227
Patient with AF has there AVN ablated and a pacemaker implanted. What drug treatment must they continue?
Anticoagulants - since atria are still fibrillating so there is no change in stroke risk.
228
Rhythm control treatments:
Class Ic Class III DC Cardioversion PVI
229
Rate control treatment:
Class II Class IV Pace and Ablate
230
Primary prevention ICD
When cardiac arrest risk is proportional to scar burden. | Prior MI and EF <30%
231
Secondary prevention ICD
Life threatening cardiac episode: Cardiac arrest with no obvious reversible cause Syncopal VT and structural Heart Disease Non syncopal VT and EF<35%
232
Management of Atrial Fibrillation
Beta blocker or CCB Ineffective? Beta blocker and CCB (or digoxin if sedentary) Ineffective? Rhythm control - VW Ic or III or DC cardioversion
233
Management of Atrial flutter
Beta blocker OR Diltiazem (CCB) or Verapamil (CCB) Ineffective? Add digoxin
234
Management of Ventricular Tachycardia
DC cardioversion OR Amiodarone and DC cardioversion
235
Management of Wolff-Parkinson White
Amiodarone Flecainide (VW Ic) Ablation of accessory pathway.

Year 2 (17 decks)

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