Cardiac Medicine 🫀✅ Flashcards
Two patients who have silent MI
Elderly women and TII DM
Use of Killip Class
Used to stratify risk post MI
Initial therapy for all ACS
MONA (morphine, oxygen if <94, nitrates, 300mg aspirin)
List 5 meds all ACS survivors should be on, and 1 extras they may be on
Aspirin, another antiplatelet (p2y12 inhib), statin, beta blockers, ACEi’s. Maybe nitrate
Antiarrythmics and other meds causing prolonged QT
Amiodarone, sotalol, class 1a’s, macrolides (except clarithromycin), TCAs, antipsychotics, chloroquine
How to investigate and manage Torsades de Pointes
ECG. IV MgSO4
After ACS, when do we give dual vs triple therapy.
Dual for 12 mo, or Triple for 6mo (only if PCI was done)
What is in the dual and triple therapy (following ACS)
Dual: aspirin or cloppy (and) NOAC or VKA = 6mo
Triple: aspirin (and) Cloppy (and) VKA or NOAC = 3mo
NSTEMI or unstable angina identified.
Management ?
MONA, then do GRACE score to determine if PCI best or not
If GRACE score is </=3%. Do what?
Conservative management with Tiggy
GRACE score of >3% and patient hemodynamically stable, do what?
PCI within 72hours, and prasgruel or tiggy, and UFH
GRACE score >3% and patient hemodynamically unstable. mx?
PCI immediately. And prasgruel or tiggy, and UFH
If a patient has a GRACE score less than 4%, yet is hemodynamically unstable… what do we do? (Unlikely scenario)
Do immediate PCI (stability takes priority)
In NSTEMI/unstable angina, when is fondaparinux given?
If PCI not planned
STEM I usually presents with how many minutes of pain
20 or more minutes
In STEMI, we give dual antiplatelet therapy before PCI. Which dual antiplatelet drugs do we use (consider if patient is already taking oral anticoagulant)
If patient already taking oral anticoagulant give clopidogrel and aspirin. If patient not taking oral anticoagulant give prasgruel and aspirin
If a patient has a STEMI, what determines whether they have a PCI or not
If PCI can be done within 120 minutes Then most likely should be done
If cannot do PCI within 120 minutes, what is the alternative treatment for an STEMI
Fibrinolysis And antithrombin
Which anti-platelet should be given alongside PCI
Prasgruel with Pci
Following fibrinolysis, Which antiplatelet should be given
tiggy
Three Cardinal features of angina pectoralis
Constricting discomfort in the chest, precipitated by exertion, relieved by rest or GTN
Pass meds Answer for best investigation for angina (stable)
CT coronary angiography
Aside from normal angina medication all patients should be taking which two medications
Aspirin and statin
What medication can be taken to abort angina attacks
GTN
 Which two medications are considered first line for angina management
CCB and beta blocker
For angina if give CCB and beta blocker together, CCB must be which type
Dihydropyridine
In angina if a CCB is used as monotherapy, which CCB should be used
Verapamil or diltiazem
Cardio respiratory arrest – cardiac arrest. It’s usually down to which four rhythm disturbances
Ventricular fibrillation, pulseless ventricular tachycardia, pulseless electrical activity and asystole
Which investigations are important for cardiac arrest
Continuous cardiac monitoring. Then consider full blood count, electrolytes, ABG, x-ray, toxicology. Aside from ECG, this is all done after Mx
Management of cardiac arrest
ABCD, CPR (30 compressions then 2 breaths) for 5 cycles. Defib is shockable rhythm… recall
If defib doesn’t work for pulseless ventricular tachycardia/Vfib… can give what?
Amiodarone or Lidocaine
Best two invx for suspected endocarditis
Blood cultures and echo
Empirical antibiotics for endocarditis:
1. If native valve
2. If native valve but penicillin allergic
3. Severe sepsis
4. prosthetic valve
- Amoxicillin (+/-) low dose gentamicin
- Vancomycin and low dose gentamicin
- Vancomycin and low dose gentamicin
- Vancomycin and low dose gentamicin and rifampicin
Treatment of native valve staphylococcus endocarditis
Flucloxacillin (of vanco and rifampicin if penicillin allergic)
Prosthetic valve endocarditis due to staphylococcus treatment
Flucloxacillin and rifampicin and low dose gentamicin (vanco and rifampicin and low dose gentamicin if penicillin allergic)
Endocarditis due to fully sensitive strep (treatment)?
Benzylpenicillin (vanco and low dose gentamicin if allergic)
Endocarditis due to more resistant strep (treatment)
Benzylpenicillin (and a low dose gentamicin)
“Ben went to sRepton”
Monomorphic VT usually due to…
MI
Polymorphic VT usually due to what…
Prolonged QT
What do you see on an ECG in VT?
Wide QRS, regular rhythm, no p wave, and more than 100 bpm. And for >120ms
When do you cardiovert a patient with VT?
If patient has adverse signs, like SBP < 90, chest pain, HF
If a patient with VT presents, and has no ‘adverse signs’, how do you manage?
Antiarrythmics. Amiodarone IV is good, lidocaine ok (not if left Vent impaired), never Verapamil. If this doesn’t work, then can cardiovert
More than how many PVCs in a row = vent tachycardia
3
First Invx for VT and VF
ECG
Management for Vfib
Defib, and then an implantable cardioverter defibrillator (ICD)
Main risk factor for TdeP
Prologued QT
If suspect HF, do what Invx?
BNP
If BNP is high in suspected HF patient, do what to further Invx?
Trans thoracic echo
Management of acute HF (clue = like pulmonary edema)
IV furosemide, O2, vasodilators (unless hypotension), CPAP. And continue regular chronic HF meds
First line Invx for chronic HF patient
BNP
First line treatment (regime) for Chronic HF with preserved ejection fraction
ACEI and Beta Blocker (can add aldosterone antag. If still symptomatic)
Good add on for HF patients (black patients)
Hydralazine and nitrates
If cannot have Beta blocker in HF therapy… what can be used as a substitute
Ivabradine
If a patient with HF has widened QRS on ECG… how do you treat
Needs cardiac desynchronisation
HF patients Vx schedule
Annual influenza and one off pneumococcal
If intolerant to ACEI for HF management, use what?
ARB
If ACEi BB spirino are given for HF, and symptoms persist. Do what?
Replace ACEI with ARNI
If ACEi BB spirino are given for HF, and symptoms persist, whilst heart rate above 75. Do what?
Add ivabradine
Best investigation for pulmonary edema to find cause?
ECG (maybe)
investigations for pulmonary edema
Chest x ray (recall signs), ECG, oxygen, ABGs, BNP
Management of acute pulmonary edema
Oxygen with venturi, diuretics, morphine, nitrates
Considered high blood pressure
140/90
How to confirm diagnosis of hypertension
24 hour blood pressure monitor.
Why do we need to do and ECG in hypertension patients
Check for left ventricular hypertrophy or IHD.
Why should a urinalysis be done in patients with hypertension
To check for hypertensive renal disease
Stage 1 hypertension is?
> = 135/85
When do you treat stage 1 hypertension?
Treat if less than 80, and if there is target organ damage, CVD, renal disease etc
Most effective lifestyle change to decrease hypertension risks
DASH diet
What is stage 2 hypertension
> = 150/95
Do we always treat stage 2 hypertension
Yes
If a patient aged <40 presents with hypertension, what should be done/considered
Consider 2° hypertension and thus refer to specialist
Patient less than 55. Best drug for hypertension
ACEi
Patient over 55, best drug for hypertension
CCB
Black patient with hypertension. Best treatment?
CCB
Patient with T2 DM history. Best treatment
ACEi
If patient cannot tolerate ACEi cough, give???
ARB
4 first line treatments for hypertension
ACEi, ARB, thiazide, CCB
If patient on CCB, ACEi, thiazide (step 3), and K+ is less than 4.5. Can add what?
Low dose spirinolactone
If patient on CCB, ACEi, thiazide (step 3), and K+ is more than 4.5. Can add what?
Alpha or beta blocker
Black patient on CCB for hypertension, and needs step up. Give what?
ARB!
First degree heart block treatment?
NO treatment needed
PR interval has to be >? Seconds (>? Small squares) in first degree heart block
> 0.2 Seconds (>5 Small squares)
Complete heart block is often due to what? (Related to MI)
RCA occlusion
Best invx to confirm heart blocks
ECG of course
Indications for pacemaker in heart block
Usually, 2°M II, and 3°. Or if symptoms severe (symptoms of respiratory acidosis )
WPW syndrome risk for what arrhythmia
VF
WPW is a type of ______ tachycardia
AV re-entrant tachycardia
3 findings of WPW on ECG
Short PR, delta wave, axis deviation (opposite to the pathway involved)
Definitive treatment for WPW
Radiofrequency ablation
Medical therapy for WPW? (First line). Then if you cannot use the first line?
That’s sooooo WPW. Sotalol (don’t use if Afib present).
Amiodarone and flecainude second line
More than __ ms (or __ small squares) is a long QT
440 ms or 10 small squares
Long QT can cause what arrhythmias
Torsades, VT or VF
Jervell Lange nielsen vs Romano ward
Jervell has deafness. Both are due to mutated potassium channels causing LONG QT
Investigation for long QT
ECG, echo, holster monitor, genetics test, electrolytes
Sotolol in prolonged QT?
No! Can prolongue it more
Management and treatment for prolonged QT
Avoid QT prolong drugs, avoid strenuous excserize; and ICD for high risk case
When do we give anticoagulant in AF. First line anticoagulant for AF? Why?
If CHADS VASc score says so. DOAC (apix, Dabi, edox, rivarox.) don’t need INR monitoring.
If patient has AF, and is stable. What meds should be given
Beta blocker or CCB (rate control) and a DOAC if CHAD VASc suggests to
When is cardioversion needed in AF
If patient is unstable
If the patient needs anticoagulant for AF, and has a valve disease. 1st line?
Warfarin
CHA2DS2 VASc stands for? Used for?
CHF, HTN, age > 75, diabetic, stroke history, vascular disease, age 65-74, Sex.
To assess need for anticoagulant I’m AF patients
CHADS VASc of 1 or more in man means?
Needs anticoagulant
CHADS VASc of 2 or more in woman means?
Anticoagulate
If patient has AF, and want to cardiovert. Started less than 48 hours ago. Do what?
Cardiovert .
Don’t worry about anticoagulating them first
If patient has AF, and want to cardiovert. Over 48 hours has elapsed. What options do we have to manage
Either anticoagulate patient for 4 weeks, then cardiovert. Or do transesophageal echo to check for thrombi in the atrial appendage
Paroxysmal AF definition
AF that terminates itself and lasts less than 7 days
Persistent AF, definition
Arrhythmia not self terminating and episodes last long than 7 days
Permanent AF, definition
Continuous AF, that cannot be cardioverted. Accepted as the final rate
Is the R-R interval regular in Afib or A flutter
A flutter
A flutter patient who is stable. Management?
Beta blocker or CCB
If want to ablate in A flutter, where to do this?
Tricuspid isthmus
If want to ablate a patient with a fib, where to do this?
Confluence of the pulmonary veins
Is a flutter more or less sensitive to cardioversion?
More, so can use lower energy levels
Difference between Afib and SVT
SVT is regular and has p waves (may be hard to see though).
Is supra ventricular tachycardia narrow or broad complex?
QRS is narrow
SVT 1st line management?
Carotid sinus massage or valsalva
Second line for SVT management. Tell me doses too
IV adenosine (6mg, then 12mg, then 18mg) (if the pervious didn’t work). if asthmatic, give verapamil instead
If patient had SVT and is unstable. How do you manage
Cardiovert
If you have a patient with SVT that is persistent to medical therapy. How do you manage?
cardioversion
How to prevent episodes of SVT
Beta blocker
Initial invx important for myocarditis suspicion
ECG (new ST and T wave changes), venupuncture for MB, troponin, BNP (all elevated), MRI is good!
Gold standard for Dx of myocarditis
Endomyocardial biopsy. MRI not bad either
Kaussmal sign is more seen in restrictive pericarditis or tamponade
Restrictive pericarditis
Pulses paradoxus is more seen in restrict pericarditis or tamponade
Tamponade (but technically both)
ECG changes for pericarditis
Saddle shaped ST elevation, in all leads. PR depression (sensitive)
All patients with suspected acute pericarditis, should have what invx done? (Aside from ECG)
Echocardiogram
First line and second line for pericarditis
NSAIDs and Colchicine
When should a pericarditis patient be hospitalised
Fever > 38°C
• Subacute onset
• Anticoagulated
• Immunocompromised
• Hypotension
• Jugular venous
distension
• Large effusion
(many signs of tamponade)
Mild mitral stenosis management
Diuretics
Moderate to severe mitral stenosis management
Valuable repair/ or valvotomy
To diagnose most/all valvulopathies, which invx should be done
Echo
Management of mitral valve prolapse
Antiplatlet therapy (aspirin) and mitral valve repair
Most common valve disease
AS (second is MR)
Potential ECG and X-ray findings in MR patients
Broad P wave (due to atrial enlargement). And cardiomegaly
Acute mitral regurgitation, management
Nitrates (increase forward flow), diuretics (decrease overload), inotropes, aortic balloon pump. Heart failure meds if the patient is in heart failure
Is repair or replacement better for MR
Repair
Aortic stenosis, asymptomatic patient. Valve pressure gradient <40. Mx?
Observe
Aortic stenosis, asymptomatic patient. Sign a of systolic dysfunction and Valve pressure gradient >40. Mx?
Consider Sx
Aortic stenosis, symptomatic patient. Mx?
Sx
What disease commonly coexists with AS? And thus prior to surgery, what can be done
CVD! So do an angiogram before Sx. Can combine surgeries
Best Sx for AS?
TAVI. Recall who gets metallic vs porcelain?
When do balloon valvuloplasty for AS?
If severe and cannot do replacement
Acute aortic valve regurgitation Mx
Emergency! Need to replace valve, but give inotropes and vasodilators first though
Chronic/asymptomatic AR Mx
Vasodilation (reduce the regurgitate)
Is WPW associated with HCM?
Yes!
What can be seen on the echo of a HCM patient? And an ECG?
MR, systolic anterior motion (SAM) of the anterior mitral valve, asymmetrical septal hypertrophy. Mega sokolovs seen on ecg
Why avoid nitrate, ACEI and inotropes on HCM?
All decrease preload and thus LVEDV (increases outflow obs)
How do you treat dilated cardiomyopathy?
Treat like HF (ACEI, beta blocker, diuretic
Important invx in shock patients
ABG (get lactate), BP monitoring, glucose,
Management of septic patient OU CALF
Oxygen admin (keep above 94), Cultures taken, Abx broach spec, Fluid resus (bonus 500ml crystalloid over less than 15 mins), Lactate measurements, Urine output hourly
Anaphylaxis management
Adrenaline (IM in thigh)
How many cm greater than normal aorta diameter is considered aneurysmal ?
3cm or more
Main risk factors for AAA
Smoking, HTN, atherosclerosis (not DM)
First line invx for AAA
US
Best invx for AAA
CT angio
How to manage a stable patient with AAA
CTA to assess suitability for endovascular repair.
How to manage an unstable AAA case?
Straight to theatre (Dx is clinical)
Suspected Tamponade. 2 Invx to do?
ECG and echo
A management of tamponade
Pericardiocentesis
Murmur for ASD
Ejection systolic murmur, and fixed split S2. Smaller ones are louder
Small ASD (pulm BF : systemic BF <1.5) Mx
No Tx needed
Large ASD (pulm BF : systemic BF >1.5) or rt atria enlarged Mx
Corrective closure
Murmur for VSD
Pansystolic murmur (louder=smaller)
Main consequence of large VSDs
Heart failure in months
Small asymptomatic VSD management
Close spontaneously usually… so monitor only
Treatment or larger VSDs/symptomatic VSDs
Surgical correction, and HF meds
S3 on <30 yo. Are you alarmed?
Not really, this is a normal finding here
Mild pulmonary stenosis treatment?
Follow up only
1st line treatment for moderate to severe pulmonary stenosis
Balloon valvuloplasty
Pulmonary stenosis patient who is cyanotic. What Medical management should he get?
Oxygen and PGE1. Even before diagnosing cause
If percutaneous balloon pulmonary valvuloplasty doesn’t work for patients with pulmonary stenosis… what can we do next
Surgical valvotomy
When do we do surgical repair for AR
If symptomatic or with LVEF of <50%
How can we medically delay surgery for AR patients
Vasodilator therapy
Signs of PDA
Parasternal systolic murmur becoming a continuous machine like murmur supraclavicularly.
Subclavicular thrill and collapsible pulse
Therapy to close a PDA
Indomethacin
When do you give PGE1 in PDA
If you want to keep the PDA open (maintain shunt)
Invx of choice for coarcted aorta
Echo to see the coarction. But best to do blood pressure measurements and radio femoral delay
A radio femoral delay of what or more, is concerning?
20mmHg
Transposition of the great vessels main risk factor
Maternal diabetes
Management of ToGVs?
PGE to keep PDA, then Sx
Tetralogy of fallout invx
Chest X-ray (boot), ecg (RV hypertrophy), echo
Medication to relieve cyanotic episodes in tet of fallot
Beta blocker
Examination sign for PAD
Absent dorsalis pedis and posterior tibial.
ABPI less than X, indicates PAD
1
ABPI < 0.5…. What does this mean?
Severe PAD, and needs urgent attention
Best invx for PAD
Doppler US
Edema, brown Pigmentation, eczema. These are all features of what kind of ulcer
Venous ulcer
Painful ulcers, with cold feet, no palpable pulses, low ankle brachial pulse index. These are features of ulcer
Arterial ulcer
Callous formation, ulcers on the plantar surface of the metatarsal head. Loss of sensation. These are features of what
Neuropathic ulcer ulcer
An ulcer above the ankle near the medial malleolus is most likely seen in which ulcer
Venous ulcer
Painful ulcers in the toes and the hill I’ll most likely scene in which ulcer
Arterial ulcer
Deep venous insufficiency is related to what other pathology
DVT
Superficial venous insufficiency is associated with which pathology
Varicose vein
What can be seen on ultrasound Dr , for venous leg ulcers
Reflux of blood
Management for venous leg ulcer
Four layer compression banding
Main management for neuropathic ulcers
Cushion shoes to reduce also formation
Two main causes of gangrene (two types of gangrene)
Infectious gangrene and ischaemic angry
What to tell you if the gangrene is ischaemic rather than infectious
A low ankle brachial pulse index
If a patient has gangrene and a low-grade fever and chills, is this likely ischaemic or infectious gangrene
Infectious
How to manage infectious gangrene
Aggressive surgical debridement and IV antibiotics
How to manage ischaemic gangrene
Revascularisation and treat the underlying disease
Diagnosed DVT, first line treatment
DOAC (apix or ribarox)
DVT suspected? Treatment?
DOAC! (Used to be heparin)
DVT patient, and cannot treat with DOAC
LMWH, followed by Dabigatran or Warfarin
Patient had anti phospholipid syndrome… and has DVT. How to Tx?
LMWH then warfarin
Anticoagulant for how long in unprovoked DVT?
6 months
Anticoagulant for how long in provoked DVT?
3 months
Which scores -2 on wells score?
Alternative diagnosis is more likely than DVT
Name as many scores on Wells
Wells of X or more, suggest DVT likely
2 or more
If Wells score of two points or more, next step management
Do proximal leg ultrasound within four hours. If cannot be done do d-dimer plus anticoagulation plus ultrasound within 24 hours
If a patient with a Wales score of two or more, has a negative proximal leg ultrasound, what investigation should be done next
Demon
If a patient has a wells score of one or less (for DVT ). Next step in management for patient
Do a D dimer within four hours
If a patient had a wells score of one or less and DD dimer came back positive, what should be done next
Proximal leg ultrasound
If patient had a Wells score of two or more, had a negative proximal leg ultrasound, but a positive D dimer. What should be done in this patient
Stop anticoagulation and repeat ultrasound in one week
An ankle brachial pulse index of 0.6-0.9 coincides with what symptom
Intermittent claudication
An ankle brachial pulse index of 0.3-0.6 coincides with what symptom
Pain at rest
If a patient presents with signs of acute limb ischaemia what investigation should be performed, and what should be calculated
Doppler ultrasound, and ankle brachial pulse index
Patient presents with acute limb ischemia. They have history of widespread vascular disease, and a history of claudication that has now suddenly deteriorated. Is it likely thrombus origin for embolus origin
Thrombus origin
Patient presents with acute limb ischemia. They have no history of claudication, no history of peripheral vascular disease but a recent atrial fibrillation. Is this likely thrombus origin or embolus origin
Embolus origin
Initial management for acute limb ischaemia
ABC, IV opioids, IV unfractioned heparin (chubby guy was right)
Some definitive management for acute limb ischaemia
Thrombolysis, embolectomy, angioplasty, bypass surgery, amputation if irreversible
First line investigation for chronic limb ischemia
Ultrasound with the Doppler
Aside from ultrasound, which investigation must be done prior to treatment for chronic limb ischaemia
Magnetic resonance angiography
What antiplatelet therapy can be used for chronic limb ischaemia
Aspirin or clopidogrel
In aortic dissection what does anterior versus back pain signify
Backpain signifies descending aorta dissection, anterior chest pain signifies ascending aorta dissection
Diagnosis of an aortic dissection is made by what (if patient is stable)
CTA
Definitive treatment for coarctation of the aorta
Angioplasty or surgical resection
If an aortic dissection patient is unstable, how do you investigate them
Trans-oesophageal echo, cannot do CT Angio in unstable patience
Investigation of choice for varicose veins
Ultrasound with Doppler, Can see venous reflux
Majority of patients do not require surgery for varicose veins. Name some conservative treatments
Leg elevation, weight loss, exercise, compression stockings
Name five reasons for referral to secondary care in varicose vein patients
Significant pain or swelling, previous bleeding, skin changes, thrombophlebitis, healed or active ulcer
Name three invasive treatments for varicose veins
Foam sclerotherapy, location or stripping surgery, and a thermal ablation using laser
NSAIDs for myocarditis?
NO, CI
Ischemic gangrene Mx if not too bad
Heparin
Ischemic gangrene with threatened non viability
Revasc
DVT stuff. What is the timeframe for doing dopplers and d dimers
stable patient with aortic dissec… invx?
CTA
unstable patient with aortic dissec… invx?
TOE
A flutter (how to tell?)
regular RR!! Can be hard to tell from afib and heart block
Troponin time frame
Rises in 2-4 hours. Falls after weeks
CK-mB time frame in MI
Rises in 4-6 hours. Falls after 48 hours
Mx for shockable cardiac arrest
shock, 2 mins CPR…. repeat. Do epinephrine after 3 shock
Mx for non-shockable cardiac arrest
adrenaline, 2 mins CPR…. repeat
HF patient. On ACEi, BB, Aldo antag. HR below 75… give what?
ARNI
HF patient. On ACEi, BB, Aldo antag. HR above 75… give what?
Ivabradine
HF patient. On ACEi, BB, Aldo antag. Black patient… give what?
hydralazine and nitrate
At what EF, does HF pharmacy start
around <40
When to focus on rate control only in AF?
Chronic/permanent A, patient stable
First onset stable AF, how to Tx?
Rhythm control = flecainide 1st (amiodarone 2nd)
Best invx for takutsobu
ventriculography
ABPI calc
ankle/brachial SBP
How long is the ischemic clock in acute limb ischemia?
6 hr
Difference between acute limb ischemia in femoral, iliac, aortoiliac
Afib vs 3rd degree AV block
p wave in 3rd degree. tachycardia in afib
myocarditis Mx
rest and monitor
HF with <35% EF… do what?
do angiogram to see if ischemic CM or not
NSAIDS or CCB in HF?
NO
When to thrombolyse patient with PE
if patient has low BP
severe AS in older patient… best Tx
TAVI
if patient with NSTEMI has HF, or low BP, or VT, or ongoing angina….. sign to do what?
angiogram and PCI to be done sooner! (all our GRACE)
if NSTEMI patient has good EF/heart function… what to do
conservative (tiggy and fonda)
when to do medical cardioversion in AF
in first 48 hours!!!
Weird ECG is likely what??
3rd degree
if do echo on patient with pericarditis… see fluid… what to do?
measure fluid then drain if large or tamponade
