rhythm Flashcards
(135 cards)
1
Q
Three types of cardiomyopathy?
A
1) Hypertrophic 2) Restrictive 3) Dilated
2
Q
What are cardiomyopathies?
A
Diseases of the myocardium (Muscular/conduction defects)
3
Q
What is the most common cause of death in young people?
A
Hypertrophic cardiomyopathy
4
Q
Causes of hypertrophic cardiomyopathy
A
Familial -inherited mutation of sarcomere proteins — troponin T and Myosin B
5
Q
Pathophysiology of of hypertrophic cardiomyopathy
A
Thick non compliant heart = impaired diastolic filling => decrease in CO
6
Q
Symptoms of hypertrophic cardiomyopathy
A
May present with sudden death Chest pain/angina Palpitations SOB Syncope/dizzy spells
7
Q
Investigations to diagnose hypertrophic cardiomyopathy
A
Confirm with abnormal ECG ECHO (diagnostic) Genetic testing
8
Q
Treatment for hypertrophic cardiomyopathy
A
Bb CCB Amiodarone (anti-arrhythmic)
9
Q
What is the most common cardiomyopathy in general
A
Dilated cardiomyopathy
10
Q
Cause of dilated cardiomyopathy
A
-Autosomal dominant familial inheritance (cytoskeleton gene mutation) -IHD -Alcohol
11
Q
Pathophysiology of dilated cardiomyopathy
A
Thin cardiac walls poorly contract leading to a decrease in CO LV/RV or 4 chamber dilation and dysfunction
12
Q
Symptoms of dilated cardiomyopathy
A
-SOB -heart failure (usually) -atrial fibrillation -thromboemboli
13
Q
Investigations to diagnose dilated cardiomyopathy
A
ECG ECHO
14
Q
Treatment for dilated cardiomyopathy
A
Treat underlying condition Eg Atrial fibrillation, heart failure
15
Q
How common is restrictive cardiomyopathy
A
Rare
16
Q
Causes of restrictive cardiomyopathy
A
-Granulomatous disease (sarcoidosis,amyloidodis) -idiopathic -post MI-fibrotic
17
Q
Pathophysiology of restrictive cardiomyopathy
A
Rigid fibrotic nyocardium fills poorly and contracts poorly => decreased CO
18
Q
Symptoms of restrictive cardiomyopathy
A
Severe: -dyspnoea -S3 + S4 sounds -oedema -congestive heart failure -narrow pulse pressure ( normally 120/80 but here it’s 105/95 and consequently blood stasis due to the decreased gradient)
19
Q
Investigations to diagnose restrictive cardiomyopathy
A
ECG ECHO cardiac catheterisation (diagnostic)
20
Q
Treatment for restrictive cardiomyopathy
A
None Consider transplant Patients typically die within 1yr
21
Q
Tachycardia vs bradycardia?
A
Tachycardia = 100< bpm Bradycardia = 60> bpm
22
Q
Types of bradycardia
A
1) RBBB/LBBB 2) 1°/2°/3° heart block 3) Sinus bradycardia
23
Q
Two major groups of tachycardia’s
A
Supraventricular tachycardias AND Ventricular tachycardias
24
Q
Types of supraventricular tachycardias (SVT)
A
1) AVRT (including WPW) 2) Atrial: -Sinus Tachycardia- Regular -Atrial fibrillation - Irregular -Atrial Flutter - Regular 3) AVNRT (functional) = most common SVT
25
Transmission pathway for heartbeats
SAN -> AVN -> Bundle of His -> Purkinje Fibres
26
What is atrial fibrillation
Irregularly irregular atrial firing rhythm
27
What is the most common cardiac arrhythmia?
Atrial Fibrillation
28
Causes of atrial fibrillation
Heart failure Hypertension 2° to mitral stenosis Sometimes idiopathic
29
Risk factors for atrial fibrillation
60+ T2DM Hypertension Valve defects (mitral stenosis) History of MI
30
Pathophysiology of atrial fibrillation
Regular,physiological impulses produced in the sinoatrial node are overwhelmed by the presence of rapid, uncoordinated electrical discharges produced in the atria. -Causes atrial spasm -Atrial blood pools instead of being pumped efficiently to ventricles
31
What does atrial blood pooling cause
Cause a decrease in cardiac output and increased risk of thromboembolic events (particularly stroke)
32
Potential underlying causes of Atrial Fibrillation
Pirates Pulmonary: PE and COPD Ischaemic heart disease: including heart failure Rheumatic heart disease: any valvular abnormality Anaemia, Alcohol, Advancing age Thyroid disease:hyperthyroidism Electrolyte disturbances eg hyper/hypokalaemia Sepsis and sleep apnoea
33
Pathophysiology pathway of atrial fibrillation
(In reality it’s an overlap of these two pathways)
34
Types of atrial fibrillation
1) First episode 2) Paroxysmel : recurrent episodes that stop on their own <7days 3) Persistant: recurrent episodes >7days 4) Permanent: continuous and refractory to treatment so management is aimed at rat control and anticoagulation
35
Symptoms and signs of atrial fibrillation
Symptoms: 1) Palpitations 2) Dyspnoea 3) Chest pain üö© 4) Syncope üö© Signs: 1) irregularly irregular pulse 2) Hypotension üö© 3) Evidence of heart failure üö©(eg pulmonary oedema)
36
Investigations to diagnose Atrial fibrillation
ECG: - irregularly irregular pulse - narrow QRS (<120ms) - absent p waves
37
Treatment of atrial fibrillation
Determine if rate or rythm control is more appropriate
38
What is rate control
Rate control accepts the fact that the patient is not in sinus rythm, but aims at controlling the rate to reduce long-term deleterious effects of AF on cardiac function = decrease in heart rate
39
What is rythm control
Rythm control aims to restore normal sinus rythm, “cardioversion”, can be either electrical or pharmalogical =restore normal PQRS shape
40
When is rate control recommended for atrial fibrillation
Onset > 48 hours or unknown
41
When is rythm control recommended for atrial fibrillation?
- younger age - onset <48 hours - no underlying heart disease - reversible cause of AF - Failure of rate control - Haemodynamic instability acutely
42
Treatment for atrial fibrillation if patient is haemodynamically unstable
Emergency electrical synchronised DC cardioversion
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Treatment of atrial fibrillation if patient is haemodynamically stable?
Onset of AF <48hrs: rate or rythm control Onset of AF >48hr/unknown: rate control and anticoagulation for at least three weeks Then offer rythm control if unsuccessful or still symptomatic
44
First line drugs for rate control
Beta-blocker OR rate limiting CCB Bispropolol OR diltiazen or verapamil Second line is to combine drugs
45
Pharmacological treatments for rythm control
- Flecainide or amiodarone
46
Electrical treatments for rythm control
Synchronised DC shock starting at 150J under shirt acting general anaesthesia
47
What does a Has-bled score assess
Assess risk of major bleeds in AF patients on anticoagulants >= 3 (max 9) = regular reviews
48
What does the CHA2DS2-VASc assess?
Assess stroke risk and therefore the anticoagulation need for Atrial fibrillation
49
Scoring criteria for CHA2DS2-VASc score
Congestive heart failure Hypertension Age 75=< (2) DM Stoke (2) Vascular disease Age 65-74 Female Total: 2=< then oral coagulation required
50
Complications of atrial fibrillation
Heart failure Ischaemic stroke Mesenteric ischeamia
51
What is an atrial flutter
Irregular organisers atrial firing ~250-350bpm Less common and less severe than AF
52
Pathophysiology of atrial flutter
Fast atrial ectopic firing (250-350bpm) causes atrial spasm, but not as uncoordinated as A-Fib. Pathway typically from opening of tricuspid valve
53
Symptoms of atrial flutter
Dyspnoea Palpitations
54
Investigations to diagnose atrial flutter
ECG : (diagnostic) f wave “saw tooth” pattern Often with a 2:1 block (2 p waves for every QRS)
55
Treatment of acutely unstable atrial flutter
DC synchronised cardioversion
56
Treatment of stable atrial flutter
Rythm/rate control with oral anticoagulation (prevent thromboemboli) Also radiofreq ablation
57
What the most common supraventricular tachycardia?
AVNRT (functional)
58
Pathophysiology of AVNRT
Re-entrant pathway goes through AVN
59
Treatment for AVNRT
Same as AVRT (WPW)
60
What is an AVRT?
AVRT ( Atrioventricular reciprocating tachycardia) -> an accessory pathway exists for impulse conduction, not re entry through AVN Often Hereditary
61
Most common example of an AVRT
Wolff-Parkinson White syndrome (WPW)
62
Pathophysiology of WPW
Accessory pathway for conduction= Bundle of Kent A pre excitation syndrome (excites ventricles earlier than typical pathway so that’s why you see delta waves)
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Symptoms of WPW
Palpitation Dizziness Dyspnoea
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Investigations to diagnose WPW
Ecg: 1) slurred delta waves 2) short PR interval 3) wide QRS
65
Treatment for WPW
First line: Valsalva manoeuvre (Forceful exhalation against a closed airway.. close nose and mouth and breath hard like ur trying to pop ur ears) This triggers never to slow down electrical signals in the heart Carotid massage 2nd line: if 1st unsuccessful IV Adenosine (will temporarily cease conduction; when patient feels like dying) 6mg, then 12mg, then further 12mg (additional doses if 6mg is unsuccessful) Can also consider surgical radiofrequency ablation of bundle of Kent
66
What is long QT syndrome?
Ventricular tachycardia Typically congenital channelopathy disorder where mutation affects cardiac ion channels and therefore heart conduction QT interval 480ms+
67
Causes of long QT syndrome
-Romano ward syndrome (autosomal dominant) -Jervell - lang - Nielsen syndrome (autosomal recessive) -Hypokalemia + hypocalcemia (non-inherited) -Drugs (Amiodarone,magnesium)
68
What is torsades de pointes?
-Polymorphic ventricular tachycardia in patients with prolonged QT -Rapid irregular QRS complexes which “twist” around baseline - can cease spontaneously or develop to ventricular fibrillation
69
What is ventricular fibrillation?
Shapeless rapid auscultations on ECG Patient becomes pulseless + goes into cardiac arrest (no effective cardiac output) 1st line treatment-> electrical defibrillation But jinn synchronised as patient is pulseless
70
Is rate control or rythm control preferred?
Rate control is generally preferred and first line for all patients unless they meet specific criteria
71
What is a 1° AV block?
PR interval prolongation (200ms+) Every P is followed by a QRS
72
Symptoms of 1° heart block?
Asymptomatic
73
Treatment of 1° heart block
No treatment as it is mild
74
Causes of 1° heart block
Drugs (Bb, CCB, digoxin —> block AVN conduction)
75
The difference between different degrees of heart block?
Severity 1° may not cause symptoms 2° sometimes troublesome symptoms 3° most serious = medical emergency
76
What is 2° heart block?
When some p waves are conducted but others aren’t
77
Two types of 2° heart block
Mobitz I (Weinkebach’s) Mobitz II
78
What is Mobitz I?
PR prolongation until a QRS is dropped (PR interval progressively elongates)
79
Causes of Mobitz I?
Same as 1° heart block (Bb, CCB, Digoxin) Inferior MI
80
Treatment of Mobitz I?
No treatment unless symptomatic eg syncope Treatment—> pacemaker
81
Symptoms of Mobitz I?
May have syncope
82
What is Mobitz II?
PR interval consistently prolonged (not progressively enlarging) with random dropped QRS
83
Causes of Mobitz II?
Drugs, Inferior MI, Rheumatic fever
84
Symptoms of Mobitz II?
Syncope SOB Chest pain
85
Treatment for Mobitz II?
Pacemaker
86
What is 3° heart block?
AV dissociation (complete heart block; atria + ventricles beat independently of each other) * ventricular ESCAPE rythm is sustaining heartbeat —> SAN (best) if dysfunctional, AVN takes over —> if dysfunctional ventricle pacemakers take over (worst, firing rate 20-40bpm)
87
Causes of 3° heart block
Acute MI Hypertension Structural heart disease
88
Treatment for 3° heart?
IV atropine + permanent pacemaker
89
What is a bundle branch block?
Blocks of bundles of His
90
Two types of bundle branch block?(BBB)
RBBB right LBBB left
91
Causes of RBBB
Pulmonary emboli IHD VSD
92
Causes of LBBB
IHD Valvular Disease
93
Pathophysiology of RBBB?
RV later activation than LV
94
Pathophysiology of LBBB?
LV activation later than RV
95
Epidemiology of hypertrophic cardiomyopathy
Affects 1 in 500 people
96
What is LVOT?
Left ventricular outflow tract obstruction is a recognised feature of hypertrophic cardiomyopathy
97
Cause of arrhythmogenic hypertrophy
Desmosome gene mutations
98
Main symptom of arrhythmogenic cardiomyopathy
Arrhythmia
99
What do all cardiomyopathies carry a risk of?
Arrhythmias
100
Likely cause of sudden cardiac death in a young person?
Often due to an inherited condition Most likely a cardiomyopathy or ion channelopothy
101
What is the cause of inherited arrhythmia? (Channelopothy)
Caused by ion channel protein gene mutations
102
Which ions do cardiac channelopothies relate to?
Potassium Sodium Calcium
103
Examples of cardiac channelopothies?
Long QT Short QT Brugada CPVT
104
Cardiac channelopothies effect on heart structure?
No effect- have a structurally normal heart
105
Symptom of cardiac channelopothy?
Syncope
106
QT prolonging drugs?
Many drugs on this list that may be used to treat other conditions eg some antidepressants But they can kill people with long QT syndrome
107
SADS sudden arrhythmic death syndrome?
Usually refers to normal heart/arrhythmia
108
Familial hypercholesterolaemia (FH)?
Inherited abnormality of cholesterol metabolism
109
What does familial hypercholesterolaemia lead to?
Serious premature coronary and other vascular diseases
110
Aortavascular syndromes
Marfan Loeys-Dietz Vascular Ehler Danos
111
What type of inheritance are inherited cardiac conditions usually?
Dominantly inherited Offspring have a 50% chance of inheritance
112
Why is screening important for inherited cardiac conditions?
Genetic testing is available Risk (arrhythmic death, vascular dissection) needs to be assessed for each individual Life saving treatments are available (ICD, beta blockers, statins, vascular surgery) Lifestyle modifications can save lives
113
Why is screening for inherited cardiac conditions highly contentious?
Because long QT has only a 1/5000 prevalence so it will very rarely be picked up and not a huge benefit to it in the normal population But for first degree relatives- 1/2 chance of it being passed on so highly recommended
114
What investigations need to be done as part of a hypertension screening?
Urine dipstick (kidneys = end organ damage) ECG (LVH) HBA1c Renal function Fundosocopy (eyes) Lipid profile Qrisk Only check cortisol if there’s a secondary cause of hypertension
115
What do you need to calculate Qrisk?
Lipid profile
116
What changes in the arteries are likely to be seen due to angina?
-Smooth muscle proliferation and migration from the tunica media to the intima -decreased release of nitric oxide - infiltration of Subendothelial space by low-density lipoprotein (LDL) particles - formation of foam cells from macrophages
117
Which blood test is the most accurate marker for acute cardiac damage?
Troponin T - short term, released by cardiac myocytes
118
Blood marker for heart failure?
Brain natriuretic peptide
119
Inflammatory blood marker?
C reactive protein
120
Which investigation is diagnostic for heart failure?
Echocardiogram- allows you to see ventricles and valves (valves cause murmurs)
121
Which medication can be prescribed to relieve symptoms (swollen ankles) of heart failure?
Oral digoxin (cardiac glycoside)
122
Which two medications can cause postural hypertension?
Bisproplol Amlodipine
123
Non pharmacological treatment to help with postural hypertension?
Increase salt intake Increase oral fluid intake Compression stockings Sit + stand slowly
124
What is postural hypertension?
Sustained reduction of systolic blood pressure of at least 20 mmHg or diastolic blood pressure of 10 mmHg within 3 minutes of standing
125
Causes of postural hypersensitivity?
Disorders affecting autonomic nervous system (eg. Parkinson’s disease) reduced blood volume, or iatrogenic causes eg. Antihypertensives
126
Pharmovological treatment options of postural hypertension?
Oral fludrocortisone
127
Prevalence of postural hypertension?
Affects 5% to 30% of people aged over 65 years and up to 60% of people with Parkinson’s disease
128
5 investigations to assess for infective endocarditis?
Bedside- ECG, urinalysis Bloods - FBC, CRP, blood cultures Imaging - Echo
129
Low amplitude p wave possible causes?
Atrial fibrosis Obesity Hyperkalemia
130
High amplitude p waves possible cause?
Right atrial enlargement
131
Broad notched ‘bifid’ p wave possible causes?
Left atrial enlargement
132
Broad QRS possible causes?
Ventricular conduction delay/ branch bundle block Pre-excitation
133
Small QRS complex possible causes?
Obese patient Pericardial effusion Infiltrative cardiac disease
134
What can T wave changes indicate?
- ischeamia/infarction - myocardial strain (hypertrophy) - myocardial disease (cardiomyopathy)
135
Ecg for ischeamia?
T wave flattening inversion ST segment depression
