Interactive cardiology cases - amir sam Flashcards
(88 cards)
1
Q
associated symptoms of cardiac pain
A
nausea, sweating, sob, dizziness, ankle swelling
2
Q
risk factors of cardiac pain
A
htn, high cholesterol, dm
3
Q
investigations for mi in order
A
ecg, troponin and echocardiography
4
Q
why do you do an ecg first for mi
A
to know if there is st elevation
5
Q
management for stemi
A
aspirin and clopidogrel and send to cath lab for percutaneous coronary intervention (PCI) aka angioplasty
6
Q
management for nstemi
A
aspirin, clopidogrel, lmwh, inpatient angiogram. thrombolyse (tPA or streptokinase) before sending to cath lab
7
Q
what do the results of the troponin test indicate
A
positive - coronary angiogram
negative - exercise tolerance test
8
Q
when is troponin done
A
tradionally at 12h but high sensitiity troponins can be done at 3h and 6hr after onset of chest pain
9
Q
what will echocardiography show
A
ventricular dysfunction and regional wall motion abnormality. if there is blockage of one of the coranaries there will be rwma in that area
10
Q
why isnt there regional wall motion abnormality in myocarditis
A
the whole heart is affected
11
Q
what are the cardiac ddx of chest pain
A
ihd, aortic dissection, pericarditis
12
Q
ischaemic heart disease (ihd) signs n symptoms
A
radiation to jaw and left arm. pressure like pain, sweating and nausea
13
Q
what are the signs n symptoms of aortic dissection
A
sudden onset tearing chest pain radiates to back. difference in bp in both arms
14
Q
what should you do in every patient with chest pain, hypotension, or murmur
A
listen to echo sound with s2. ask patient to breath out and lean forward. s2 and murmur sounds will combine
15
Q
signs n symptoms of pericarditis
A
pleuritic chest pain that is worse on inspiration. relieved by leaning forward. may have had flu like illness recently.
16
Q
resp ddx of chest pain
A
pe, pneumonia, pneumothorax
17
Q
pe signs, symptoms
A
sudden onset sob, pleuritic chest pain, haemoptysis, swollen leg
18
Q
pe risk factors
A
immobility, previous history/fh of dvt/pe, smoking, recent surgery, ocp, hrt, long haul flight
19
Q
pneumonia signs n symptoms
A
cough, sputum, fever
20
Q
pneumothorax signs n symptoms
A
sudden onset sob, tall thin young man or someone w resp disease
21
Q
if sudden onset sob what could it be
A
pe, ptx or foreigh body. if no risk factors likely to be ptx
22
Q
gi ddx of chest pain
A
oesophageal spasm, oesophagitis, gastritis
23
Q
gastrtitis signs n symptoms
A
waterbrash - sour taste in mouth, retrosternal pain and alcohol use (rf)
24
Q
musculoskeletal ddx of chest pain
A
costochondritis
25
what will cxr show in aortic dissection
widening of the mediastinum. so need to ask for ct angiogram of the aorta
26
difference between stable and unstable angina
stable - pain on exertion, unstable - pain at rest
27
ddx of pleuritic chest pain
```
pericarditis
pe
pneumonia
pneumothorax
pleural pathology
sub-diaphragmatic pathology
```
28
what can the ecg tell you
ischaemia, conduction problems and structural problems
29
what is an anterolateral stemi
evidence of ischaemia - st elevation in v2,v3,v4,v6 and I. st depression in the other leads - reciprocal changes
30
what is an anterior mi
changes seen in v1,, v2, v3,v4 and left anterior descending artery is affected
31
what is a lateral mi
changes seen in v5,v6, I and aVL and circumflex artery is affected
32
what is an inferior stemi and which artery is affected
st elevation in II, III and aVF. it affects the right coronary artery
33
what does the hpc of this collapse case tell you:
before - no warning
during - no tongue biting
after - not confused
no warning suggests cardiac cause with VT (brady/tachyarrhtmia). not an epileptic fit as no prodromal aura
no tongue biting --> cardiac
not confused --> usually drowsy/confused after a seizure but not after an arrhythmia
34
ddx of this collapse case
aortic stenosis - examination would show ejection systolic murmur with a soft s2 and slow rising pulse
pe - no risk factors
postural hypotension - lying and standing bp were same
seizure - no post-ictal phase
tachyarrhythmia
35
hypoglycaemia cause of collapse - what do you do
ask for capillary blood glucose. fast test - insulinoma
36
cardiac ddx of collapse
VOAP - vasovagal, outflow obstruction, arrhythmia, postural hypotension
37
vasovagal collapse causes
P’s: posture, prodrome, provoking factors - standing up in hot weather, cough reflex, micturition reflex. associated with increased vagal activity slowing down the heart. benign
38
how to tell if arrhythmia caused collapse
look at ecg... is there a fh of sudden death
39
right vs left outflow obstruction causes
left - aortic stenosis (old) or HOCM (young)
| right - pe
40
neurological cause of collapse
seizure
41
o/e and investigations of arrhythmia
1. ECG: Long QT - predisposes to VT
2. Cardiac monitor: to catch episode
3. 24h tape
42
o/e and investigations of outflow obstruction
Left -> Low volume/slow rising pulse, ejection systolic murmur, echocardiogram.
Right -> d-dimer and ct pulmonary angiogram
43
o/e and investigations of postural hypotension
Lying and standing blood pressure
44
how to know if they have long qt syndrome from ecg
Draw a line between two R waves. The t wave should finish before the half-way point.
45
causes of abnormal ventricular repolarisation aka long qt interval
Congenital: mutations in K channels (long qt syndrome) --> FH of sudden death.
Acquired: low K/Mg, drugs.
46
difference between left and right sided murmurs
Left sided murmurs are louder on expiration. Right sided murmurs are louder on inspiration.
47
causes of pan systolic murmurs
mirtal and tricuspid regurg
48
ddx of high jvp
r heart failure. tricuspid regurg. constrictive pericarditis.
49
what would make you think ddx is r heart failure
1. Would see a precipitating factor → pulmonary hypertension, infarction, left sided heart failure.
2. Could be secondary to left HF (Congestive cardiac failure, previous MI)
3. Pulmonary HTN (recurrent PE, long-standing COPD etc) → High pressure in the
pulmonary artery, the heart would be working really hard and may fail.
4. Infarction – patient may present with chest pain.
50
what would make you think ddx is tricuspid regurg
high temp. infective endocarditis. right ventricular dilation
51
what is common in iv drug users
right sided endocarditis that can damage valve leaflets
52
causes of constrictive pericarditis
infection - tb
inflammation - connective tissue disease (lupus, sarcoidosis)
malignancy
53
constrictive pericarditis signs
raised jvp, hepatomegaly, peripheral oedema
54
ddx of systolic murmurs
1. Aortic stenosis
2. Mitral regurgitation
3. Tricuspid regurgitation
4. Ventricular septal defect (VSD)
55
how to differentiate between ddx of systolic murmurs
1. Where is it loudest?
a. Aortic area: AS
b. Mitral area: MR
c. Does it radiate?
i. To carotids = AS.
ii. To axilla = MR.
2. Associated features?
a. AS - Slow rising pulse (thrill under thumb), soft S2
b. Hyperdynamic displaced apex beat mitral area (MR)
c. TR: Pulsatile liver, high JVP
3. normal fit man w no other features of other murmus -> VSD
56
What would you expect to see on his ECG:
| pr - 160 irregular
atrial fibrillation or sinus tachycardia
57
if ecg shows sinus tachycardia what is the ddx
1) Sepsis → hypotension (reflex tachy)
2) Hypovolemia
3) Endocrine: thyrotoxicosis, phaeochromocytoma
58
what does a supraventricular tachycardia (SVT) look like on ecg
- Missing p wave
- Fast and regular
- QRS-T pattern
- Narrow complex < 3 small squares
59
how to treat svt
adenosine
60
what type of svt has a slurred upstroke (delta wave)
avrt
61
if ecg shows SVT what is the ddx
re-entry circuit: re-entrant tachycardias
62
what is avnrt
- Reentry circuit at the AV node: conducted down and goes round in circles
- No p wave because the depolarisation comes from the AVN not the SAN
- Normal ECG after it has resolved - no slurred upstroke
63
what is avrt - Wolff Parkinson White
- Big accessory bundle
| - Depolarisation gets to AVN, travels down the septum and then back up the accessory pathway to reach the AVN again
64
if ecg shows atrial fibrillation what is the ddx
Metabolic: Thyrotoxicosis, alcohol
Heart (by layer): pericarditis, muscle (CM, IHD, HTN, myocarditis), valves (MS, MR)
Lungs: pneumonia, PE, cancer
65
if ecg shows VT what is the ddx
Ischaemia (collapse w mi due to arrhythmia), electrolyte abnormality (check k,mg) , long QT(look at old ecgs)
66
atrial fib on ecg
no p waves, irregular, narrow qrs
67
vt on ecg
broad qrs complexes,regular
68
what is the management for svt and bp 120/80
1. vagal manoeuvres - massage n valsalva
2. adenosine w cardiac monitor if vagal manoeuvres dont work
3. dc cardioversion if haemodynamically compromised
69
contraindication of adenosine
asthmatics and warm patients
70
what patients have dc cardioversion
anyone with
| any arrhythmia that has haemodynamic instability needs DC cardioversion.
71
Management Plan for Acute Fast AF and BP 120/80
1. Rhythm control → convert to sinus rhythm. If onset > 48hours, anticoagulate for 3-4 weeks before cardioversion or a clot may dislodge --> stroke
2. Rate control using Beta blocker or Digoxin
3. Treat underlying Cause (pnuemonia, infection - abx n fluid)
4. think of the Complications (Anticoagluation - warfarin)
72
how do you manage a ventricular tachycardia
1. If no haemodynamic compromise (hypotn): IV amiodarone.
2. Look for and treat underlying cause - electrolyte abnormalities
3. ICD - implanted cardiac defibrillator
4. Pulseless VT: defibrillate
73
what is the voltage criteria for left ventricular hypertrophy and ddx
deep S in v1 and v2
tall R in v5/v6
S in v1 and R in v5 or V6 (whichever is larger) ≥ 7 large squares
ddx - hypertension as ventricle has hypertrophied due to working hard against systolic pressure
74
1st degree heart block in ecg
prolonged pr interval (>1 large square)
75
what to look at when interpreting an ecg
1. rate, rhythm, axis - sinus, positive QRS in I and II so normal axis
2. any ischaemia , st elevation or depression or t wave inversion
2. electrical abnormalities - pr, qrs, qt intervals
76
2nd degree heart block in ecg
p waves that are not followed by QRS complexes
77
3rd degree (complete) heart block in ecg
no association between p waves and QRS complexes . broad QRS complexes
78
pathologies suggested by ECG
1. Ischaemia - ST ele/dep , T inversion (NNSTEMI), Q (old infarct)
2. Arrhythmias or conduction defects:
- Rate, rhythm
- PR interval (prolonged → 1st degree HB), QRS intervals (prolonged → BBB), QT interval
(prolonged → predisposes to VT).
3. Ventricular strain or hypertrophy
- Axis (R/L deviation), R, S waves
79
quickest way to find axis
1. If QRS complexes in V1 and V2 both positive → no axis deviation.
2. If either is negative → axis deviation. Right or left?
aVL is positive → Left axis.
aVL negative → right axis.
80
what is s3 associated with
ventricular filling (heart failure)
81
what is s4 associated with
ventricular hypertrophy - atria contracting against stiff ventricle
82
Can you tell the difference between the fixed wide splitting of S2 and S3?
The fixed wide splitting is best heard with the diaphragm whereas S3 is a low pitched sound and is
therefore better heard with the bell.
83
acute heart failure management
1. Sit up
2. 60-100% O2
3. Reduce preload - GTN infusion - venodilators
4. Diamorphine
5. Furosemide (IV) - (not for diuresis, venodilator as well)
a. Given IV because if they have gut oedema they will not absorb the drug orally
b. Daily weights needed
6. Treat the underlying cause e.g. MI
84
chronic heart failure management
beta blocker and acei and spironolactone
85
causes of cardiac arrest (4Fs and 4Ts)
- Hypoxia
- Hypothermia
- Hypovolaemia
- Hypo/hyperkalaemia
- Tamponade
- Tension pneumothorax
- Thromboembolism
- Toxins / metabolic disorders: drugs, therapeutic agents, sepsis
86
what is the management for VF/pulseless VT
1. shock
2. CPR (2mins)
3. Re-assess rhthym
4. Adrenaline every 3-5 mins
5. correct reversible causes
87
why do you not give adrenaline to patient that is cold (hypothermia)
metabolism slows down when the patient is cold. so adreanaline would build up and could be toxic
88
what is the management for asystole/pulseless electrical activity --> ecg looks fine but pt has no pulse
1. cpr
2. correct reversible causes
3. no drugs
