Cardio Flashcards
ECG findings anteroseptal MI? Which vessel supplies it?
ST elevation in the anterolateral leads V1-V4
Reciprocal changes (T wave inversion) in lead III and AVF
LAD
How does a post MI VSD present?
Shock
New pan-systolic murmur
How does papillary rupture post MI present?
Mitral regurgitation - early-to-mid systolic murmur
Cardiac failure
How do left ventricular aneurysms present?
persisting ST elevation on ECG
pain
arrhythmias
stroke
Mx of post MI VSD?
Inotropes
Balloon pump (counterpulsation inside aorta to augment blood pressure during diastole)
Percutaneous closure of defect
Consider PPV
Consider Swann Ganz pulmonary artery catheter
ECG findings anterolateral MI?
ST segment elevation leads V2, V3 and leads I and aVL
reciprocal ST segment depression in leads, II, III and aVF
What is the blood supply to the anterior/lateral wall?
LAD
What is the blood supply to the inferior wall? Where would you see ecg changes?
RCA
II, III, AVF
What is the blood supply to the posterior/lateral wall? Where would you see ecg changes?
LCA, also some RCA
V1-3
There is an increased risk of developing hyperkalaemia when ramipril is used with which drugs?
potassium-sparing diuretics
aldosterone antagonists
ciclosporin
heparins
Which drugs are likely to increase the risk of myopathy when given with simvastatin?
CYP450 inhibitors e.g.: amiodarone ciclosporin erythromycin fibrates ketoconazole
Contraindications to treatment with β-blockers?
Bronchospasm Sick sinus syndrome Peripheral arterial disease Prinzmetal angina Heart block
Define Isolated systolic hypertension
systolic pressure ≥160 mmHg with a diastolic pressure <90 mmHg
MoA of thiazide diuretics?
Inhibits sodium and chloride reabsorption in the early distal tubule via the Na-Cl co-transporter
MoA of loop diuretics?
Inhibits the luminal Na-K-Cl co-transporter in the thick ascending limb of the loop of Henle
MoA of Amiloride?
inhibits ENaC (epilthelial sodium channels)
There is a doubling of risk of stroke for every how many mmHg in mean systolic blood pressure?
15mmHg
CIs of statins?
Active liver disease
Pregnancy
Breast feeding
Infectious causes of sinus bradycardia?
Legionnaire’s disease
Typhoid fever
Lyme disease
What medications can cause digoxin toxicity?
Macrolides Thiazide diuretics Loop diuretics CCBs Amiodarone
CIs to digoxin tx?
WPW
Heart block
HOCM
SEs of verapamil?
Flushing
Headache
CIs to verapamil tx?
Chronic HF
Beta blocker use
The New York Heart Association (NYHA) 4 classes of HF?
Class 1: No limitation of physical activities
Class 2: Slight limitation of physical activity in which ordinary physical activity leads to fatigue, palpitation, dyspnea, or anginal pain; the person is comfortable at rest
Class 3: Marked limitation of physical activity in which less-than-ordinary activity results in fatigue, palpitation, dyspnea, or anginal pain; the person is comfortable at rest
Class 4: Inability to carry on any physical activity without discomfort but also symptoms of heart failure or the anginal syndrome even at rest, with increased discomfort if any physical activity is undertaken
INR target in AF?
2-3
INR target in DVT/PE?
2-3
INR target in recurrent DVT/PE?
3-4
INR target mechanical heart valve?
2.5-3.5
Example of class I anti-arrhythmic and MOA?
Lidocaine
Membrane stabilising
Example of class II anti-arrhythmic and MOA?
Beta blockers
Example of class III anti-arrhythmic and MOA?
Amiodarone
Sotalol
act on both supraventricular and ventricular arrhythmias
Example of class IV anti-arrhythmic and MOA?
CCBs
CIs to amiodarone tx?
Sinus bradycardia
Sino-atrial heart block
What should you do if INR >8 and not bleeding?
Give Vit K (IV orally)
Stop warfarin until INR <5
ECG findings WPW? What is the accessory pathway called and what type of arrhythmia is it?
Short PR
Slurred upstroke (delta wave)
Broad QRS
Bundle of Kent - AVRT
Medical tx for WPW?
Sotalol
Flecainide/Procainamide
Amiodarone
Major Modified Jones Criteria for rheumatic fever?
carditis, cardiac murmur, subcutaneous nodule, arthritis (migratory large joints), erythema marginatum (red geographical rash), chorea (Sydenham’s, St Vitus dance)
Minor Modified Jones Criteria for rheumatic fever?
fever, raised ESR/CRP, long PR interval, arthralgia
Tx of acute rheumatic fever?
Benzylpenicillin 1.2mg IM stat
10 day course po penicillin V
NSAIDs
Long term secondary abx prevention can be needed for up to 10 years if mild murmur of lifelong if loud murmur
Mitral stenosis on auscultation?
Tapping apex (palpable and loud first HS) Low rumbling mid-diastolic murmur
What are two signs of mitral stenosis on ECG?
Bifid p waves (P mitrale)
No p waves
Major diagnostic criteria for infective endocarditis?
1+ positive blood culture (typical organism in 2 separate cultures or presistently positive blood cultures)
Positive echocardiogram findings of vegetation, abscess or abscess prosthetic valve
Minor diagnostic criteria for infective endocarditis?
predisposition (cardiac lesion, IV drug abuse);
fever over 38 °C;
vascular signs, e.g. mycotic emboli, Janeway lesions (painless palmar/plantar macules);
immunological signs e.g. Oslers nodes (painful swelling fingers/toes), positive RhF, glomerulonephritis
microbiological evidence not fitting major criteria
How is diagnosis made of infective endocarditis?
2 major, 1 major/3minor or >5 minor criteria
Why should NSAIDs not be prescribed with digoxin?
Digoxin is renally cleared so can become toxic if NSAIDs are prescribed and decrease renal clearance
ECG changes in digoxin toxicity?
Flattened, inverted, or biphasic T waves
Shortened QT interval (scooped)
Downsloping ST depression
Symptoms of digoxin toxicity?
nausea, vomiting, abdominal pain, headache, dizziness, confusion, delirium and vision disturbance (blurred or yellow vision)
Main ecg finding in hypercalcaemia?
Shortening of QT interval
What is coarctation of the aorta associated with?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
Auscultation of coarctation of aorta?
mid systolic murmur, maximal over back
apical click from the aortic valve
Mx of AF if obvious reversible cause?
Rhythm control
What is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?
Bisoprolol
When to give 3 (stacked) shocks in cardiac arrest?
If a patient has a monitored and witnessed cardiac arrest in the catheter laboratory, coronary care unit, a critical care area or whilst monitored after cardiac surgery, and a manual defibrillator is rapidly available and shows VF/pVT
What to do regarding anti diabetic meds in ACS?
Stop oral agents and switch to sliding scale insulin
first line investigation for stable chest pain of suspected coronary artery disease aetiology?
Contrast-enhanced CT coronary angiogram
Whatis Killip class used for and what are the 4 classes?
system used to stratify risk post myocardial infarction I: No clinical signs heart failure II: Lung crackles, S3 III: Frank pulmonary oedema IV: Cardiogenic shock
What to do if major bleeding in someone on warfarin?
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
What to do if INR >8 and minor bleeding on warfarin?
Stop warfarin
Give intravenous vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0
What to do if INR 5.0-8.0 and minor bleeding on warfarin?
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
What to do if INR 5.0-8.0 and no bleeding on warfarin?
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
Gradient cut off for valve replacement in AS?
SA cut off?
> 40 mmHg (unless symptomatic)
<1cm squared
2nd line antihypertensive in black patients after CCB?
ARB in preference to an ACE inhibitor
1st line tx in angina?
Beta blocker or CCB
if CCB monotherapy give diltiazem/verapamil
if CCB given with BB give nifedipine (long acting)
3rd line = long-acting nitrate, ivabradine, nicorandil or ranolazine
What is Wellen’s syndrome? What do you see on ecg?
specific ecg abnormalities in the precordial T-wave segment, which are associated with critical stenosis of the proximal left anterior descending
ECG: deeply inverted or biphasic waves in V2-3 in a person with the previous history of angina
NSTEMI (managed conservatively) antiplatelet choice?
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
STEMI antiplatelet prior to PCI?
aspirin, plus either:
if the patient is not taking an oral anticoagulant: prasugrel
if taking an oral anticoagulant: clopidogrel
Drug therapy during PCI in STEMI?
Radial access: unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
Femoral access: bivalirudin with bailout GPI
NSTEMI drugs if PCI tx not immediate?
aspirin + fondaparinux (if not high risk of bleeding)
NSTEMI drugs if PCI tx immediate? What is the other indication for this tx?
aspirin + unfractionated heparin
creatinine is > 265 µmol/L
Drug therapy during PCI in NSTEMI?
unfractionated heparin (regardless of whether pt had fondaparinux or not)
further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI:
- if not on oral anticoagulant: prasugrel or ticagrelor
- if on oral anticoagulant: clopidogrelChronic HF with preserved ejection fraction tx? BASHD
Beta-blocker + ACEi
Spironolactone/eplerenone (reduces LV fibrosis)
Ivabradine/sacubitril-valsartan/Hydralazine in combination with nitrate/Digoxin (symptomatic relief only)/cardiac resynchronisation therapy
What valve abnormality is associated with polycystic kidney disease?
Mitral valve prolapse
Clinical features of mitral valve prolapse?
patients may complain of atypical chest pain or palpitations
mid-systolic click (occurs later if patient squatting)
late systolic murmur (longer if patient standing)
ECG changes in pericarditis?
widespread ‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis
Which territory MI is most likely to cause AV block?
Inferior MI
Which territory MI is most likely to cause pericarditis within 24 hours?
Transmural MI
Which territory MI is most likely to cause acute mitral regurge?
infero-posterior MI
Causes of Dilated cardiomyopathy?
alcohol
Coxsackie B virus
wet beri beri
doxorubicin
Causes of Restrictive cardiomyopathy?
amyloidosis
post-radiotherapy
Loeffler’s endocarditis (eosinophilic infiltration)
How does mitral stenosis cause haemoptysis? How else would it present?
secondary to rupture of the bronchial veins caused by raised left atrial pressure
Loud 1st HS
Diastolic murmur
New onset AF
Posterior MI ecg changes?
Leads V1-V3 - reciprocal STEMI changes horizontal ST depression tall, broad R waves upright T waves dominant R wave in V2
Complete heart block following a MI?
right coronary artery lesion
Causes of a prolonged QT interval?
Congenital: Romano Ward, Jervell-Lange-Nielsen
Drugs: Amiodarone, sotalol, TCAs, SSRIs, methadone, chloroquine, erythryomycin, haloperidol, ondansetron
Electrolytes: Hypokalaemia, hypomagnesaemia, hypocalcaemia
Acute MI
Hypothermia
SAH
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ < 4.5mmol/l?
Add spironolactone
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ > 4.5mmol/l
Add alpha or beta blocker
What drug should not be used in VT?
Verapamil
Which artery supplies the posterior intraventricular septum usually?
posterior descending artery (80% of the time a branch of the RCA)
ECG changes for thrombolysis or percutaneous intervention?
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
Which antihypertensive is most likely to cause a reduction in bone mineral density?
Loop diuretics (hypocalcaemia)
Most common causative organism of bacterial endocarditis?
Staphylococcus aureus
Staphylococcus epidermidis if < 2 months post valve surgery
Strep viridans if subacute
Endocarditis empirical tx?
Native valve endocarditis (NVE): amoxicillin + gentamicin
NVE with severe sepsis, penicillin allergy or suspected MRSA: vancomycin + gentamicin
NVE with severe sepsis and RFs for gram -ve infection: vancomycin + meropenem
Prosthetic valve endocarditis: vancomycin, gentamicin + rifampicin
What to do regarding shocks if a patient is in cardiac arrest due to hypothermia?
defibrillation is less effective and only 3 shocks should be administered before the patient is rewarmed to 30 degrees centigrade
Bifascicular block ecg findings?
RBBB + Left axis deviation (secondary to LAFB)
Trifascicular block ecg findings?
Trifascicular block (Complete) = Bifascicular + 3rd degree Heart block Trifascicular block (incomplete) = Bifascicular + 1st/2nd degree heart block
HOCM A to E mx?
Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*
Drugs to avoid in HOCM?
nitrates
ACE-inhibitors
inotropes
Digoxin
VT Mx?
If HISS - synchronised DC cardioversion
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
If drugs fail: electrophysiological study, implant ICD (esp if LV function poor)
What is WPW associated with?
- Congenital cardiac defects
- Ebstein’s anomaly
- Mitral valve prolapse
- Cardiomyopathies e.g. HOCM
What drugs are CI in WPW and why?
What can you give instead?
Any AVN-modulating agents such as adenosine, verapamil, diltiazem, beta-blockers, digoxin
Can lead to VF (transmission down accessory path)
Can give amiodarone, flecainide or sotalol
GRACE score components?
age heart rate blood pressure cardiac (Killip class) renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels
HOCM ecg changes?
Left Ventricular hypertrophy
Non-specific T wave inversions/ST abnormalities
Deep Q waves
Sometimes AF
Echo findings in hocm? MR SAM ASH
mitral regurgitation (MR) systolic anterior motion (SAM) of the anterior mitral valve leaflet asymmetric hypertrophy (ASH)
In patients with gout on an ACEi for HTN, what is the next best additional tx?
CCB
SE of nicorandil and who is at increased risk?
GI ulcers
Patients with diverticular disease
Which anti-anginal drugs can result in tolerance and how can this be mitigated?
Nitrates
A nitrate-free interval each day (lasting at least 4 hours) should be ensured to maintain sensitivity - this involves either taking the second dose at an earlier time (e.g. 8 am and 3 pm) or switching to a once-daily modified-release preparation
Which anti-anginal med can cause reduced libido and erectile dysfunction?
Beta blockers
Clinical features of Takayasu’s arteritis?
Intermittent limb claudication
Absent or weak peripheral pulses
Young woman
What is useful for measuring re-infarction 4-10 days after initial MI?
CK-MB
What can cause a falsely low BNP?
Aldosterone antagonists
Beta blockers
ACEi/ARBs
Diuretics
Tx for a stroke with concurrent AF?
Aspirin 300mg (2 week) + warfarin/DOAC life long for post stroke
Causes of LBBB?
MI Aortic stenosis Dilated cardiomyopathy Chronic HTN Extensive coronary artery disease
Which drugs increase and decrease INR on warfarin?
Inducers: cause decrease in INR “SCARS” • S → Smoking • C → Chronic alcohol intake • A → Antiepileptics: Phenytoin, Carbamazepine, Phenobarbitone (all barbiturates) • R → Rifampicin • S → St John's Wort
Inhibitors: cause increase in INR
“ASS-ZOLES”
• A → Antibiotics: Ciprofloxacin, Erythromycin, Isoniazid, Clarithromycin
• S → SSRIs: Fluoxetine, Sertraline
• S → Sodium Valproate
• - Zoles → Omeprazole, Ketoconazole, Fluconazole
Causes of S3?
Normal if <30y/o
LVF (dilated cardiomyopathy)
Constrictive pericarditis
Mitral regurgitation
Causes of S4?
Aortic stenosis
HOCM (may also feel double pulsation at apex)
HTN
How does a left ventricular aneurysm cause a stroke?
Thrombus can form within the aneurysm
How does left ventricular free wall rupture present?
Recent MI
Sudden HF
Raised JVP
Pulsus paradoxus
When to start treating HTN in patients >80y/o?
Do not treat stage 1: 135/85
Treat stage 2: 150/95
What is electrical alternans a pathognomic sign of?
Cardiac tamponade
Rate control in AF if asthmatic?
Diltiazem
The criteria for urgent valvular replacement in infective endocarditis?
Severe congestive cardiac failure
Overwhelming sepsis despite antibiotic therapy (+/- perivalvular abscess, fistulae, perforation)
Recurrent embolic episodes despite antibiotic therapy
Pregnancy
ASD murmur?
ejection systolic murmur louder on inspiration
ix for suspected aortic dissection?
Stable: CTA chest abdo pelvis
Unstable: TOE
DVLA advice for heart issues?
CABG: 4 weeks ACS: 4 weeks PCI: 1 week Pacemaker: 1 week Angina: stop if symptoms at wheel Transplant: 6 weeks Group 2 ICD: permanent ban
ECG findings in hypothermia?
bradycardia 'J' wave - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias
Causes of orthostatic hypotension?
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
physiological: pregnancy, post-prandial
ECG findings in dextrocardia?
inverted P wave in lead I
right axis deviation
loss of R wave progression
Features of Buerger’s disease?
extremity ischaemia - intermittent claudication - ischaemic ulcers superficial thrombophlebitis Raynaud's phenomenon
Progression of an ecg in an STEMI?
- Hyperacute T waves
- ST elevation
- T wave inversion (within first 24 hours)
- Pathological Q waves (hours to days)
Infective endocarditis caused by fully-sensitive streptococci (e.g. viridans) tx?
Benzylpenicillin
If penicillin allergic: vancomycin + low-dose gentamicin
Infective Endocarditis caused by less sensitive streptococci tx?
Benzylpenicillin + low-dose gentamicin
If penicillin allergic
vancomycin + low-dose gentamicin
Most common cause of drug-induced angioedema?
ACEi
Drugs contra-indicated in AS?
CCBs
GTN and nitrites
ACEi (moderate to severe AS)
Indications for permanent pacemaker?
mobitz II
complete heart block
HFrEF with EF <35%
some HOCM
How do you manage patients with stable CVD who have AF?
Anticoagulate only
Indications for temporary pacemaker?
symptomatic/haemodynamically unstable bradycardia, not responding to atropine
post-ANTERIOR MI: type 2 or complete heart block*
trifascicular block prior to surgery
How to differentiate between Type A and B WPW?
type A (left-sided pathway): dominant R wave in V1 type B (right-sided pathway): no dominant R wave in V1
