Cardio Flashcards
1
Q
Acute LVF + Pulmonary Oedema
how does acute left ventricular failure occur?
A
when the L ventricle is unable to adequately move blood through the L side of the heart and out into the body
this causes a backlog of blood that increases the amount of blood stuck in the L atrium, pulmonary veins + lungs
as the vessels in these areas are engorged with blood due to the increased volume + pressure they leak fluid and are unable to reabsorb fluid from surrounding tissue
this causes pulmonary oedema
2
Q
Acute LVF + Pulmonary Oedema
what is pulmonary oedema
A
where the lung tissues and alveoli become full of interstitial fluid
this interferes w/ the normal gas exchange in the lungs, causing SOB, O2 desats + other signs + symptoms
3
Q
Acute LVF + Pulmonary Oedema
triggers
A
- Iatrogenic (eg aggressive fluids in frail elderly pt with impaired ventricular function)
- sepsis
- MI
- arrhythmias
4
Q
Acute LVF + Pulmonary Oedema
presentation
A
- rapid onset breathlessness
- exacerbated by lying flat + improves on sitting up
- T1 resp failure (low O2, normal CO2)
5
Q
Acute LVF + Pulmonary Oedema
symptoms
A
- SOB
- looking + feeling unwell
- cough (frothy white/pink sputum)
6
Q
Acute LVF + Pulmonary Oedema
examination findings
A
- increased RR
- reduced O2 sats
- tachycardia
- 3rd heart sound
- bilateral basal crackles ‘wet’ on auscultation
- hypotension in severe cases (cardiogenic shock)
may also be signs + symptoms related to underlying cause eg
- chest pain in ACS
- fever in sepsis
- palpitations in arrhythmias
7
Q
Acute LVF + Pulmonary Oedema
right sided heart failure examination findings
A
- raised JVP (backlog on the R side of the heart leading to an engorged jugular vein in the neck
- peripheral oedema (ankles, legs, sacrum)
8
Q
Acute LVF + Pulmonary Oedema
work up
A
- hx
- clinical examination
- ECG: ischaemia + arrhythmias
- ABG
- CXR
- Bloods: BNP + trop if suspecting MI
9
Q
Acute LVF + Pulmonary Oedema
inx
A
diagnosis confirmed by BNP or echo
10
Q
Acute LVF + Pulmonary Oedema
what is BNP
A
B-type Natriuretic Peptide is a hormone released from the heart ventricles when the myocardium is stretched beyond the normal range
11
Q
Acute LVF + Pulmonary Oedema
what does a high BNP indicate?
A
the heart is overloaded w/ blood beyond its normal capacity to pump effectively
12
Q
Acute LVF + Pulmonary Oedema
what is the action of BNP
A
to relax the smooth muscle in blood vessels
this reduces the systemic vascular resistance making it easier for the heart to pump blood through the system
Also acts on kidneys as a diuretic to promote the excretion of more water in the urine
this reduces the circulating volume helping to improve the function of the heart
13
Q
Acute LVF + Pulmonary Oedema
disadvantage of testing for BNP
A
sensitive but not specific
-ve –> rule out heart failure
+ve –> can have other causes
14
Q
Acute LVF + Pulmonary Oedema
other causes of a raised BNP
A
- tachycardia
- sepsis
- PE
- renal impairment
- COPD
15
Q
Acute LVF + Pulmonary Oedema
what is an echo useful in assessing?
A
the function of the LV and any structural abnormalities in the heart
16
Q
Acute LVF + Pulmonary Oedema
what is the main measure of LV function
A
ejection fraction
17
Q
Acute LVF + Pulmonary Oedema
what is the ejection fraction
A
the % of the blood in the LV squeezed out with each ventricular contraction
and ejection fraction above 50% is considered normal
18
Q
Acute LVF + Pulmonary Oedema
CXR findings
A
ABCDE
Alveolar oedema (Bat’s wings)
Kerley B lines
Cardiomegaly: cardiothoracic ratio of >0.5
upper lobe venous Diversion: prominent upper lobe vessels
bilateral pleural Effusion
19
Q
Acute LVF + Pulmonary Oedema
why is there prominent upper lobe vessels on CXR
A
usually when standing erect, the lower lobe veins contain more blood and the upper lobe veins remain relatively small
In LVF, there is such a back-pressure that the upper lobe veins also fill will blood and become engorged
referred to as upper lobe diversion. This is visible as increased prominence and diameter of the upper lobe vessels on a CXR
20
Q
Acute LVF + Pulmonary Oedema
mnx
A
Pour SOD
Pour away (stop) their IV fluids
Sit up
Oxygen
Diuretics eg IV furosemide
21
Q
Acute LVF + Pulmonary Oedema
mnx of severe acute pulmonary oedema or cardiogenic shock
A
- IV opiates
- NIV: CPAP or if not, may need full intubation and ventilation
- inotropes eg noradrenalin to strength force of heart contraction
22
Q
Chronic Heart Failure
causes (2)
A
- systolic heart failure: impaired left ventricular contractions
- diastolic: left ventricular relaxation
this impaired LV function results in chronic back-pressure of blood trying to flow into and through the left side of the heart
23
Q
Chronic Heart Failure
presentation
A
- breathlessness worsened by exertion
- cough: frothy white/pink sputum
- orthopnoea: how many pillows?
- Paroxysmal Nocturnal Dyspnoea
- peripheral oedema
24
Q
Chronic Heart Failure
what causes paroxysmal nocturnal dyspnoea
A
- fluid settling across a large SA of their lungs as they sleep lying flat. If standing up, fluid sinks to lung bases and upper lungs clear to be used more efficiently for gas exchange
- during sleep, the resp centre in the brain becomes less responsive so RR and effort does not increase in response to reduced O2 sats. More pulmonary congestion and hypoxia before waking up and feeling very unwell
- less adrenalin during sleep so myocardium is more relaxed which reduced CO
25
Chronic Heart Failure
dx
- clinical presentation
- N-terminal pro-B-type natriuretic peptide (NT-proBNP)
- Echo
- ECG
26
Chronic Heart Failure
causes (4)
1. IHD
2. valvular heart disease (commonly aortic stenosis)
3. HTN
4. Arrhythmias (commonly AF)
27
Chronic Heart Failure
first line medical treatment (4)
ABAL
ACE inhibitor: Ramipril
BB: bisoprolol
Aldosterone antagonist if not controlled with A + B: spironolactone or eplerenone
Loop diuretics improves symptoms: furosemide
28
Chronic Heart Failure
guidelines before implementing medical trx
- refer to specialist
- discussion + explanation of condition
- surgical trx in severe aortic stenosis or mitral regurg
- HF specialist nurse input
additional
- yearly flu + pneumococcal
- stop smoking
- optimise trx of co-morbidities
- exercise as tolerated
29
Chronic Heart Failure
what to use instead of an ACEi if they're not tolerated
Angiotensin Receptor Blocker (ARB)
30
Chronic Heart Failure
what medicine to avoid in patients with valvular heart disease
ACEi
31
Cor pulmonale
what is it
right sided heart failure caused by respiratory disease
32
Cor pulmonale
pathophysiology
the increased pressure + resistance in the pulmonary arteries (pulmonary HTN)
results in the right ventricle being unable to effectively pump blood out of the ventricle and into the pulmonary arteries
this leads to back pressure of blood in the RA, vena cava and systemic venous system
33
Cor pulmonale
respiratory causes
- COPD (most common)
- PE
- interstitial lung disease
- CF
- primary pulmonary HTN
34
Cor pulmonale
presentation
- SOB
- peripheral oedema
- increased breathlessness on exertion
- syncope (dizziness + fainting)
- chest pain
35
Cor pulmonale
signs
- hypoxia
- cyanosis
- raised JVP (due to back log of blood in jugular veins)
- peripheral oedema
- 3rd heart sound
- murmur: pan-systolic in tricuspid regurg)
- hepatomegaly
36
Cor pulmonale
why is there hepatomegaly
due to back pressure in the hepatic vein (pulsatile in tricuspid regurg)
37
Cor pulmonale
mnx
treat underlying cause and symptoms
long term o2 therapy is often used
38
Cor pulmonale
prognosis
poor prognosis unless there's a reversible underlying cause
39
Hypertension
what BP would suggest a dx
>140/90 in clinic
or >135/85 with ambulatory or home readings
40
Hypertension
what is primary hypertension
essential hypertension (accounts for 95%)
HTN has developed on its own and does not have a secondary cause
41
Hypertension
secondary causes of HTN
ROPE
Renal disease (most common secondary cause)
Obesity
Pregnancy induced HTN/ pre-eclampsia
Endocrine: Conn's syndrome
42
Hypertension
If BP is very high or does no respond to trx, what condition should you consider
renal artery stenosis
43
Hypertension
complications (5)
- IHD
- cerebrovascular accident (stroke or haemorrhage)
- hypertensive retinopathy
- hypertensive nephropathy
- HF
44
Hypertension
how often to NICE recommend measuring BP to screen for HTN
every 5years but more often in patients on the borderline for dx
every year in pts with T2DM
45
Hypertension
define white coat effect
>20/10mmHg difference in BP between clinic + ambulatory or home readings
46
Hypertension
which reading do you use if the difference in of each arm is >15?
the higher pressure
47
Hypertension
stage 1
clinic: >140/90
home: >135/85
48
Hypertension
stage 2
clinic: >160/100
home: >150/95
49
Hypertension
stage 3
clinic: >180/120
50
Hypertension
what inx should all patients with a new dx have
- urine albumin:creatinine ratio for proteinuria
- dipstick for microscopic haematuria for kidney damage
- Bloods: HbA1c, renal function and lipids
- fundus examination for hypertensive retinopathy
- ECG for cardiac abnormalities
51
Hypertension
medical mnx: stage 1 aged <55 and non-black
A
ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily)
52
Hypertension
medical mnx: step 1 aged >55 and black
C
Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily)
53
Hypertension
medical mnx: step 2 non black
A+C
| alternatively A+D or C+D
54
Hypertension
medical mnx: step 2 black
ARB + C
Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily)
55
Hypertension
medical mnx: step 3
A+C+D
Thiazide-like diuretic (e.g. indapamide 2.5mg once daily)
56
Hypertension
medical mnx: step 4
A + C + D + additional
if serum K ≤ 4.5mmol/l --> K sparing diuretic such as spironolactone
if serum K > 4.5 --> alpha blocker (doxazosin) or BB (atenolol)
57
Hypertension
how does spironolactone work
a potassium sparing diuretic
blocks the action of aldosterone in the kidneys
sodium excretion + potassium reabsorption
58
Hypertension
when can potassium sparing diuretics be helpful
when thiazide diuretics are causing hypokalaemia
59
Hypertension
which meds can cause hyperkalaemia
- spironolactone
| - ACEi
60
Hypertension
trx targets for <80years
<140 / <90
61
Hypertension
trx targets for >80years
<150 / <90
62
Murmurs
what is the first heart sound (S1) caused by
the closing of the AV valves (tricuspid + mitral valves)
at the start of the systolic contraction of the ventricles
63
Murmurs
what is the second hear sound (S2) caused by?
the closing of the semilunar valves (pulmonary + aortic valves)
once the systolic contraction is complete
64
Murmurs
what is a 3rd heart sound (S3) caused by?
rapid ventricular filling causing the chordae tendineae to pull their full length and twang
65
Murmurs
why can a 3rd heart sound be normal in a young healthy person
because the heart functions so well that the ventricles easily allow rapid filling
66
Murmurs
| what can a 3rd heart sound indicate in older patients
HF because their ventricles and chordae are stiff and weak so they reach their limit much faster than normal
67
Murmurs
what does a 4th heart sound indicate
rare and always abnormal
stiff or hypertrophic ventricles
caused by turbulent flow from an atria contracting against a non-compliant ventricle
68
Murmurs
where is the pulmonary valve anatomically
2nd ICS left sternal border
69
Murmurs
where is the aortic valve anatomically
2nd ICS right sternal border
70
Murmurs
where is the tricuspid valve anatomically
5th ICS left sternal border left sternal border
71
Murmurs
where is the mitral valve anatomically
5th ICS mid clavicular line (apex area)
72
Murmurs
where is Erb's point
3rd ICS on the left sternal border
the best area for listening to heart sounds S1 and S2
73
Murmurs
what special manoeuvre can emphasise mitral stenosis
patient on their left hand side
74
Murmurs
what special manoeuvre can emphasise aortic regurgitation
patient sat up leaning forward and holding exhalation
75
Murmurs
how to assess a murmur (SCRIPT)
Site: where is it loudest
Character: soft/blowing/ crescendo/decrescendo
Radiation
Intensity: what grade?
Pitch: high/low/grumbling
Timing: systolic/diastolic
76
Murmurs
what is murmur grade 1
difficult to hear
77
Murmurs
what is murmur grade 2
quiet
78
Murmurs
what is murmur grade 3
easy to hear
79
Murmurs
what is murmur grade 4
easy to hear with a palpable thrill
80
Murmurs
what is murmur grade 5
can hear with stethoscope barely touching chest
81
Murmurs
what is murmur grade 6
can hear with stethoscope off the chest
82
Murmurs
where does mitral stenosis cause hypertrophy
left atrial hypertrophy
83
Murmurs
where does aortic stenosis cause hypertrophy
left ventricular hypertrophy
84
Murmurs
where does mitral regurg cause dilatation
left atrial dilatation
85
Murmurs
where does aortic regurg cause dilatation
left ventricular dilation
86
Murmurs
what is mitral stenosis caused by
- RHD
| - Infective endocarditis
87
Murmurs
describe a mitral stenosis murmur
mid-diastolic
low pitched 'rumbling' murmur
loud S1
88
Murmurs
why is there a loud S1 in mitral stenosis
due to thick valves requiring a large systolic force to shut, then shutting suddenly
can palpate a tapping apex beat due to loud S1
89
Murmurs
what is mitral stenosis associated with
malar flush
AF
90
Murmurs
why is malar flush associated with mitral stenosis
back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation
91
Murmurs
why is mitral stenosis associated with AF
LA struggling to push blood through the stenotic valve causing strain, electrical disruption and resulting fibrillation
92
Murmurs
what condition does mitral regurgitation cause
congestive cardiac failure because the leaking valve causes a reduced ejection fraction and a backlog of blood that is waiting to be pumped through the left side of the heart
93
Murmurs
describe the murmur in mitral regurgitation
pan-systolic
high pitched 'whistling' murmur
radiates to L axilla
may hear 3rd heart sound
94
Murmurs
| causes of mitral regurgitation
- idiopathic weakening of the valve with age
- ischaemic heart disease
- Infective endocarditis
- RHD
- connective tissue disorders
95
Murmurs
what is the most common
aortic stenosis
96
Murmurs
describe an aortic stenosis murmur
ejection-systolic
high pitched murmur
crescendo-decrescendo
radiates to the carotid
97
Murmurs
signs of a pt with an aortic stenosis
- murmur radiates to the carotids as the turbulence continues up into the neck
- Slow rising pulse and narrow pulse pressure
- exertional syncope due to difficulty maintaining good flow of blood to the brain
98
Murmurs
causes of aortic stenosis (2)
- idiopathic age related calcification
| - RHD
99
Murmurs
describe an aortic regurgitation murmur
early diastolic
soft
associated with Corrigan's pulse
100
Murmurs
aortic regurg: what is Corrigan's pulse
aka collapsing pulse
rapidly appearing and disappearing pulse at carotid as the blood it pumped out by ventricles and then immediately flows back through the aortic valve back into the ventricles
101
Murmurs
why does aortic regurgitation result in heart failure
due to back pressure of blood waiting to get through the left side of the heart
102
Murmurs
aortic regurg: what is an Austin-Flint murmur
early diastolic 'rumbling' murmur
heard at the apex
caused by blood flowing back through the aortic valve and over the mitral valve causing it to vibrate
103
Murmurs
causes of aortic regurg (2)
- idiopathic age related weakness
| - connective tissue disorders
104
Atrial Fibrillation
pathophysiology
disorganised electrical activity that overrides the normal, organised activity from the sinoatrial node
105
Atrial Fibrillation
presenting sx (4)
- palpitations
- SOB
- syncope
- assc conditions: stroke, sepsis, thyrotoxicosis
106
what are the 2 Ddx for an irregularly irregular pulse?
1. Atrial Fibrillation
| 2. Ventricular ectopics
107
how to tell the difference between AF and ventricular ectopics
ventricular ectopics disappear when the HR gets over a certain threshold
a regular heart rate during exercise suggests ventricular ectopics
108
Atrial Fibrillation
ECG (3)
- absent P waves
- narrow QRS tachycardia
- irregularly irregular ventricular rhythm
109
Atrial Fibrillation
what is valvular AF
pts with AF who also have moderate or severe mitral stenosis or a mechanical heart valve
110
Atrial Fibrillation
what are the most common causes of AF
SMITH
Sepsis
Mitral valve pathology (stenosis or regurg)
Ischaemic Heart Disease
Thyrotoxicosis
Hypertension
111
Atrial Fibrillation
what are the 2 principles to treating AF
1. rate or rhythm control
| 2. anticoagulation to prevent stroke
112
Atrial Fibrillation
what is the 1st line trx
rate control
113
Atrial Fibrillation
when would rate control not be 1st line trx (4)
1. reversible cause of AF
2. within last 48hrs
3. causing HF
4. remain symptomatic despite rate controlled
114
Atrial Fibrillation
what are the options for rate control (3)
1st line: BB e.g. atenolol 50-100mg once daily
2. CCB e.g. diltiazem
3. digoxin
115
Atrial Fibrillation
rate control: when should you not use CCB (diltiazmem)
in HF
116
Atrial Fibrillation
rate control: when is digoxin used
only in sedentary people, needs monitoring and risk of toxicity
117
Atrial Fibrillation
when is rhythm control offered (4)
1. reversible cause
2. new onset <48hrs
3. AF is causing HF
4. remain symptomatic despite being rate controlled
118
Atrial Fibrillation
options for rhythm control
1. single cardioversion event
| 2. long term medical rhythm control
119
Atrial Fibrillation
rhythm control: when should immediate cardioversion be done?
<48hrs
or severely haemodynamically unstable
120
Atrial Fibrillation
rhythm control: when should delayed cardioversion be done
>48hrs and they are stable
121
Atrial Fibrillation
rhythm control: in delayed cardioversion, what should they have whilst waiting
anticoagulation for a minimum of 3w prior to cardioversion
and rate control
122
Atrial Fibrillation
rhythm control: what are the 2 options for cardioversion
- pharmacological cardioversion
| - electrical cardioversion
123
Atrial Fibrillation
rhythm control: what is the first line for pharmacological cardioversion
- flecanide
| - amiodarone (drug of choice in pts with structural heart disease)
124
Atrial Fibrillation
rhythm control: what does electrical cardioversion involve
sedation or GA + a cardiac defibrillator to deliver controlled shocks to restore sinus rhythm
125
Atrial Fibrillation
rhythm control: what drugs can be used for long term medical rhythm control
1st line: BB
2nd line: Dronedarone for when pts have had successful cardioversion
Amiodarone: useful in pts with HF or L ventricular dysfunction
126
Atrial Fibrillation
what is paroxysmal AF
when the AF comes and goes in episodes
127
Atrial Fibrillation
mnx for paroxysmal AF
1. anticoagulation based on CHADSVASc
| 2. pill in the pocket: Flecanide
128
Atrial Fibrillation
paroxysmal AF: what criteria is needed to be able to use pill in the pocket approach
- infrequent episodes without any underlying structural heart disease
- able to identify when they are in AF
129
Atrial Fibrillation
when should you avoid flecanide
in atrial flutter as it can cause 1:1 AV conduction resulting in a significant tachycardia
130
Atrial Fibrillation
how does AF cause an ischaemic stroke
- uncontrolled movement of atria leads to blood stagnating in the LA, particularly the atrial appendage
- stagnated blood leads to a thrombus
- then mobilised (embolus) and trvels with the blood
- atrial--> ventricle --> aorta --> carotid arteries --> brain
- lodge in cerebral arteries
131
Atrial Fibrillation
how much does anticoagulation reduce the risk of stroke
2/3
132
Atrial Fibrillation
Anticoagulation: what is warfarin
a vitamin K antagonist
133
Atrial Fibrillation
Anticoagulation: what does an INR of 2 indicate
the patient takes them twice as long to form a blood clot
134
Atrial Fibrillation
Anticoagulation: what is the target INR if on warfarin
2-3
135
Atrial Fibrillation
Anticoagulation: why does warfarin react with many drugs
because the cytochrome P450 system in the liver is involved in the metabolism of warfarin
136
Atrial Fibrillation
Anticoagulation: what affects the INR
food containing vit K:
- leafy green veg
things that affect P450:
- cranberry juice
- alcohol
137
Atrial Fibrillation
Anticoagulation: what can reverse the DOACS, apixaban and rivaroxaban
Andexanet alfa
138
Atrial Fibrillation
Anticoagulation: what can reverse the DOAC, dabigatran
Idarucizumab
139
Atrial Fibrillation
Anticoagulation: what are the advantages of DOACs
- no monitoring required
- no major interaction problems
- equal or better than warfarin at preventing strokes in AF
- equal or less risk of bleeding than warfarin
140
Atrial Fibrillation
what tool is used for assessing whether a pt with AF should be started on anticoagulation
CHA2DS2-VASc
141
Atrial Fibrillation
CHA2DS2-VASc
```
C – Congestive heart failure
H – Hypertension
A2 – Age >75 (Scores 2)
D – Diabetes
S2 – Stroke or TIA previously (Scores 2)
V – Vascular disease
A – Age 65-74
S – Sex (female)
```
142
Atrial Fibrillation
what assessment tool is used to establish a pt's risk of major bleeding whilst on anticoagulation
HAS-BLED
143
Atrial Fibrillation
HAS-BLED
```
H – Hypertension
A – Abnormal renal and liver function
S – Stroke
B – Bleeding
L – Labile INRs (whilst on warfarin)
E – Elderly
D – Drugs or alcohol
```
144
Atrial Fibrillation
what does a CHA2DS2-VASc of 0 mean
no anticoagulation
145
Atrial Fibrillation
what does a CHA2DS2-VASc of 1 indicate
consider anticoagulation
146
Atrial Fibrillation
what does a CHA2DS2-VASc score of >1 indicate
offer anticoagulation
147
Atrial Fibrillation
CHA2DS2-VASc >1 and high HAS-BLED score
usually the risk of stroke significantly outweighs the risk of bleeding so should anticoagulate
148
Arrhythmias
what can the 4 possible rhythms seen in a pulseless unresponsive pt be categorised into?
shockable rhythms: defibrillation may be effective
non-shockable: defibrillation will not be effective
149
Arrhythmias
what are the 4 possible rhythms seen in a pulseless unresponsive pt
ventricular tachycardia
ventricular fibrillation
pulseless electrical activity
asystole
150
Arrhythmias
what are the 2 shockable rhythms
ventricular tachycardia
| ventricular fibrillation
151
Arrhythmias
what are the 2 non-shockable rhythms
pulseless electrical activity: all electrical activity except VF/VT, including if you see sinus rhythm without a pulse
Asystole
152
Arrhythmias
trx of tachycardia in an unstable pt
- consider up to 3 synchronised shocks
| - consider an amiodarone infusion
153
Arrhythmias
3 narrow complex (QRS<0.12s) tachycardias
- atrial fibrillation
- atrial flutter
- SVT
154
Arrhythmias
3 broad complex (QRS>0.12s) tachycardias
- VT
- SVT w/ BBB
- AF variation
155
Arrhythmias
what is atrial flutter caused by
a re-entrant rhythm in either atrium
the electrical signal re-circulates in a self-perpetuating loop due to an extra electrical pathway
156
Arrhythmias
Atrial flutter: atrial bpm and ventricular bpm
atrial contraction at 300bpm
ventricular contraction at 150bpm
157
Arrhythmias
what does ECG show if pt has atrial flutter
sawtooth appearance
P wave after P wave
158
Arrhythmias
what conditions are associated with atrial flutter
- HTN
- IHD
- cardiomyopathy
- thyrotoxicosis
159
Arrhythmias
trx of atrial flutter
similar to AF:
- rate/rhythm control: BB or cardioversion
- treat the reversible underlying condition
- radiofrequency ablation of the re-entrant rhythm
- anticoagulation based on CHA2DS2-VASc
160
Arrhythmias
what is SVT caused by
the electrical signal re-entering the atria from the ventricles
self-perpetuating loop as once the signal is back in the atria it travels back through the AV node and causes another ventricular contraction
161
Arrhythmias
what does the ECG look like in SVT
narrow complex tachycardia (QRS<0.12)
QRS complex followed immediately by a T wave, QRS, T wave etc
162
Arrhythmias
what is paroxysmal SVT
SVT reoccurs and remits in the same pt over time
163
Arrhythmias
what are the 3 main types of SVT based on the source of the electrical signal
1. Atrioventricular nodal re-entrant tachycardia
2. Atrioventricular re-entrant tachycardia
3. Atrial tachycardia
164
Arrhythmias
SVT: what is atrioventricular nodal re-entrant tachycardia
when the re-entry point is back through the AV node
165
Arrhythmias
SVT: what is atrioventricular re-entrant tachycardia
when the re-entry point is an accessory pathway (WPW)
166
Arrhythmias
SVT: what is atrial tachycardia
where the electrical signal originates in the atria somewhere other than the sinoatrial node
not caused by a signal re-entering from the ventricles
but from abnormally generated electrical activity in the atria
this ectopic electrical activity causes an atrial rate of >100bpm
167
Arrhythmias
SVT: acute mnx of stable pt with SVT stepwise approach
continuous ECG monitoring
1. Valsalva manoeuvre
2. carotid sinus massage
3. adenosine
4. or verapamil
5. direct current cardioversion
168
Arrhythmias
SVT: what is the valsalva manoeuvre
forced expiration against a closed glottis. e.g. blowing hard against resistance into a plastic syringe
169
Arrhythmias
SVT: what is the modified valsalva manoeuvre (REVERT trial)
1. Position pt in a semi-recumbent position (45º)
2. blow into syringe for 15 seconds
3. Lower pt flat and passively raise their legs to a 45º angle for 15 seconds
4. Return the patient to a semi-recumbent position for an additional 45 seconds
170
Arrhythmias
SVT: how does adenosine work
slows cardiac conduction primarily through the AV node
it interrupts the AV node/ accessory pathway during SVT and 'resets' it back to sinus rhythm
171
Arrhythmias
SVT: whom should you avoid adenosine in
if pt has:
- asthma
- COPD
- HF
- heart block
- severe hypotension
172
Arrhythmias
SVT: what should you warn pts before giving adenosine
the scary feeling of dying/impending doom when injected
173
Arrhythmias
SVT: how should adenosine be administered
fast IV bolus into a large proximal cannula (e.g. grey cannula in the antecubital fossa)
followed by a 20 ml IV Normal Saline bolus
6mg --> 12mg --> 12mg
174
Arrhythmias
what is the long term mnx of pts with paroxysmal SVT
medication:
- BB
- CBB
- amiodarone
radiofrequency ablation
175
Arrhythmias
what is Wolff-Parkinson White Syndrome caused by
an extra electrical pathway connecting the atria and ventricles
176
Arrhythmias
WPW: what is the extra pathway called
the Bundle of Kent
177
Arrhythmias
WPW: definitive trx
radiofrequency ablation of the accessory pathway
178
Arrhythmias
WPW: ECG changes
- delta wave: slurred upstroke on the QRS complex
- Wide QRS complex (0.12s)
- Short PR interval
179
Arrhythmias
why are most antiarrhythmic meds (BB, CBB. adenosine) CI'd in pts with WPW that develop AF or flutter
they increase the risk of the chaotic atrial electrical activity to pass through the accessory pathway into the ventricles
causing a polymorphic wide complex tachycardia
because they reduce conduction through the AV node therefore promoting conduction through the accessory pathway
180
Arrhythmias
where is radiofrequency ablation performed
in a electrophysiology lab aka 'cath lab'
181
Arrhythmias
what does radiofrequency ablation involve
- catheter into femoral veins
- feeding a wire through venous system under xray guidance to the heart
- find location of abnormal electrical pathway
- radiofrequency ablation (heat) applied to burn the abnormal area
182
Arrhythmias
when can radiofrequency ablation be used
- AF
- atrial flutter
- SVTs
- WPW
183
Arrhythmias
what is Torsades de pointes
'twisting of the tips'
a type of polymorphic (multiple shape) ventricular tachycardia
184
Arrhythmias
Torsades de pointes: whom does it occur in
pts with a prolonged QT interval
185
Arrhythmias
Torsades de pointes: ECG changes
normal ventricular tachycardia
QRS complex twists around baseline
QRS height progressively gets smaller, then larger, then smaller etc
186
Arrhythmias
Torsades de pointes: what is it
prolonged Qt = prolonged repolarisation of the muscle cells in the heart after contraction
resulting in spontaneous depolarisation in some areas of heart myocytes (afterdepolarisations)
they spread through the ventricle, leading to a ventricular contraction prior to proper repolarisation occurring
when this occurs and the ventricles continue to stimulate recurrent contractions without normal repolarisation, it is called Torsades de pointes
187
Arrhythmias
Torsades de pointes: what can it lead to
1. terminate spontaneously and revert back to sinus rhythm
| 2. progress to ventricular tachycardia -->cardiac arrest
188
Arrhythmias
Torsades de pointes: causes of prolonged QT (3)
1. Long QT syndrome (inherited)
2. meds: antipsychotics, citalopram, flecainide, sotalol, amiodarone, macrolide abx
3. electrolyte disturbance: hypokalaemia, hypomagnesaemia, hypocalcaemia
189
Arrhythmias
Torsades de pointes: acute mnx
- correct cause (electrolyte disturbance or medications)
- Mg infusion (even if they have normal serum Mg)
- Defibrillation if VT occurs
190
Arrhythmias
Torsades de pointes: long term mnx of prolonged QT syndrome (inherited)
- avoid meds that prolong the QT interval
- correct electrolyte disturbances
- BB (not sotalol)
- pacemaker or implantable defibrillator
191
Arrhythmias
what are ventricular ectopics
premature ventricular beats caused by random electrical discharges from outside the atria
192
Arrhythmias
Ventricular ectopics: what do pts often complain of
random, brief palpitations 'an abnormal beat'
193
Arrhythmias
Ventricular ectopics: whom are they more common in
pts with pre-existing heart conditions e.g. IHD or HF
but relatively common at all ages
194
Arrhythmias
Ventricular ectopics: ECG changes
individual random, abnormal, broad QRS complexes on a background of a normal ECG
195
Arrhythmias
Ventricular ectopics: what is Bigeminy
where the ventricular ectopics are occurring so frequently that they happen after every sinus beat
196
Arrhythmias
Ventricular ectopics: what does the ECG look like in Bigeminy
normal sinus beat followed immediately by an ectopic, then a normal beat, then ectopic and so on
197
Arrhythmias
Ventricular ectopics: mnx
- check bloods for anaemia, electrolyte disturbance and thyroid abnormalities
- reassurance + no trx for otherwise healthy ppl
- seek expert advice in pts with background heart conditions or other concerning features or findings (e.g. chest pain, syncope, murmur, FH of sudden death)
198
Arrhythmias
when does 1st degree heart block occur
when there is delayed AV conduction through the AV node
199
Arrhythmias
1st degree heart block ECG changes
- every p wave results in a QRS complex
| - PR interval >0.2s (1 big square)
200
Arrhythmias
what is 2nd degree heart block
where some of the atrial impulses do not make it through the AV node to the ventricles
some p waves do not lead to QRS complexes
201
Arrhythmias
what are the different types of 2nd degree heart block
- Wenckebach's phenomenon (Mobitz Type 1)
| - Mobitz Type 2
202
Arrhythmias
2nd degree heart block: what is Wenckebach’s phenomenon (Mobitz Type 1)
the atrial impulses become gradually weaker until it does not pass through the AV node
after failing to stimulate a ventricular contraction, the atrial impulse returns to being strong
cycle repeats
203
Arrhythmias
Wenckebach’s phenomenon (Mobitz Type 1) ECG changes
- increasing PR interval until QRS complex is missed
| - the cycle repeats
204
Arrhythmias
2nd degree heart block: what is Mobitz type 2
where there is intermitted failure or interruption of AV conduction
205
Arrhythmias
2nd degree heart block: Mobitz type 2 ECG changes
- PR interval remains normal
| - a set of P waves for each QRS complexes e.g. 3:1 block is 3 P waves to each QRS complex
206
Arrhythmias
2nd degree heart block: what is there a risk of in Mobitz type 2
asystole
207
Arrhythmias
2nd degree heart block: what is 2:1 block
2 P waves for each QRS complex
every 2nd p wave is not a strong enough atrial impulse to stimulate a QRS complex
difficult to tell if caused by Mobitz type 1 or 2
208
Arrhythmias
what is 3rd degree heart block
aka complete heart block
no relationship between P waves and QRS complexes
209
Arrhythmias
what is there a significant risk of in 3rd degree heart block
asystole
210
Arrhythmias
trx for stable bradycardia or heart block
observe
211
Arrhythmias
trx for unstable bradycardia or heart block or risk of asystole (i.e. Mobitz Type 2, complete heart block or previous asystole)
1st line: atropine 500mcg IV
no improvement:
- atropine 500mcg IV repeated (up to 6 doses for a total to 3mg)
- other inotropes: noradrenalin
- transcutaneous cardiac pacing (using a defibrillator)
212
Arrhythmias
trx In patients with high risk of asystole (i.e. Mobitz Type 2, complete heart block or previous asystole)
- temporary transvenous cardiac pacing
| - permanent implantable pacemaker
213
Arrhythmias
what is temporary transvenous cardiac pacing
using an electrode on the end of a wire that is inserted into a vein and fed through the venous system to the RA or ventricle to stimulate them directly
trx for pts with high risk of asystole
214
Arrhythmias
what is atropine
an antimuscarinic
inhibits the parasympathetic nervous system
215
Arrhythmias
what are the side effects of atropine
antimuscarinic: inhibits the parasympathetic nervous system
so
pupil dilatation, urinary retention, dry eyes and constipation
216
Stable Angina
pathophysiology
narrowing of the coronary arteries reduces blood flow to the myocardium
chest pain when there is insufficient supply of blood to meet demand
217
Stable Angina
what is unstable angina
when the sx come on randomly whilst at rest
and this is considered as an Acute Coronary Syndrome
218
Stable Angina
what is the gold standard diagnostic inx
CT Coronary Angiography
219
Stable Angina
what is CT Coronary Angiography
injecting contrast and taking CT images timed with the heart beat
to give a detailed view of the coronary arteries, highlighting any narrowing
220
Stable Angina
baseline inx
- physical exam: heart sounds, BMI
- ECG
- FBC (anaemia)
- U&Es
- LFTs
- Lipid profile
- TFTs
- HbA1c
221
Stable Angina
why check U&Es
prior to ACEi and other meds
222
Stable Angina
why check LFTs
prior to statins
223
Stable Angina
what are the 4 principles to mnx
RAMP
Refer to cardiology (urgent if unstable)
Advise them about the dx, mnx and when to call an ambulance
Medical trx
Procedural or surgical interventions
224
Stable Angina
immediate symptomatic relief medical mnx
take GTN, then repeat after 5 min
still pain after repeated dose? call ambulance
225
Stable Angina
how does GTN work
it causes vasodilation and helps relieve the sx
226
Stable Angina
long term symptomatic relief
BB (bisoprolol 5mg OD)
or/and
CBB (amlodipine 5mg OD)
227
Stable Angina
long term symptomatic relief other options (not 1st line)
- long acting nitrates (isosorbide mononitrate)
- Ivabradine
- Nicorandil
- Ranolazine
228
Stable Angina
secondary prevention of CVD
- aspirin (75mg OD)
- Atorvastatin (80mg) OD
- ACEi
- BB (already on for symptomatic relief)
229
Stable Angina
if CT coronary angiography shows 'proximal or extensive disease', what is offered
PCI (Percutaneous Coronary Intervention) with coronary angioplasty
230
Stable Angina
what is PCI with coronary angioplasty
put catheter into brachial or femoral artery
feed up to coronary arteries under xray guidance
inject contrast
dilate the blood vessel with a balloon and/or inserting a stent
231
Stable Angina
what is offered to patients with severe stenosis
Coronary Artery Bypass Graft (CABG)
232
Stable Angina
what does CABG involve
open chest along sternum
take a graft from great saphenous vein
sew it on the affected coronary artery to bypass the stenosis
233
Stable Angina
what scars are present in someone who has had a CABG
- midline sternotomy scar
| - great saphenous vein harvesting
234
Stable Angina
what scars are present in someone who has had a PCI
- femoral artery access
or
- brachial artery access
235
ACS
cause
thrombus from an atherosclerotic plaque blocking a coronary artery
236
ACS
why are anti-platelet meds (aspirin, clopidogrel, ticagrelor) the mainstay of treatment
when a thrombus forms in a fast flowing artery, it is made up of mostly platelets
237
ACS
what does the left coronary artery branch into
the circumflex and LAD
238
ACS
what does the RCA supply
- RA
- RV
- inferior aspect of LV
- posterior septal area
239
ACS
what does the circumflex artery supply
- LA
| - posterior aspect of LV
240
ACS
what does the LAD supply
- anterior aspect of the LV
| - anterior aspect of septum
241
ACS
what are the 3 types
- unstable angina
- STEMI
- NSTEMI
242
ACS
dx if there is ST elevation or new LBBB
STEMI
243
ACS
next inx if there is no ST elevation
troponin blood test
244
ACS
diagnosis of NSTEMI
- raised trop
and/or
- other ECG changes (ST depression, T-wave inversion, pathological Q waves)
245
ACS
diagnosis of unstable angina or MSK chest pain
- normal trop
| - no pathological changes on ECG
246
ACS
sx
Central, constricting chest pain associated with:
- N+V
- Sweating + clamminess
- Feeling of impending doom
- SOB
- Palpitations
- Pain radiating to jaw or arms
247
ACS
what is silent MI
Diabetic patients may not experience typical chest pain during an acute coronary syndrome
248
ACS
ECG leads: I, aVL, V3-V6
heart area and artery?
anterolateral
| LCA
249
ACS
ECG leads: V1-V4
heart area and artery?
Anterior
| LAD
250
ACS
ECG leads: I, aVL, V5-6
heart area and artery?
Lateral
| Circumflex
251
ACS
ECG leads: II, III, aVF
heart area and artery?
Inferior
| RCA
252
ACS
when is troponin measured
at baseline and 6 or 12 hours after onset of sx
253
ACS
what does a rise in troponin indicate
myocardial ischaemia as the proteins are released from the ischaemic muscle.
254
ACS
other causes of a raise in trop
- Chronic renal failure
- Sepsis
- Myocarditis
- Aortic dissection
- Pulmonary embolism
255
ACS
why perform CXR
other causes of chest pain and pulmonary oedema
256
ACS
why perform an echo
to assess functional damage
257
ACS
why perform a CT coronary angiogram
to assess coronary artery disease
258
ACS
acute STEMI mnx
if within 2hr: PCI
| if not available within 2hr: thrombolysis
259
ACS
examples of thrombolytic agents
streptokinase, alteplase and tenecteplase.
260
ACS
Acute NSTEMI trx
BATMAN
BB unless contraindicated
Aspirin 300mg stat dose
Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)
Morphine titrated to control pain
Anticoagulant: Fondaparinux (unless high bleeding risk)
Nitrates (e.g. GTN) to relieve coronary artery spasm
Give oxygen only if their oxygen saturations are dropping (i.e. <95%).
261
ACS
what is the scoring system that gives a 6-month risk of death or repeat MI after having an NSTEMI
GRACE score
262
ACS
if GRACE score is medium or high (>5%), what may be considered
early PCI (within 4d of admission) to treat underlying coronary artery disease
263
ACS
complications of MI
DREAD
Death
Rupture of the heart septum or papillary muscles
“Edema” (Heart Failure)
Arrhythmia and Aneurysm
Dressler’s Syndrome
264
ACS
what is Dressler's syndrome
aka post-MI syndrome
occurs 2-3w after an MI.
localised immune response causes pericarditis
265
ACS
Dressler's syndrome presentation
- pleuritic chest pain
- low grade fever
- pericardial rub on auscultation
- pericardial effusion
- rarely a pericardial tamponade (where the fluid constricts the heart and prevents function).
266
ACS
Dressler's syndrome dx
ECG: global ST elevation and T wave inversion
echo: pericardial effusion
CRP+ESR: raised
267
ACS
Dressler's syndrome mnx
NSAIDs (aspirin / ibuprofen)
severe cases: steroids (prednisolone)
may need pericardiocentesis to remove fluid from around the heart.
268
ACS
Secondary Prevention Medical Management
6A's
Aspirin 75mg OD
Another antiplatelet: clopidogrel/ticagrelor up to 1y
Atorvastatin 80mg OD
ACE inhibitors
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
269
Type 1 MI
Traditional MI due to an acute coronary event
270
Type 2 MI
Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)
271
Type 3 MI
Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
272
Type 4 MI
MI associated with PCI / coronary stunting / CABG
273
CXR: Water-bottle-shaped enlarged cardiac silhouette
pericarditis
274
what is Fleischner sign
Prominent central pulmonary artery
Fleischner sign is found in 20% of patient's presenting with a pulmonary embolism
275
Cardiac Tamponade
what is it
accumulation of fluid, blood, purulent exudate or air in the pericardial space raises the intra pericardial pressure.
thus diastolic filling is reducing thereby reducing the cardiac output
276
Cardiac Tamponade
signs (3)
Beck's Triad
1. hypotension
2. quiet heart sounds
3. raised JVP
277
Cardiac Tamponade
sx
- SOB
- tachycardia
- confusion
- chest pain
- abdo pain
278
Cardiac Tamponade
what may ECG show
low voltage QRS complexes or electrical alternans
279
Cardiac Tamponade
what may CXR show
large globular heart
280
Cardiac Tamponade
what may echo demonstrate
the amount of fluid around the heart and quantify the level of ventricular compromise.
281
Cardiac Tamponade
1st line mnx in patients that are haemodynamically unstable
Pericardiocentesis: sampling of the fluid to find the underlying cause and treat the immediate problem
282
Cardiac Tamponade
1st line mnx in pts haemopericardium, associated malignancy, traumatic/purulent effusion
surgical drainage
283
Cardiac Tamponade
complications of pericardiocentesis
pneumothorax
284
Acute bradycardia
definition
<60bpm
285
Acute bradycardia
causes (4)
- Sinus/AV nodal disease
- Drug induced: BB, CBB
- Electrolyte abnormalities
- Hypothyroidism
286
Acute bradycardia
clinical features (3)
- dizziness
- syncope
- tiredness
287
Acute bradycardia
initial mnx if there are any adverse features (shock, syncope, myocardial ischemia or HF)
IV atropine 500 micrograms
Repeat boluses can be given up to 3mg
288
Acute bradycardia
how does atropine work
blocks the vagus nerve activity on the heart, which increases the firing rate of the SA node.
289
Acute bradycardia
If there is a risk of asystole, or if the patient is unstable and has failed to respond to atropine sulfate, what next?
adrenaline/epinephrine should be given by intravenous infusion, and the dose adjusted according to response ( 2-10 mcg per minute.
290
Patients with occlusion of the left anterior descending artery are particularly at risk of?
rupture of the interventricular septum due to infarction of the septal area.
291
what may be heard in rupture of the interventricular septum
harsh and holosystolic murmur
292
how may a rupture of the interventricular septum present
- haemodynamic instability
- hypotension
- biventricular failure (often largely right-sided)
293
what is the most common cause of sudden cardiac death in the young
Hypertrophic obstructive cardiomyopathy
294
signs of Hypertrophic obstructive cardiomyopathy
harsh ejection systolic murmur that decreases in intensity on squatting.
295
what should be considered in all patients with reasonable quality of life and a poor left ventricular ejection fraction (LVEF) of < 35% despite optimum medical therapy
Implantable cardioverter-defibrillator (ICD)
296
what do J waves indicate
hypothermia
297
leads V1-2: a coved ST elevation >2mm with subsequent negative T waves.
what could this be
brugada syndrome
298
How is the QT interval correctly defined
Start of Q-wave to the end of the T-wave
299
pt presents with acute bradycardia. Doesn't respond to atropine or adrenaline. What is the next step
Transcutaneous pacing
300
single chamber right ventricular pacemaker ECG findings
Pacing spikes preceding the P waves. Broad QRS complexes with an RSR pattern in V5-6.
301
When Adenosine is contraindicated (asthma, COPD, HF). what can be given
Verapamil 2.5 - 5mg
302
fever and weight loss. audible tumour "plop", nail clubbing, sx of mitral obstruction / stenosis (such as atrial fibrillilation
what could this be
cardiac myoma
303
what is high output cardiac failure
cardiac output is normal, but there is an increase in peripheral metabolic demands which exceed those that can be met with maximal cardiac output
304
Causes of high output cardiac failure
```
AAPPTT:
Anaemia
Arteriovenous malformation
Paget's disease
Pregnancy
Thyrotoxicosis
Thiamine deficiency (wet Beri-Beri)
```
305
mode of inheritance for hypertrophic cardiomyopathy
autosomal dominant
306
57 year old lady has HTN and DM. What medication do you give
ACEi!
all diabetics no matter what age should be on this
307
ECG shows widespread downsloping ST segments
what drug causes this
digoxin
308
mnx of heart failure after optimum medication (ABAL)
Cardiac resynchronisation therapy (CRT)
309
an implantable cardiac defibrillator is inserted due to VF.
How long must he wait until he can drive a car again?
6m
310
definition of syncope
transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
311
classification of syncope (3)
1. Reflex syncope (neurally mediated)
2. Orthostatic syncope
3. Cardiac syncope
312
what is 1. Reflex syncope (neurally mediated)
- vasovagal: triggered by emotion, pain or stress. Often referred to as 'fainting'
- situational: cough, micturition, gastrointestinal
- carotid sinus syncope
313
what is . Orthostatic syncope
- primary autonomic failure: Parkinson's disease, Lewy body dementia
- secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
- drug-induced: diuretics, alcohol, vasodilators
- volume depletion: haemorrhage, diarrhoea
314
what is cardiac syncope
- arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (SVT)
- structural: valvular, MI, HOM
- others: PE
315
inc for syncope
- CVS examination
- postural BP
- ECG
- carotid sinus massage
- tilt table test
- 24 hour ECG
316
mnx of pericarditis
Naproxen and advise bed rest
317
mnx of digoxin poisoning
digiband
318
which JVP waveform is expected to be seen in a patient with tricuspid regurg
Prominent A-wave (which signifies forceful atrial contraction)
319
what is the only recommended trx for asystole
IV adrenaline
320
Why do you give high dose, long term antibiotics for endocarditis
no vascular supply to the valves
