Cardio Flashcards
When is a patient unstable in arrhythmia?
- shock
- syncope
- MI
- heart failure
-> DC cardiovert
Cardioversion if AF<48 hours?
Heparinise
Electrical - DC
OR
Amiodarone or Flecainide
(not flecainide if structural damage)
Factors favouring rate (2)/rhythm (4) control strategy in AF?
Rate - age >65, Hx of IHD
Rhythm - age <65, symptomatic, first presentation, CCF
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
Antihypertensive causing constipation and abdo pain?
Thiazides (hypercalcaemia)
3 criteria for angina?
What is atypical angina?
- Constricting discomfort in chest, neck, shoulders, jaw or arms
- Brought on by physical exertion
- Relieved within 5 mins by GTN spray
Atypical angina - 2/3 of these - e.g. if pain is ‘stabbing’ instead of ‘constricting’ (more common in women and diabetics)
If only 1/3 - non-anginal chest pain
Angina pectoris treatment ladder?
All patients should receive aspirin 75mg, a statin and GTN (unless CI)
- B-blocker or rate-limiting CCB
- Once at max dose, add second drug:
B-blocker + dihydropyridine CCB - If still symptomatic, refer for assessment for PCI/CABG and add a 3rd drug:
- ivabradine (funny current HCN channel blocker)
- long-acting nitrate
- nicorandil (K channel opener/NO activity)
- minoxidil (K channel opener/NO activity)
If thrombolysed MI, what is next management?
Re-check ECG for signs of improvement after 90 mins, if none then organise transfer for PCI
Which type of MI most commonly causes AV block?
Inferior
Sign of LV aneurysm?
Heart failure, persistent ST elevation
Sign of LV free wall rupture?
1-2 weeks after
Raised JVP
Pulsus paradoxus
Diminished heart sounds
What type of MI causes mitral regurg?
Signs
Infero-posterior
Acute hypotension and pulmonary oedema
Early-mid diastolic murmur
2 main causes of pulsus paradoxus?
Tamponade
Severe asthma
Treatment of pericarditis?
NSAID + colchicine
What is Kussmaul sign seen in constrictive pericarditis?
3 other signs?
Rise in JVP during inspiration
Pericardial knock (s3)
Signs of RV failure
CXR - pericardial calcification
Typical presentation of myocarditis?
Bloods?
ECG?
Young person, acute chest pain, dyspnoea, may go into arrhythmia
Raised cardiac enzymes and BNP
Can cause ST elevation/T inversion
Diagnosis of chronic heart failure?
What causes release of BNP?
What is its physiological effect? (4)
What to do if raised/high levels?
BNP and NT-proBNP
BNP:
Normal <100
Raised 100-400
High >400
NT-proBNP:
Normal <400
Raised 400-2000
High >2000
Released by LV myocardium in response to strain
- causes vasodilation, diuresis, natriuresis, and suppresses RAAS
Raised: specialist assessment within 6 weeks
High: specialist assessment within 2 weeks
Treatment ladder of chronic heart failure?
Other treatments these patients should get?
All patients start on:
ACEI + B1-blocker
2nd line: aldosterone antagonist
(careful as these + ACEI can cause hyperkalaemia)
3rd line options - to be started by specialist:
- Ivabradine
- Digoxin
- Hydralazine
- Sacubitril-Valsartan
- Cardiac resynchronisation therapy
Other things:
- annual influenza vaccine
- One off pneumococcal vaccine
(asplenic or CKD patients need booster every 5 years)
What is subclavian steal syndrome?
Presentation? (2)
Rx? (1)
Subclavian stenosis proximal to the origin of the vertebral arteries - resulting in retrograde blood flow from the vertebral arteries to the arm during exercise
Presentation:
- Dizziness/vertigo during exercise
- Concurrent arm pain
(typically posterior circulation symptoms)
Rx: stent
3 cyanotic heart defects?
Tetralogy of Fallot
Transposition of Great Arteries
Tricuspid atresia
TOF more common but usually present at 1-2 months
TGA more commonly recognised at birth
How to determine if neonatal cyanosis is of cardiac origin?
What to do as initial supportive management if it is ductal dependent?
Nitrogen washout test - give 100% O2 for 10 mins then do ABG, pO2 <15kPa indicates cardiac cause
If duct-dependent give PGE2
3 drugs to avoid in HOCM?
ACEI
Nitrates
Inotropes
Presentation of aortic dissection?
Ix?
Type A management?
Type B management?
BP variation >20mmHg between arms
Hypertension
Aortic regurg if ascending aorta
TEARING pain
IX: CT angiography CAP
Trans-oesophageal echo if unsuitable/unstable
Type A - ascending - surgical management but maintain BP 100-120 systolic before
Type B - conservative, IV labetalol
Which drug is assoc w GI ulcers and can cause perforation?
Nicorandil
ECG changes and arteries for MI:
- Anteroseptal?
- inferior?
- anterolateral?
- lateral?
- posterior?
anterolateral:
- V1-V4
- LAD
inferior:
- II, III, aVF
- RCA
anterolateral:
- V4-V6, I, aVL
- LAD or Left Circumflex
Lateral:
- I, aVL +/- V5-V6
- Left circumflex
Posterior:
- Tall R waves V1-V2
- May cause ST depression
- Circumflex or Right Coronary
Isolated new onset LBBB may also point to MI
What can raise and reduce BNP?
Raise - CKD (eGFR <60), and ACEI/ARB
Lower - Diuretics
In VF/VT arrest, what is the shock:CPR ratio?
When is it changed?
When should adrenaline and amiodarone be given?
What is an alternative if amiodarone not available?
When should adrenaline be given for non-shockable rhythm?
Single shock followed by 2 mins CPR
If witnessed on a monitor e.g. in CCU - 3 quick shocks can be given in succession followed by 1 min CPR
Adrenaline: after the 3rd shock (not stacked) then every 3-5 mins after
Amiodarone also after 3 shocks and after 5 shocks
Lidocaine is alternative to amiodarone
In non-shockable rhythm, give adrenaline ASAP and every 3-5 mins after
CI adenosine?
Asthma
4 week old infant presents with poor feeding, on exam tachycardia, tachypnoea, hypertension and weak femoral pulses, no cyanosis. Systolic murmur best heard at left sternal edge?
Coarctation of aorta
What is stage 1, stage 2 and severe HTN?
When to start medication?
What are BP targets?
Stage 1 - ABPM >135/85
Stage 2 - ABPM >150/95
Severe - clinic BP >180/110
Stage 1 - treat only if <80 y/o and Q-RISK >10%, or evidence of organ damage
Stage 2 - start medication for all
Targets: 135/85 if <80, 145/85 if >80
