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Year 3 Medicine > Year 3 Cardiology > Flashcards

Year 3 Cardiology Flashcards

1
Q

How is CVS pain different?

A
  • Chest pain
    • Dull, central, crushing, retrosternal.
    • Prolonged (>0.5h) suggests MI
    • Pain radiates to both arms, shoulder jaw/ neck
    • Aortic dissection - pain is instantaneous like a tearing
    • Sometimes epigastric
  • Trigerred by cold, exercise, palpitations or emotion, lying flat, hot drinks or alcohol
  • Relieved by GTN sprays or within minutes by rest
  • Associated with: nausea, sweating, vomiting, palpitations, dyspnoea and syncope
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2
Q

What are some of the associated symptoms and how would you confirm these with a patient?

A
  • Dyspnoea - from LVF, PE, any resp cause
    • Orthopnea - number of pillows used at night
    • PND - do they wake up in the night coughing
  • Palpitations - ectopics, AF, SVT, VT. Ask if patient has checked his pulse
  • Syncope - vasovagal faints. Ask if there was a pulse, limb jerking, tongue biting or urinary incontinence.
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3
Q

Define a STEMI

A
  • Cardiac sounding chest pain
  • ST segment elevation above 1mm in limb leads and 2mm in chest
  • Elevated TnI >100ng/L and CK >400
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4
Q

Define what happens in NSTEMI

A
  • Cardiac sounding chest pain
  • ST segment depression and T wave inversion
  • Tn100 >100ng/L
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5
Q

What is the relevance of troponin and what levels do we expect

A
  • Troponins rise 4-6 hours after onset of infarction, peak at 18-24 hours, and may persist for 14 days or longer
  • Males: over 34 ng/L
  • FM: over 16ng/L - Take on admission and after 1 hr
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6
Q

What can cause false postitive TnI increases

A
  • Large PE
  • Renal failure
  • Congestive HF
  • Myocarditis
  • Aortic dissection/ stenosis
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7
Q

What conditions can mimic STEMI in ECG

A
  • Brugada syndrome
  • Pericarditis
  • Early repolarisation - younger pt, african american, athletic
  • Takotsubo cardiomyopathy
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8
Q

What can cause ST segment depression and T wave inversion

A
  • LV hypertrophy
  • Digoxin toxicity
  • Old MI
  • NSTEMI
  • Unstable angina
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9
Q

How do you manage a STEMI

A

MONAC

  1. IV access
  2. M- Analgesics - morphine + anti emetics metacloperamide
  3. O - Oxygen (if hypoxic, <94%)
  4. N - Nitrate (GTN)
  5. A - Aspirin (300mg loading and 75mg od life) 5.
  6. C - Clopidogrel (600mg loading + 75mg od 1 year)
    1. 2nd line - Plasugrel (60mg loading and 10 mg od 1 yr) -> if PPCI yes, <65 yo, no stroke and >60kg weight) 6
    2. 3rd line - Ticragelor (loading 180mg and 90mg bd 1 year
  7. PPCI - If <2 hrs of first presentation
  8. Long term medication: ABCDE:
    1. ARB/ AceI - ramipril (2.5mg od)
    2. B - bisoprolol (1.25mg od)
    3. C - cholesterol - Statin - atorvastatin (80mg od)
    4. D - Dual antiplatelet: aspirin (75mg od life) and clopidogrel (75mg od 12 mos)
    5. E - Everything else: Diabetic control - insulin infusions, HbAc1 measured, metformin - introduce with caution if suspected LV hypertrophy, smoking cessation and hypertension
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10
Q

How do you manage NSTEMI / unstable angina?

A

MONA(T)+L+Grace

  1. Pain relief: M: morphine + metacloperamide
  2. Oxygen
  3. Nitrates
  4. A- Aspirin (300mg loading + 75mg od life)
  5. T - Ticragelor if risk is > 3 % 180mg loading and 90mg BD
  6. L- LMWH enoxaparin - 48 hrs (depends on weight + creatinine)
  7. Repeat ECG
  8. Risk assessment if increased TnI: Grace score
  9. Whilst waiting for ip angiography - consider anti anginals, nitrates, ranazoline and CBB
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11
Q

Define stable angina

A
  • Chest discomfort
  • Caused by effort or emotion
  • Relieved by rest + GTN
  • Radiated symptoms: throat tightness + arm heaviness
  • Autonomic symptoms: fear, sweating + nausea
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12
Q

How do NICE define stable angina?

A

NICE define anginal pain as the following:

  1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
  2. Precipitated by physical exertion
  3. Relieved by rest or GTN in about 5 minutes
  • patients with all 3 features have typical angina
  • patients with 2 of the above features have atypical angina
  • patients with 1 or none of the above features have non-anginal chest pain
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13
Q

What are some of the risk factors for coronary artery disease:

A
  • Cigarette smoking
  • Hypertension
  • DM
  • Hypercholesterolaemia
  • FMH
  • PMH
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14
Q

When is angina unlikely

A
  • Pain is continuous or prolonged
  • Pain is unrelated to activity
  • Pain brought on by breathing
  • Associated symptoms: dysphagia or dizziness
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15
Q

What do you examine angina

A
  • Weight and height
  • BP
  • Murmus - aortic stenosis
  • Evidence of Hyperlipidemia
  • Evidence of peripheral vascular disease and carotid bruits
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16
Q

What investigations help diagnose angina

What Ix do NICE recommenD?

A
  1. FBC / Hbac1
  2. Lipid profile
  3. 12 lead ECG

NICE recommend:

  • 1st line: CT coronary angiography
  • 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
  • 3rd line: invasive coronary angiography
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17
Q

How is stable angina characterised?

A

Typical angina is:

  1. Chest pressure or squeezing lasting several minutes
  2. Provoked by exercise or emotional stress
  3. Relieved by rest or glyceryl trinitrate
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18
Q

Coronary artery disease CAD - what percentage mean what treatment ?

A
  • CAD 61-90% - Invasive coronary angiography
  • CAD 30-60% - Functional imaging (stress MRI, echp, myoview)
  • CAD 10-29% - CT calcium scoring
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19
Q

How do you manage stable angina?

A

AS(S-ABCDS)

  • A - Aspirin - 75mg OD (If allergic - clopidogrel)
  • S - Sublingual GTN
  • S - Symptomatic:
    • Acei
    • 1st: Bisoprolol, 2nd: CCB (diltiazem/ verapamil)
      • ​3rd: line: ivabrandine/ isosorbide mononitrate (sinus node blocking agent) - can be used for pt with impaired LV function but not to be prescribed with CCB
    • Diabetes
    • Statin
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20
Q

What are some of the causes of non cardiac chest pain

A
  1. Costochondritis
  2. Gastrooesophageal
  3. PE
  4. Pneumonia
  5. Pneumothorax
  6. Psychosomatic
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21
Q

Define stage 1, 3 and severe hypertension

A
  • Stage 1: Clinical BP 140/90 mmHg/ home BP 135/85 mmHg
  • Stage 2: Clinic BP 160/100mmHg/ home 150/95 mmHg
  • Severe: Clinical sytolic >180 or diastolic >110mm
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22
Q

What are some of the symptoms of hypertension

A
  • Nil/ headache
  • Sweating/ headaches/ palpitations/ anxiety - phaeochromacytoma?
  • Muscle weakness/ tetany
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23
Q

What investigations are used for hypertensive emergencies?

A
  • Protein in urine - albumin: creatinine
  • Blood sample
  • Fundi: hypertensive retinopathy
  • ECG
  • Consider echocardiopgraphy
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24
Q

How do you treat hypertension pharmacology

A

Step 1: <55 yo: A, >55/ black any age: C

Step 2: A+C

Step 3: A, C + D (thiazide like diuretic)

Step 4: A, C, D (thiazide like diuretic) + spironolactone (only if K+ < 4.5mmol/L)

Non pharmacological: salt reduction, weight loss, smoking and drinking cessation, exercise

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25
Q

What are the consequences of hypertensive emergencies:

A
  • Immediate end organ damage: encephalopathy, LV failure, aortic dissection, unstable angina, renal failure
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26
Q

What are the triad of symptoms with a phaeochromacytoma?

A
  • Headache
  • Sweating
  • Tachycardia
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27
Q

How are phaemachromacytomas diagnosed

A
  1. 24hr urine collection - metanephrines and catecholamines
  2. CT/MRI of chest abdo pelvis
  3. MIBG scan
28
Q

How are phaechromacytomas treated?

A
  1. Medical Treatment
    • 1st: a blockers: phenoxybenzamine
      • ​2nd: doxazosin
      • B blockers: atenolol/ propanolol
    • Hydration and reduced salt diet
      • CCB (nifedepine)
  2. Surgery: Tumour excision
29
Q

What are some of the causes of HF?

A
  • Ischaemic heart disease
  • Hypertension
  • Valvular heart disease
  • AF
  • Chronic lung disease
  • Cardiomyopayhy
  • Previous chemo
  • HIV
30
Q

What are the differences in symptoms between left and ventricular failure?

A
  • LVF: dyspnoea, poor exercise tolerance, fatigue, orthopnea, PND, nocturnal cough
  • RVF: pulmonary stenosis, lung disease, facial engorgement, raised JVP, peripheral oedeam, ascites, nausea, anorexia. pulsation in face and neck
31
Q

What happens in low output heart failure?

A
  • Low output - CO↓, HR↓, ↑preload and afterload
32
Q

What investigations would you use in HF?

A
  • Bloods: UE, FBC, LFT (hepatic congestion), BNP (<100), trop IT
  • ECG, CXR, echocardiography
33
Q

What are some of the X ray characteristics you would see in HF?

A

ABCDE

  • A: Alveolar oedema
  • B: Kerley B lines/ Bat wings
  • C: Cardiomegaly (>50 cardiothoracic ratio)
  • D: Dilated prominent upper lobe vessels (upper lobe diversion)
  • E: Pleural Effusion
34
Q

How do you treat HF (non acute)?

A

DABS-D-DILATE

  1. Diuretics +thiazide like diuretics - furosemide 40mg/24hr - monitor U+E and for hypokalaemia, if refractory oedema + thiazide like diuretic e.g. metalazone 5-20mg/24
  2. Ace i - angiotensin. Carvediol 3.125mg Or Candesartan.
  3. Beta blockers - start low go slow - carvediol
  4. Spironolactone - 25mg/ 24PO
  5. Digoxin
  6. Nitrates - Isosorbide dinitrate or hydralazine
35
Q

Management of acute HF?

A
  • Pt upright
  • Give oxygen (100%)
  • IV access and ECG monitoring
  • Dimorphine (1.25-5mg)
  • Furosemide (40-80mg)
  • GTN 2 sprays
  • systolic >100 - give nitrate infusion - isosorbide dinitrate

If pt worsens:

  • Another bolus of furosemide 40-80mg
  • Consider CPAP
  • If systolic <100 > cardiogenic > refer to ICU
36
Q

What are the signs and symptoms of aortic stenosis?

A
  1. Dyspnoea
  2. Chest pain
  3. Syncope

Signs: ejection systolic (crescendo-decrescendo) murmur

Diminished S2 sound

37
Q

What are the causes of aortic stenosis?

A
  • Age related
  • Congenital
  • Rheumatic fever
  • CKD
38
Q

How do you assess for aortic stenosis?

A

Echocardiography to assess severity

39
Q

How do you treat aortic stenosis?

A
  • Poor prognosis unless surgery
  • TAVI - Transcathetar aortic valve implantation (from the femoral artery)
    • Long term anticoagulant
40
Q

Where is the murmur heard in aortic stenosis?

A
  • Aortic area - 2nd ICS RHS
  • Radiate to carotids
  • Ejection systolic murmur
  • Radiates to left sternal edge
41
Q

How can aortic regurgitation turn into heart failure?

A

Chronic regurgitation -> assymptomatic –> Î Volume -> Î LV dilatation -> HEART FAILURE

42
Q

What are some of the causes of idiopathic aortic dilatation?

A
  • Rheumatic fever
  • Calcific degeneration
  • Infective disease
  • Infective endocarditis
  • Marfan syndrome
  • Ehlers dahnlos syndrome
43
Q

What are some of the symptoms of aortic regurgitation?

A
  • Weakness
  • Dyspnoea
  • Fatigue
  • Orthopnoea
  • PND
  • Pallor
  • Mottled extremeties
  • Murmur: diastolic
44
Q

How do you treat aortic regurgitation?

A
  • Acei –> reduce LV hypertrophy
  • Surgery
45
Q

How do you work out the rate on an ECG?

A
  • Number of QRS X 6
  • 300/ R-R interval in big squares
46
Q

What are the causes of sinus tachycardia?

A
  • >100:
  • anaemia, anxiety, exercise, pain, hypovolaemia, HF, PE, preggers, CO2 retention, caffeine, adrenaline nicotine, infection
47
Q

What are the causes of Sinus bradycardia: <60:

A

vasovagal attacks, acute MI, drugs (B-blocker, digoxin, amiodorone, verapamil)

48
Q

What are the causes of LAD?

A

LVH, left anterior hemiblock, inferior MI, VT from LV focus, WPW syndrome p120, LVH

49
Q

What are the causes of RAD?

A

RVH, PE, anterolateral MI, WPW, syndrome, left posterior hemiblock (rare)

50
Q

What are some of the causes of AF?

A
  • : IHD**, HT, MI, HF, PE, Mitral valve, pneumonia
51
Q

What are the risks of AF?

A
  • Thromboembolic stroke
  • Haemodynamic instability:
    • MI
    • Tachy/ bradycardia
    • Congestive HF
52
Q

What are the main ECG changes in AF?

A
  • No p waves
  • irregular QRS complexes
53
Q

How do you diagnose AF?

A
  • ECG
  • Bloods: u&e, cardiac enzymes, thyroid function tests.
  • Echo: left atrial enlargement, mitral valve disease, poor lv function, and other structural abnormalities
  • If paroxysmal (intermittent) AF > further cardiac monitoring
    • AliveCor app/ cardiac monitoring (primary care)
  • Unexplained syncope, prolonged cardiac monitoring > refer to cardiology
  • Do not delay anticoagulants!
54
Q

What are the signs / symptoms of AF?

A
  • Asymptomatic
  • Chest pain
  • Palpitations
  • Dyspnoea
  • Faintness.
  • Signs: Irregularly irregular pulse
55
Q

How would you manage acute AF?

A
  • ABCDE > escalate > Emergency cardioversion > +/- AMIODORONE
  • If the patient is stable & af started <48h ago , try rate and rhythm control
    • RATE: bisoprolol or diltiazem
    • RHYTHM: cardioversion or (1) flecainide or amiodarone (if there is SHD)
  • Anticoagulants - LMWH - to keep options open for cardioversion
56
Q

How do you manage (chronic) AF?

A
  • Anticoagulation: DOAC (rivoroxaban, apixiban, edoxaban)
  • Rate control (BCDA): 1: B blocker (bisoprolol), CCB (verapamil), digoxin (then consider amiodorone)
  • DONT GIVE B BLOCKERS AND VERAPAMIL
  • Rhythm control:
    • Cardioversion therapy (if urgent): echo, pre 4 wks amiodorone
57
Q

How do you treat bradycardia post MI?

A
  1. <40bpm/ assymptomatic: nothing, stop drugs (digoxin/ B blockers)
  2. Atropine (0.6-1.2mg)
  3. Temporary pacing wire
  4. Isoprenaline infusion
58
Q

What are supraventricular tachycardias?

A
  • Narrow complex tachycardia
  • >100bpm
  • Arrhythmias depending on AV nodal conduction:
    • AV nodal re-entry tachycardia - AVNRT - 60%
    • Atrioventricular re-entry tachycardia - AVRT - 30%
    • Terminated by blocking AV node conduction
59
Q

How are SVTs treated?

A
  • Vagal manoevres:
    1. Breath holding
    2. Valsava manoevre
    3. Carotid sinus massage: massage non cerebral hemisphere, auscultate for bruits due to risk of stroke
  • Pharmacologically:
    • Adenosine: IV bolus into anti cubital fossa, flush with 0.9% NaCl, 3 way stopcock (6>12>12)
    • Can use synchronised cardioversion - immediately in pt who are hypotensive and have pulmonary oedema
    • 2nd line: CCB (verapamil) (not with B blocker/ LV systolic dysfunction)
    • 3rd line: Flecainide IV (avoid with pt with previous MI)
  • Do note use ve
60
Q

Define a ventricular tachycardia.

A
  • Broad complex tachycardia
  • Common post STEMI
  • QRS >5 ss (>120ms)
  • >100bpm
61
Q

How do you treat ventricular tachycardia?

A
  • Acute: IV Amiodorone (300mg then 900mg in 24 hrs) or IV Lidocaine (50-100mg over 3-5mins)
  • Beta blockers
  • If meds dont work, DC cardioversion (rare)
62
Q

What are the cardiac conditions which predispose you to infective endocarditis?

A
  • Mitral valve collapse
  • Prosthetic valve
63
Q

How is orthostatic hypotension treated?

A

Fludrocortisone

64
Q

How would you manage a hypertensive urgency or emergency?

What is the difference between the two?

A
  • The aim of therapy is to reduce the diastolic BP to 110 mmHg in 3 - 12 hours (emergency) or 24 hours (urgency)
  • Emergency: high BP associated with a critical event: encephalopathy, pulmonary oedema, acute kidney injury, myocardial ischaemia)
  • Urgency : high BP without a critical illness, but may include ‘malignant hypertension’: associated with grade 3/4 hypertensive retinopathy
  1. Sodium nitroprusside
  2. Labetalol
  3. GTN (1 - 10 mg/hr)
  4. Esmolol
65
Q

What are the different types of HB and how do they present on an ECG?

How are they treated?

What are tri and bifascular blocks?

A
  • Type 1 - PR > 0.2s. Can mimic digoxin toxicity
    • No treatment. Check for digoxin toxicity.
  • Type 2
    • Wenkebach: Prolonged PR interval then dropped QRS
      • No treatment.
    • Mobitz T2: Sudden failure of P wave to be conducted to ventricles. Sudden dropped QRS
      • Treatment: pacemaker
  • Type 3: Complete dissociation between P and QRS - check for presence of BBB
    • Causes: digoxin toxicity, STEMI, hyperkalaemia
    • Treatment:
      • Haemodynamically unstable: atropine 600ug-3mg max
      • Severe hyperkalaemia: IV Calcium Chloride 10ml of 10% solution
      • Isoprenaline infusion at rate of 5ug/min
      • Urgent pacemarker within 24h
  • Trifascicular: RBBB, LAD /- prolonged PR
  • Bifascular: alternating LBBB + RBBB

Year 3 Medicine (11 decks)

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