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Phase 2CARDIORESP > Cardio > Flashcards

Cardio Flashcards

1
Q

ECG timings

A

PR - 0.12-0,2 secs
QRS - 0.1s
QT interval - 0.4 secs
QTc - <450ms

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2
Q

Causes of PR interval shortening and lengthening

A

• Shortening - WPW syndrome

Lengthening - beta blockers, type 1 heart block, fit pt

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3
Q

What is the timing of the ECG squares?

A

• Small square = 0.04 seconds

Large square = 0.2 seconds

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4
Q

State the arteries of the leads on ECG

A

I, aVL, V5, V6 - LCx or diagonal branch of LAD (lateral)
V1-V4 - LAD (anterior)
II, III, aVF - RCA or LCx (inferior)

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5
Q

Sequence of evolving MIs on ECG?

A
  1. In minutes - ST elevation and T wave bigger
    1. Hours - R wave begins to decrease and Q wave begins to deepen
    2. 1-2 days - T wave inverts and Q wave deeper.
    3. Days later - ST normalises
    4. Weeks later - normal except for Q wave persistence
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6
Q

How would posterior MI present on ECG?

A

Reciprocal changes - ST depression

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7
Q

ECG changes for NSTEMI?

A

• ST segment depression
• T wave flattening or depression
NSTEMI is more persistant than UA

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8
Q

How can you clinically differentiate between unstable angina and NSTEMI?

A

NSTEMI - ELEVATED BIOMARKERS. UA NO ELEVATION

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9
Q

ECG changes for pericarditis?

A

Widespread ST elevation with saddle back shape

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10
Q

ECG changes for pace makers?

A

paceing spikes before QRS.

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11
Q

ECG changes for wandering pacemeker? Patho of wandering pacemaker? Pts who get it?

A

• Atrial arrhythmia where cardiac pacemaker switches between SAN, atria, and AVN
• Pts with resp failure eg exacerbation of COPD
Varying PP and PR intervals. 3 distinct P wave morphologies in the same lead

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12
Q

Causes of long QT

A

• Antiarrhythmics - amiodarone, sotalol
• TCAs
• Erythromycin and azithromycin
Electrolyte - hypocalcemia, hypokalaemia, hypomagnesaemia

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13
Q

Patho of WPW

A

• Congenital accessory conducting pathway leading to atrioventricular re-entry tachycardia (AVRT)
Can degenerate rapidly to VF

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14
Q

ECG changes for WPW

A

• Short PR

Wide QRS complex with delta wave - slurred upstroke

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15
Q

Tx of WPW?

A

• Ablation of accessory pathway - definitive

Medical management - sotalol (avoid if AF), amiodarone, flecainide

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16
Q

Hypokalaemia on ECG?

A
  • U waves
    • Small or absent T waves
    • Prolonged PR interval
    • ST depression
    • Long QT

“In hypokalaemia, U have no Pot and no T, but a long PR and a long QT”

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17
Q

Hyperkalaemia on ECG?

A
  • Flattened P waves
    • Widened QRS
    • Tall tented T waves
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18
Q

ECG changes for hypothermia?

A
  • Bradycardia

* J wave - size of wave is proportional to hypothermia

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19
Q

ECG changes for digoxin?

A
  • Downsloping ST depression
    • Flattened, inverted or biphasic T waves
    • Shortened QT
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20
Q

Acute tx for STEMI?

A

Acute Treatment (MONA):
• M - Morphine + metoclopramide
• O - Oxygen (if O2 <94%)
• N - Nitrates (if hemocompromised DO NOT USE)
• A - Antiplatelets (aspirin + prasugrel)

Is PCI available within 120 mins?
a. Yes - pci
No- Fibrinolysis (tPA) with rescue PCI if not successful

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21
Q

ECG indications for PCI for STEMI

A

• ST elevation of >2mm in V1-V6 OR
• ST elevation of >1mm in inferior leads OR
New left bundle branch block

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22
Q

Post MI tx?

A 
• Lifelong therapy of:
		○ Aspirin
		○ Antiplatelet eg clopidogrel
		○ Beta blocker
		○ ACEi
		○ Statin
	• Lifestyle advice:
		○ Mediterranean diet
		○ Exercise - until slight breathlessness
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23
Q

PCI contraindications?

A 
• Due to antiplatelets
	• High risk of bleeding
	• Allergy 
	• Uncontrolled HT
	• Stroke 
Bleeding disorders
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24
Q

Acute tx of NSTEMI?

A
  1. Morphine +anti emetic (metoclopromide) + GTN (don’t use if hemocompromised)
    1. Antiplatelets - aspirin (300mg PO) + clopidogrel
    2. Beta blockers to limit ischemia (metoprolol) or verapamil if contra
    3. Fondaparindux to disrupt thrombus
    4. IV nitrate if pain continues
    5. Record ECG and stratify risk using GRACE + TIMI
      a. High risk - infusion of GPIIb/IIIa antagonist + angiography referral
      b. Low risk - Treat medically and arrange further investigation eg stress test
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25
Q

Pathology of STEMI/atheroma?

A
  1. Initial endothelial damage caused by smoking, HT, or hyperglycemia etc
    1. Results in inflammation and oxidative damage
    2. LDL particles infiltrate subendothelial space
    3. Macrophages infiltrate and phagocytose LDL and turn into foam cells. Macrophages die and propagate inflammation
      Smooth muscle proliferation and migration into tunica intima results in formation of fibrous capsule covering fatty plaque
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26
Q

IHD RFs modifiable and non modifiable

A 
HOPEFULS
H - HTN
O - Obesity
P - PVD
E - Elevated LDL
F - FHx
U - Up glucose (DM)
L - Low HDL
S - Smoking, Sex (male), Sedentary
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27
Q

S&S of ACS

A 
Chest pain:
	• Typically central or left sided
	• May Radiate to jaw or left arm
	• Described as heavy or constricting
Certain pts eg elderly or diabetics may experience no CP

Other symptoms:
• Dyspnoea
• Sweating
N&V

Examination:
• Cold and Clammy
All life signs may be normal

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28
Q

Diagnostic criteria for ACS?

A

2 of 3 needed:
• Clinical history
• ECG changes
Blood results

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29
Q

Ix for ACS?

A

ECG

Bloods - troponin

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30
Q

S&S of stable angina

A

• Chest pain on exertion

Relieved by rest or GTN spray

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31
Q

What must you remember about CCBs and why?

A

NEVER EVER MIX 2 TYPES OF CCB - causes complete heartblock

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32
Q

Ix for stable angina?

A

• ECG Exercise tolerance test shows:

ST depression

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33
Q

Tx for stable angina?

A

1st line - bisoprolol + aspirin + statin + glyceryl nitrate
2nd line - + CCB (nifedipine, amlodopine)
3rd line - + long acting nitrate or ivabradine
4th line - ? PCI or CABG

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34
Q

S&S of unstable angina

A

• Pain on exertion NOT relieved by rest

NO elevated serum biomarkers

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35
Q

Complications of MI?

A
  1. Cardiac arrest following V fib
    1. Cardiogenic shock
    2. Chronic heart failure
      Arrhythmias
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36
Q

Qs to ask for cardiac history

A

• Chest pain - Does it hurt to touch? MSK likely.
• SOB
• Dizziness and syncope?
• Palpitations - abnormality in heartbeat causes conscious awareness
• Orthopnoea or PND?
Peripheral oedema

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37
Q

S&S of pericarditis pain

A

Sharp pain relieved by sitting forwards.

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38
Q

S&S of dissecting aortic aneurysm pain

A

Tearing chest pain radiating to back

Unequal upper limb blood pressure

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39
Q

Angina S&S and features of typical + atypical angina

A

Angina symptoms:
• Constricting Discomfort in front of chest, neck, shoulders, jaw or arms
• Precipitated by exercise
• Relived with rest or GTN in about 5 mins

All 3 features is typical angina. 2 features is atypical. 1 or less is non angina.

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40
Q

Chest pain referral criteria

A

• Current CP in past 12 hrs with abnormal ECG - Emergency admission
• CP 12-72 hrs ago - Refer to hospital for same day assessment
CP >72 hrs ago - ECG and troponin then assess

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41
Q

Signs of CVS instability?

A

• Pulmonary oedema
• Angina
Decrease BP

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42
Q

Investigation to be done for all possible cardiac problems?

A

TFT

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43
Q

Patho of S3 and S4?

A

S3 - • Caused by stiff or dilated ventricle which reaches sudden elastic limit and decelerates rush of blood,

S4 - • Atrial contraction into a non-compliant or hypertrophied ventricle

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44
Q

Where do the 4 common left murmurs radiate to?

A

• Aortic stenosis - to carotids
• Aortic regurg - 3rd ICS on left on expiration with pt leaning forward
• Mitral regurg - Left axilla
Mitral stenosis - little radiation

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45
Q

Classification of HF

A

Class I - no limitations
Class II - slight limitations
Class III - Marked limitations
Class IV - Symptoms at rest

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46
Q

S&S of HF

A

Pulmonary oedema, ankle swelling, exercise intolerance, raised JVP, PND, cardiomegaly

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47
Q

LT pharm tx of HF

A

1st line - ACEi + BB
2nd line - + Aldost antag OR +ARB +Hydralazine with nitrate
3rd line - +digoxin OR + ivabradine

Fluid overload - furosemide

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48
Q

Which drugs improve mortality and which only improve symptoms in HF?

A

Drugs which improve symptoms ONLY:
• Loop diuretics eg furosemide
Digoxin

Drugs which improve mortality in HF:
	• ACEi
	• Spironolactone
	• Beta blockers
Hydralazine with nitrates
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49
Q

Non pharm tx of HF

A 
Non drug management:
	• Cardiac resynchronisation therapy:
		○ If HF and wide QRS
		○ Biventricular pacing
	• Exercise training improves symptoms
	• Annual flu vaccine
One off pneumococcal vaccine - if asplenic or CKD need booster every 5 yrs
50
Q

S&S of acute HF

A

Symptoms:
• Dyspnoea
• Orthopnoea
Pink frothy sputum

51
Q

Ix for acute HF

A 
• CXR - ABCDE
BNP
	• ECG - Signs of MI, arrhythmias
	• U&E, troponin, ABG
Echo
52
Q

Tx of acute HF

A
  1. Sit pt upright
    1. 100% oxygen non rebreath mask
    2. IV access and ECG. Treat arrhythmias
    3. Investigations whilst continuing treatment
    4. Diamorphine IV 1.25-5mg
    5. Furosemide 40-80mg IV
    6. GTN spray 2 puffs. DON’T GIVE IF HEMOCOMPROMISED
    7. If systolic >100mmHg, nitrate infusion eg isosorbide dinitrate
    8. If pt worsening, consider CPAP

Consider discontinuation of beta blockers in short term.

53
Q

Ix for HF

A

Echo
Bloods - BNP, U&E, FBC to find underlying cause
CXR

LOOK FOR CAUSE OF HF.

54
Q

Causes of HF cardiac and extra cardiac

A

Causes of HF:
1. Cardiac - IHD, congenital, valvular disease, cardiomyopathies
Extra Cardiac - HTN, pulmonary, iatrogenic

55
Q

AF Tx

A

Rate control for older than 65 or history of IHD
Everything else rhythm control.

Rate control - atenolol, diltiazem or verapamil, or digoxin (if HF coexistant)

Rhythm control - if pt hemo stable:
• Flecainide - Flecainide if no structural heart disease
• Amiodarone - AMIODARONE ONLY THROUGH CENTRAL LINE
Sotalol
If pt not hemostable:
• Electrical cardioversion.
Give midazolam for sedation before shocking.

56
Q

What is CHADSVASC?

A 
Risk factor	Points	
C	Congestive heart failure	1
H	Hypertension (or treated hypertension)	1
A2	Age >= 75 years	2
	Age 65-74 years	1
D	Diabetes	1
S2	Prior Stroke or TIA	2
V	Vascular disease (including ischaemic heart disease and peripheral arterial disease)	1
S	Sex (female)	1
57
Q

What is HAS-BLED

A 
Risk factor	Points	
H	Hypertension, uncontrolled	1
A	Abnormal renal function	1
	Or	
	Abnormal liver function	1 
S	Stroke, history of	1
B	Bleeding, history of bleeding	1
L	Labile INRs 	1
E	Elderly (> 65 years)	1
D	Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs)	1 for drugs
	Or	
	Alcohol Use (>8 drinks/week)	1 for alcohol

3+ = high risk

58
Q

Diagnosing HTN?

A

If a clinic reading is >140/90mmHg, repeat. If still above:

• Offer ABPM - ambulatory blood pressure monitoring, or HBPM

59
Q

When to treat HTN

A 
○ If >135/85 mmHg - treat if <80 yo AND:
			§ Organ damage
			§ Established CVD
			§ Renal disease
			§ Diabetic
			§ 10 yr CV risk of 20+%
		○ If >150/95 mmHg - treat regardless
60
Q

Tx of HTN?

A

If below 55:
1st line - ramipril
2nd line - ramipril + diltiazem
3rd line - + thiazide diuretic (indapamide)
4th line - K less 4.5 mmol add spiro if more increase dose thiazide diuretic

If above 55 or black:
1st line - diltiazem and then continue as usual

61
Q

Consequences of HTN

A 
• Increased risk of MI + Stroke
	• Aneurysms
	• HF
	• Retinopathy
Nephropathy
62
Q

Lifestyle advice for HTn

A

• Low salt diet - <6g/day
• Caffeine intake reduce
Stop smoking, less alcohol, balanced diet, exercise, lose weight

63
Q

S&S of malignant HTN

A

• Headache
• +/- visual disturbance
Underlying causes may be present eg pain

64
Q

Tx of malignant HTN

A

• Use oral therapy with short half life so you can monitor the drop in BP without taking ages
Reduce BP by not more than 25% to avoid stroke risk

65
Q

Signs of hypertensive retinopathy?

A

Graded:

1. Tortuous arteries with thick shiny walls - copper wiring
2. A-V nipping (narrowing where arteries cross veins)
3. Flame haemorrhages and cotton wool spots 4. Papilloedema
66
Q

After how many weeks gestation is pre eclampsia seen

A

20

67
Q

Tx of pre-eclampsia

A

• Treat if above 160/110 mmHg
• Oral labetalol first line. Nifedipine and hydralazine may also be used
Delivery of baby is definitive step if gestation allows.

68
Q

RFs for pre-eclampsia

A 
• >40 yrs old
	• Multiple pregnancy
	• Fat
	• T2DM
	• FHx
Pre-existing vascular disease eg htn
69
Q

S&S of severe pre-eclampsia

A 
• Hypertension above 170 systolic
	• Headache
	• Visual disturbance
	• Papilloedema
	• RUQ pain
	• Hyperreflexia
Low platelet count
70
Q

How many korotkov sounds are there

A

5

71
Q

RFs for infective endocarditis

A 
• Previous episode of endocarditis (strongest)
	• Rheumatic valve disease
	• IVDU
	• Immunocompromised
	• Congenital heart defects
Prosthetic valve
72
Q

S&S of IE

A

• Fever + New murmur = Endocarditis until proven otherwise
• Sepsis - fever, rigors, night sweats, malaise, weight loss
• Look at hands - janeway lesions (painless), oslers node (painful), splinter hemorrhages, clubbing
IE can cause emboli to occur anywhere in body. Janeway lesions and oslers nodes are emboli in the skin

73
Q

MOs causing IE. What are they each associated with?

A
  • Strep viridans - 50% cause - Usually following dental procedure or poor dental hygiene
    • Staph epidermis - especially prosthetic
    • Staph aureus - IVDUs, acute presentation
    • Strep bovis - associated with colorectal cancer. MUST UNDERGO COLONOSCOPY FOR MALIGNANCY
74
Q

S&S of aortic stenosis

A

• Exertional Syncope - Most severe symptom.
• Chest pain/Angina
SOB
ESM radiating to neck

75
Q

Causes of aortic stenosis

A
  • Degenerative calcification - most common if pt >65

* Bicuspid aortic valve - most common if pt <65

76
Q

Tx of aortic stenosis

A

• If asymptomatic + valvular gradient <50mmHg - observe
• Asymptomatic but valvular gradient >50mmHg AND features eg LV systolic dysfunction consider surgery
If symptomatic - valve replacement

77
Q

Pros/cons of mechanical or biological valve replacement?

A

• Biological - LT Anticoag not needed. Deteriorates faster

Mechanical - Need LT anticoag. Lasts longer

78
Q

signs of severe aortic stenosis?

A 
Signs of severe stenosis:
	• Narrow pulse pressure - small difference in pressures
	• Delayed ESM
	• Delayed radial pulse
	• Soft or absent S2
LVH or failure
79
Q

Mitral regurg features

A

• Pan systolic murmur
• Soft S1, split S2
Mitral area/apex heard. Radiation to L axilla

80
Q

Causes of mitral regurg

A

• Calcification

Endocarditis

81
Q

Mitral stenosis causes

A

Rheumatic fever

82
Q

Ix for mitral stenosis

A

echo

CXR - atrial enlargement

83
Q

Symptoms of mitral stenosis

A

• SOBOE progressing to SOB at rest

PND with severe MS

84
Q

Features of mitral stenosis

A 
• Mid-late diastolic murmur louder expiration. Roll pt to their left and use the bell of the steth
	• Loud S1
	• Low volume pulse
	• Malar flush
AF
85
Q

features of aortic regurge

A

• Early diastolic murmur - ‘blowing murmur’. Heard best when pt upright on expiration.
• Collapsing pulse
• Wide pulse pressure - big difference in pressures. Results in multiple signs:
○ Double impulse pulse
○ De Musset sign - head bobbing with each systole
○ Quicke sign - capillary pulsation visible at proximal nail beds

86
Q

Aortic regurg causes

A 
Valve disease causes:
	• Rheumatic fever
	• Infective endocarditis
	• Connective tissue disease eg RA/SLE
Bicuspid aortic valve

Aortic root causes:
• Aortic dissection
• HTN
Marfans

87
Q

S&S of cardiac tamponade

A

• Beck’s triad:
○ Low arterial BP
○ Distended neck veins - raised JVP with an abscent Y descent
○ Distant muffled heart sounds
• Tachycardia
• Pulsus Paradoxus (large fall in systolic BP on inspiration, due to additional pressure on heart)

88
Q

Tx of cardiac tamponade

A

Pericardiocentesis under USS. Subxiphoid approach

89
Q

Causes of pericardial effusion

A 
• Infectious pericarditis
	• Uraemia
	• Post MI
	• Malignancy
HF
90
Q

S&S of pericarditis

A
  • Chest pain may be pleuritic. Relieved by sitting forwards
    • Dyspnoea
    • Pericardial rub
    • Non productive cough
    • Tachypnoea and tachycardia
91
Q

Causes of pericarditis

A 
• Viral infections (coxsackie)
	• TB
	• Uraemia
	• Trauma
Post MI
92
Q

RFs for aortic dissection

A
  • Hypertension
    • Trauma
    • Bicuspid aortic valve
    • Collagen deficiency - marfans, ehlers danlos
93
Q

Classify aortic dissection

A
  • Type A - Ascending aorta, 2/3rd of cases

* Type B - descending aorta

94
Q

Tx of aortic dissection

A

• Type A - Surgery (aortic root replacement), reduce BP

Type B - Conservative, bed rest, reduce BP

95
Q

Ix for aortic dissection

A

• CXR - widened mediastinum, abnormal aortic knob, tracheal and oesophageal deviation
• CT angiography of thoracic aorta
MRI angiography

96
Q

MO for rheumatic fever?

A

group a strep

97
Q

What are the 2 types of CCB and give egs

A

Non-dihydropyridines - verapamil, diltiazem. Selective for myocardium

Dihydropyridines - nifedipine, amlodopine, felodopine. Non selective

98
Q

How to treat non hemo compromised broad complex tachy peri-arrests

A

• Loading dose amiodarone followed by 24 hr infusion

IF torsades de pointes - magnesium IV

99
Q

How to treat non hemocompromised narrow complex tachy peri arrests

A

• Use vagal maneouvre. Eg valsalva maneouvre
• If doesn’t work use IV adenosine (contra in asthmatics, use verapamil instead)
Electrical cardioversion

100
Q

How to treat hemocompromised peri arrests if tachy or brady

A

Tachy - immediate synced DC cardioversion and thromboprophylaxis

Brady - atropine first line. Transvenous pacing second line.

101
Q

Asystole Tx?

A

Transvenous pacing.

If there is a delay of transvenous pacing, administer:
• Atropine up to 3mg
• Transcutaneous pacing
Adrenaline titrated to response

102
Q

Tx of TCA overdose

A

• IV bicarb

IV lipid emulsion

103
Q

Describe JVP waveform

A 
A - Atrial contraction
C - RV Contraction. Tricuspid bulges into atria
X  - atrial relaXation and filling
V - Venous filling
Y - passive emptYing of atria into RV.
104
Q

Define broad QRS. Patho of broad QRS?

A

QRS more than 160ms

• Re-entry caused by a blocked/slowed pathway resulting in a loop. Commonly after MI. Abnormal conduction caused by medication eg digoxin or abnormalities eg torsades and Mg.
105
Q

Causes of VF

A

• MI
• Electrolyte abnormalities
• Cardiomyopathy
Long QT –> TdP –> VF

106
Q

Tx of VF

A

IMMEDIATE DC SHOCK UNSYNCHRONISED (synchronised wont work as there isnt a rhythm to sync to so the machine will waste time trying to find a rhythm before delivering a shock).

107
Q

S&S of AVNRT

A
  • Sudden onset rapid regular palpitations

* Well tolerated and rarely life threatening

108
Q

Tx of AVNRT

A
  1. Valsalva maneouvre

Adenosine

109
Q

ECG changes of AVNRT

A

• P waves present BUT buried in QRS complex.

REGULAR RHYTHM

110
Q

Tx of AVN block

A

Atropine A1 agonist

111
Q

Give cyanotic congenital heart disease

A

TTT
Tricuspid atresia
Transposition of great arteries
Tetralogy of Fallot

112
Q

Pattern of inheritance for HOCM?

A

Auto dom

113
Q

Patho of HOCM?

A
  • Common defect is gene encoding beta-myosin or myosin binding protein C
    • 1 in 500
114
Q

ECG changes of HOCM

A

• LVH
• Progressive T wave inversion
Deep Q waves

115
Q

Echo changes of HOCM?

A

Echocardiogram - MR SAM ASH:
• Mitral Regurg
• Systolic Anterior Motion of anterior mitral valve leaflet
• Asymmetric Hypertrophy

116
Q

S&S of HOCM?

A

• Young person presenting with unusual collapse or sudden death
• Often asymptomatic
• Dyspnoea, angina, syncope
• Double apex beat, jerky pulse, large ‘a’ waves
• Ejection systolic murmur which increases with Valsalva manoeuvre
Associated with WPW and friedrichs ataxia

117
Q

Patho of aneurysm

A

• Dilatation of all layers of arterial wall
• Caused by degenerative disease
Dilatation of 50+% is aneurysm

118
Q

S&S of aneurysm

A

• Silent. MAY cause abdo/back pain

Can burst leading to shock - hypovolemic

119
Q

Ix of anuerysm

A

Investigations:
• USS - first line
CT with contrast

120
Q

Common sites of anuerysms

A

• Aorta
• Iliac
• Femoral
Popliteal

Phase 2CARDIORESP (11 decks)

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