Cardio Flashcards
Broad complex tachycardia, BP 88/59, Rx?
DC cardioversion
If systolic BP <90 in tachyarrhythmia then DC cardioversion
When is a patient classified as stable or unstable in the context of tachyarrhythmia?
Unstable if any of the following adverse signs:
- Shock (systolic BP <90, pallor, clammy, confusion, impaired consciousness)
- Syncope
- Myocardial ischaemia
- Heart failure
If any of the above are present then give synchronised DC cardioversion. Rx following this is dependent on if it was broad or narrow complex, and if it was regular or irregular
What are potential causes of a broad complex tachycardia with regular and irregular rhythms?
What are their treatments (if stable)?
Regular:
- Assume VT - amiodarone (300mg loading dose then 900mg over 24 hours)
- SVT with BBB - treat as per SVT
Irregular:
- AF with BBB - treat as per narrow complex tachycardia
- Polymorphic VT (torsades de pointes) - IV Magnesium
Potential causes of narrow complex tachycardia with regular and irregular rhythms?
Treatments?
Regular:
- SVT - vagal manoeuvres then IV adenosine
- If unsuccessful, consider atrial flutter and control rate
Irregular:
- Probably AF
- If onset <48 hrs consider electrical/chemical cardioversion
- Rate control (B blocker/Digoxin) and anticoagulation required
Treatment of acute native valve endocarditis?
IV Flucloxacillin 2g 6 hourly
Treatment of subacute (indolent) native valve endocarditis?
IV Amoxicillin + Gentamicin
Treatment of prosthetic valve endocarditis or suspected MRSA?
IV Vancomycin + Gentamicin + PO Rifampicin
4 common bacterial causes of endocarditis and their associations?
Staph Aureus - most common, IVDU
Staph epidermis - peri-operative, <2 months post-op
Strep Viridans - dental procedures
Strep Bovis - colorectal cancer
5 causes of culture negative endocarditis?
Previous antibiotic therapy Coxiella burnetti Bartonella Brucella HACEK (haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
common drugs which prolong QT interval?
Antipsychotics (mainly typical) Type 1a, 1c and 3 arrhytmatics Tricyclics Other antidepressants (citalopram, moclobemide etc) Loratadine Hydroxychloroquine Macrolides (clarithromycin)
How to tell between aortic stenosis and sclerosis?
Aortic sclerosis doesn’t radiate to carotids and has normal ECG
What 2 scenarios is cardioversion used in AF?
When should you offer rate/rhythm control?
Haemodynamically unstable - electrical
Electively where rhythm control strategy preferred - electrical or chemical
Offer rate/rhythm control if onset <48 hours
Offer rate control if >48 hours
Management of haemodynamically stable AF onset <48 hours?
Heparinise patient, then cardiovert
Electrical - synchronised DC OR Pharmacological: - Amiodarone if structural heart disease - Amiodarone/Flecainide without
If no other risk factors for ischaemic stroke, further anticoagulation unnecessary. If present, oral anticoagulation for life
Management of haemodynamically stable AF onset >48 hours?
Rate control and anticoagulation for at least 3 weeks.
If recurrent AF or previous cardioversion failure, amiodarone/sotalol for 4 weeks.
Electrical cardioversion
Anticoagulation continued for at least 4 weeks after - decision on continuation based on risk factors
Drugs to control rate in AF?
Bisoprolol
Verapamil/Diltiazem
Digoxin - normally not preferred, but 1st choice if co-existing heart failure as positive inotropic effect
Drugs to maintain sinus rhythm in Hx of AF?
Amiodarone
Sotalol
Flecainide
Factors favouring rate (2)/rhythm (4) control strategy in AF?
Rate - age >65, Hx of IHD
Rhythm - age <65, symptomatic, first presentation, CCF
Stroke risk score in AF?
CHA2DS2VascS
C - congestive HF H - hypertension A - age 75 or above = 2 age 65-74 = 1 D - diabetes S - stroke or TIA (previous) = 2 V - vascular disease (IHD/PVD) S - sex (female)
0 = no anticoagulation
1 = males consider anticoagulation
females don’t (they got this score from their sex)
2 = offer anticoagulation
When is catheter ablation used in AF?
What medication must the patient take beforehand?
What does it do to stroke risk?
3 complications?
Failure to respond to cardioversion, or wish to avoid antiarrhythmatics
Anticoagulants for 4 weeks minimum beforehand
Whilst ablation might restore to sinus rhythm, it doesn’t reduce stroke risk
tamponade, stroke, pulmonary valve stenosis
How do thiazides cause hypokalaemia?
They block Na/Cl co-transporter in DCT, so more Na reaches collecting duct
More K lost in collecting duct as a result
Side effects of thiazide-like diuretics, such as indapamide and chlortalidone?
Same as thiazides
Hypokalaemia/Hyponatraemia Hypercalcaemia Gout Postural hypotension Impaired glucose tolerance Impotence
Rarely: agranulocytosis, pancreatitis, thrombocytopenia, photosensitive rash
Hypertension ladder?
1:
<55 OR T2DM - A
55+ or black, no T2DM - C
2: A+C or A+D
3: A+C+D
4: If K+ 4.5 or less - spironolactone
If K+ >4.5 B-blocker or A-blocker
5: Specialist
What tests should be done before starting amiodarone?
Monitoring after this?
TFT, LFT, U&E, baseline CXR
TFT and LFT every 6 months
Blood pressure targets for clinic and ABPM for someone:
<80 y/o?
>80 y/o?
<80:
clinic - <140/90
ABPM - <135/85
> 80:
clinic - <150/90
ABPM - <145/85