Ax CVS Flashcards
Inferior MI leads
II, III, aVF
How long does troponin takes to be positive
6-8hours
If STEMI within 12 hours of onset of symptoms what to do
Emergency reperfusion therapy by-
Primary percutaneous coronary intervention ( PCI ) ( aka ANGIOPLASTY) or fibrinolytic therapy.
If more than 12 hours - Thrombolytic therapy ( tenecteplase, alteplase,reteplase)
Post MI follow up plan ( 13 components)
How to manage acute limb ischemia
Urgent Endovascular or open surgery is required.
For guidance CT angiography is used. Or MRA if available ( and if both unavailable USS can be used)
What are SVT ecg features
Tachycardia with regular and monomorphic QRS complexes and absence of P waves.
Common symptoms of svt
Palpitations
Dizziness
SOB
Syncope
Chest pain
Fatigue
Diaphoresis
What’s the management of SVT
50yo Asthma, reflux nephropathy, uremia,high creatinine , proteinuria - what’s a the preferred anti hypertensive
Proteinuria and hypertension may benefit from ACE-I and ARB. But they are not given in CKD.
Beta blockers sis an options here but As he has asthma they are contraindicated.
So the best choice is a calcium channel blocker.
Management of decompensated congestive heart failure
Pericarditis ECG changes
Wide saddle shaped ST elevation and PR segment depression.
What’s the management of pericarditis
What’s aortic stenosis murmur
Ejection systolic murmur
Radiating to apex and carotids.
Best heard over aortic /right second IC space area.
Thrills may present.
What’s PDA murmur
Machinery systolic or diastolic murmur
Beat heard at left infraclavicular region
What’s a paidoanurysm and how to manage pseudoaneurysm in femoral artery catheterization?
Paeudoaneurysm- hematoma that forms as a result of leaking hole in an artery.
A hematoma must communicate with artery for it to be considered a paeudoaneurysm
Rx- direct US guided thrombin injection.
What’s thromboembolism prophylaxis for planned DC cardioversion
What are shockable rhythms
VF and pulseless VT
How to manage ventricular tachycardia
What’s the Ecg rhythm of VT
Ventricular muscle depolarizes with high frequency.
Wide and abnormal QRS complex in all 12 leads.
What’s the most appropriate treatment option for venous ulcers of lower limbs
Compression stockings and walking program.
Contraindicated in moderate to severe PAD and in cellulitis features.
Anterior wall STEMI ECG findings
ST elevation in V2-V4
What’s the commonest arrhythmia
AF
Seen in 15% of acute MI patients.
How to manage when MI and AF is present together
Priority goes to MI where of within 12 hours of onset—> either PCI or thrombolysis.
( TPA, alteplase)
AF persisting after reperfusion should be managed accordingly as follows
Then next MOST IMP STEP- give IV heparin and after reaching INR to 2-3 —-> start on warfarin therapy ( anticoagulation)
Which percentage of block in angiography indicates angioplasty/ stenting
Management of symptomatic non sustained wide QRS tachycardia in a child
What’s are features of UEDVT
Vague shoulder and neck discomfort
Pain and discomfort of arm
Non-pitting edema of arm
Extremity cyanosis
Lowe grade fever
Facial edema( if SVC syndrome occurs)
Common locations of UEDVT
Axillary and subclavian veins
Types of UEDVT
What’s SVC syndrome
What’s are 3 murmurs produced by aortic regurgitation
Backflow of blood from aorta into left ventricle during diastole- dastoic crescendo murmur (best heard at L sternal border)
Back flow of blood from aorta—> increased end diastolic L ventricular volume —> causes functional flow murmur during the systole ( beat heard at apex)
Additionally in severe AR , backflow of blood during diastole causes rumbling mid diastolic murmur.
Mitral stenosis murmur
Opening snap after S2 and Rumbling diastolic murmur ( best heard at apex)
Mitral regurgitation murmur
Pansystolic( holosyatolic) murmur radiating to axillary ( best heard at Apex)
How to a manage PEA
Immediate CPR (30:2) —> secure airway and IV access —> IV adrenaline —> look for correctable causes and correct.
Defibrillation has no role in PEA ( bcos organized electrical activity is preserved)
What’s PEA
Organized semi organized ECG rhythm without pulse.
Commonest complication of left ventricular MI
Post MI papillary muscle dysfunction and rupture.
Resulting in mitral valve insufficiency and regurgitation.
Papillary muscle Dysfunction Associated with mildly reduced ejection fraction.. but rupture associated with significant drop in EF.
What’s CHA2DS2VASc score
How to interpret chdsvasc score
Diagnosis of STEMI
Chest pain/discomfort suggestive of acute MI in the presence of ST elevation more than 1mm in two contagious leads or newly developed LBBB.
What’s the role of heparin in AF for theomboprophylaxis
Heparin started initially in conjunction with warfarin and stopped once INR is 2-3 ( therapeutic range )
Does bradyarrhythmias cause high troponin levels
Nope.
But aortic dissection, hypotension, HF, endocarditis , pericarditis, hypertension, blunt chest trauma,PE, ARDS, SEPSIS, severe GI bleeding, stroke, head trauma, diabetes, CKD, hypothyroidism, rhabdomyolysis, burns.
What to do if chadsvasc core is 0
No prophylaxis or low dose aspirin
What’s re 2 most imp investigations in new onset or newly diagnosed AF
Echocardiography and TSH. But they aren’t urgent.
After diagnosis of acute limb ischemia , what’s the guide for urgent surgery
CT angiogram
What are modified wells criteria
What to do if wells score <2
Do d-dimer test.
If positive DVT is only suggestive—> further investigations should be done. If negative it rules out DVT ( and PE)
What’s Bisggard regimen
Conservative management regimen for venous ulcers. Four components.
1. Patient education
2. Elevation of the foot
3. Elastic compression
4. Evaluation.
Elastic compression is contraindicated if -
ABI below 0.8 or if patient is diabetic.
What’s the initial management of DVT
Start injectable Heparin ( IV heparin or S/C LMWH)
Warfarin can be started within 24-48 hours with close monitoring of INR.
Once INR is within therapeutic range ( 2-3) Heparin is STOPPED and Warfarin is continued for 6 MONTHS ATLEAST.
What are risk factors ( if present in the history) for peri operative thromboembolism during hospital stay
What’s the ABI in critics limb ischemia and what’s the next step
Next step is urgent vascular surgical referral for surgery. Otherwise limb necrosis and severe ischemia
Management of peripheral arterial disease
- Smoking ( biggest predisposing factor for PAD) cessation.
- Exercise- on as tolerated basis, improves pain free walking distance
- ACE-I ( particularly RAMIPRIL) improves walking ability.
- Statins - improve revascularization, walking distance and survival.
- Aspirin and clopidogrel- reduce risk of MI and stoke.
Cramping buttock and leg pain for 3 months , pain presents at walking and relived after stopped walking.. wats the work up
Cramping nature and brought on by walking and reliving after rest suggestive of chronic limb ischemia ( buttock claidication) suggestive of common iliac or external iliac artery stenosis.
- spinal cord stenosis - pain by standing and relived by recumbency.
What test is used to monitor heparin therapy
aPTT.
Goal is to keep 1.5- 2.5 times above patients baseline.
From beginning APTT is measured 6 hourly until it reaches 65-100 seconds and then 24 hourly afterwards.
What’s the post embolectomy management of an acute limb ischemia patient
Warfarin therapy for 3-6 months.
Aspirin and warfarin together doesn’t show extra benefits than warfarin Therapy alone. Instead that will increase risk of bleeding.
What’s reperfusion syndrome
Complication of blood restoration to a limb with chronic ischemia
Features-
1. Metabolic acidosis ( lactic acidosis)
2. Elevates creative kinase
3. Hyperkalemia.
4. Myiglobinemia and myoglobinuria
What’s the safe window for surgery in acute limb ischemia
Golden time for surgical intervention is 4 hours, if passes 6 hours it can leave permanent irreversible damage and deficits.
Commonest cause of acute limb ischemia
Thrombotic occlusion
Smoking, CHF, vasculitis etc are only risk factors.
Features of aortic dissection and how to manage
Sudden chest pain radiating to back, widened mediastinum in CXR.
If MI is involved thrombolytics , aspirin , clopidogrel are contraindicated.)
Initial therapy- morphine, beta blockers to maintain BP below 120
Trans esophageal USS to confirm diagnosis. ( If not available - can do CT Angiogram as well)
Mortality risk of rupture if AAA
80-90%
What’s the urgent and easy Ix for ruptured AAA
Bedside USS
Indications for surgical repair of aortic aneurysm (5)
What’s the screening protocol for asymptomatic AORTIC ANEURYSM
Best Ix for AAA
Ultrasound
High sensitivity and specificity
Risk factors of AAA, and does family history affect
First degree relative with AAA has a risk of 20%.
Others- advancing age, male gender, smoking, hypercholesterolemia, DM, chronic hypertension
When to do CT angiography for AAA
When surgery is planned
Hypercalcemia ECG changes
Shortening of QT interval. No QT prolongation
What’s the commonest tachycardia after MI
Ventricular tachycardia.
Commonest in first 24hrs after MI
CF- weak pulse, tachycardia, light headedness ( ventricular fibrillation causes LOC. so it can’t be VF)
Preferred management of AF with HF
Cardio selective beta blockers ( metaprolol, atenolol, carvedilol, bisoprolol) —-> if fails can use digoxin to control rate.—-> if still not controlled amiodarone can be added or used alone.
What are CI for beta blockers (8)
Ecg shows typical delta wave characteristic of pre existing syndrome ( Wolff- parkinson white syndrome)
Although 60 is normal in adults it’s Bradycardia in a 4 yo.
As he has symptomatic bradycardia he should be treated initially with ATROPINE.
What’s third degree AV block
How to manage 3 degree AV block
Even if atropine is the management for symptomatic bradycardias, in complete heart blocks emergency rescue transcutaneous pacemaker is the management of choice.
Atropine is given if emergency peacemaking cannot be done.
How to manage symptomatic Bradycardia
Asymptomatic bradycardia is left alone usually.
Symptomatic bradycardia = bradycardia and
1. Presyncope or syncope
2. SOB
3. Ligtheadedness
4. Chest pain
Management -
1. medical management - atropine ( best) or adrenaline ( second line )
2. Pacemaker insertion - for not responding to medical mx, recent asystole, mobitz 2 AV block, 3rd degree AV block, pulse <40
- initial pacing done percutaneously in ED. Permanent pacemaker inserted with specialist opinion.
MVP is present in upto …… in population.
10%
Which valve problem causes most complications in pregnancy
MITRAL STENOSIS( MS)
Plasma volume increases in 50% during pregnancy—> leads to pronounce LA congestion —> backflow of blood to lungs—> pulmonary congestion ( symptoms- fatigue, dyspnia, oethopnea, PND, pul edema )
What’s diastolic dysfunction and what’s the cause
“Decreased compliance of left ventricle during diastole , resulting in reduced CO”
Main causes- hypertrophied L ventricle due to chronic hypertension ( leading cause) , restrictive cardiomyopathy, constrictive pericarditis.
What’s the mainstay of Rx in diastolic dysfunction
“Heart failure with preserved systolic function)
Mainstay is cardioselectve beta blockers (- atenolol, metaprolol, carvedilol ) and CCBs( can be added to beta blockers later as second line)
Beta blockers by slowing heart rate give more time for ventricles to get filled and enhance CO.
What are contraindicated for diastolic dysfunction
How to manage CHF
Initially ACE-I improve prognosis of all patients in all grades of HF and should use in ALL PATIENTS and initial therapy.
ARB ( Losartan) can be used if ACE-I is not tolerated)
Diuretics are added to control congestive symptoms and signs.
Beta blockers can only be given if EUVOLEMIC AND STABLE.
What’s Kussmal sign
Normal sign - JVP drop during inspiration and elevation during expiration.
Kussmal sign- JVP increase in inspiration and drop in expiration.
Causes-
1. constrictive pericarditis
2. restrictive cardiomyopathy
3. cardiac tamponade.
What’s Budd chiari syndrome
Thrombus formation in hepatic vein, leading to portal hypertension.
May present with hypertension, RHC pain, mild jaundice , hepatosplenomegaly. But JVP is normal.
What are contraindications for thrombolytic therapy in STEMI
Normal intervals in ECG
Is first degree heart block common among elderly, how to manage?
Yes.
Due to age related fibrotic changes.
Asymptomatic patients do not need any management.
If symptomatic ( dizziness, SOB, chest pain) - atropine or pacemaker
How to manage DVT in pregnancy
Should start Therapeutic dose of LMWH for remainder of pregnancy + 6 weeks postpartum. ( minimum of 3 months of treatment should be given )
Prximal DVT- minimum of 6 months treatment.
How to manage PE in pregnancy
Initial choice- UFH ( pregnant of not)
When patient is stable - LMWH
Therapy for 6 months given.
Warfarin in pregnancy ?
Contraindicated.
Could cause warfarin embryopathy.
Cava filters as an alternative can be used in following patients
- DVT or PE in patients with contraindications to anticoagulation therapy -
1. Hemorrhagic stroke
2. Recent neurosurgery or major surgery
3. Major or multiple trauma
4. Active internal bleeding ( GI,hematuria)
5. IC neoplasm
6. Bleeding diathesis ( thrombocytopenia , ITP)
7. Pregnancy.
8.poor compliance with drugs. - DVT OR PE patients with complication of anticoagulation therapy( bleeding)
- failure of anticoagulation therapy.
What’s orthostatic ( postural) hypotension
Drop of SBP in 20 , DBP in 10 or drop of both when the upright position is taken on.
What are the causes of O.hypotension
(.Acute 4 chronic 3)
How to diagnose and work up of O.hypotension
Management of O.hypotension
A. Conservative - increase salt and water intake( not in CHF AND HYPERTENSION)
B. Medical - Fludrocortisone ( helps in sodium retention and volume expansion)
Management of acute pulmonary edema
Features of acute pulmonary edema
Background of CHF
Dyspnea
Bilateral crackles
Tachycardia
Pallor and cold limbs due to hypoperfusion.
What has the most prognostic value in systolic heart failure
JVP and S3 heart sound indicates poor prognosis
Patients with PCI after STEMI, for how long is antiplatelet recommended?
12 months
Which thrombolytic therapy is inappropriate for aborigineal patients
Streptokinase
Bcos they have IgG anti- streptokinase antibody which makes treatment ineffective.
Silent MI is common among
Women, elderly and diabetic.
1/3 of all MIs are silent
Arrhythmias induced by exercise in a young patient who has rapid regular pulse. Possible cause?
Proxysmal supraventricular tachycardia.
VT , Heart blocks and atrial flutter are unlikely in a healthy patient.
A fib has irregular pulse
What’s the commonest cause of ACS
Commonest cause of IHD - arthrrosclerosis or coronary arteries.
Commonest cause of ACS - acute thrombosis
What’s consist of ACS
Unstable angina
NSTEMI
STEMI
They all have same clinical features.
What’s stable angina
Management stops in stable angina
- A stress test - to check stenosis
- If positive ( reproduction of chest pain, ST depression >2mm or drop of BP in >10mmHg) do angiography.
- Ballooning with or without stent placing or CABG.
Causes of shoulder tip pain
What’s sustained VT and how to manage
VT sustained for more than 30 seconds.
If pulse palpable- DC cardioversion.
If no pulse - CPR + defibrillation when ready.
Which drug reverses anti coagulation effect of Heparin
Protamine sulfate
How to diff papillary muscle rupture and dysfunction
In rupture - significant EF drop
In dysfunction - no drop of EF or small drop
What’s the main priority in asymptomatic AF
Prevention of thromboembolism
So
Apply chadsvasc score —> add the anticoagulation type.
How to manage symptomatic non sustained VT in and adult ?
If HD unstable- pulse present- DC cardioversion, if no pulse- defibrillation.
If HD stable(adult)
1. Amiodarone
2. Satolol
3. Lignocaine
