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Year 6 > Cardio > Flashcards

Cardio Flashcards

1
Q

Aortic stenosis

  • pulse
  • HS
  • murmur
A

slow rising, narrow pulse pressure <30

HS:
soft S2 ± S4 (blood filling a non-compliant ventricle)

ejection systolic murmur
Right 2nd ICS, radiates to carotids

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2
Q

Aortic stenosis Sx

A

SAD

syncope
angina
dyspnoea

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3
Q

Aortic stenosis Ix

A
  • ECG (LVH, arrhythmias)
  • Bloods (FBC, U&E, BNP, lipids, glucose)
  • CXR (calcified valves, LVH, pul. oedema)
  • Echo ± doppler (severity, cause, LV function); severe AS:
  • – Valve area <1cm2
  • – Pressure gradient >40mmHg]
  • – Jet velocity >4m/s
  • Coronary angiography
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4
Q

Aortic stenosis Mx

A

General:

  • MDT (cardio, GP, specialist nurse, surgeon, dietician)
  • RF modification (statin, anti platelet, manage HTN angina)
  • regular f/u

Surgery

1) open replacement
(ix: symptomatic, non-symptomatic w/ low EF (<50%), severe undergoing CABG)

–> artificial
——Starr-Edwards / ball-in-cage (3 artificial sounds:)
Quiet click as valve opens
Rumbling as ball rolls in the cage
Loud thud as valve closes
——Tilting disc / bileaflet [1 artificial sound]
High-pitched click as valve closes

–> biological (normal HS)

2) TAVI (transcatheter AV implantation)
+ve = no bypass required, no large scars
-ve = higher risk of stroke compared to open

3) balloon valvuloplasty
4) sutureless AV replacement

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5
Q

Aortic regurgitation

  • peripheral signs
  • pulse
  • apex
  • HS
  • murmur
A
  • all the peripheral signs e.g. Beckers, de musset, corrigans neck sign, quincke’s
  • Corrigan’s pulse (water hammer), wide pulse pressure e.g. 180/45

displaced apex

HS: soft S2 + S3 (blood filling a compliant ventricle)

Murmur:

  • Early diastolic murmur
  • LLSE
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6
Q

Becker’s sign

A

AR

Retinal artery pulsation

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7
Q

Mueller’s sign

A

AR

systolic pulsations of the uvula

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8
Q

De Musset’s sign

A

AR

nodding head

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9
Q

Corrignan;s neck sign

A

AR

carotid pulsation

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10
Q

Quincke’s sign

A

AR

pulsatile nail bed

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11
Q

Traube’s sign

A

AR

pistol shot femoral pulses

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12
Q

Duroziez’s sign

A

AR

femoral artery compression - systolic murmur on proximal compression, diastolic murmur on distal compression

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13
Q

Severe AR S+S

A

collapsing pulse, wide PP, LVF

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14
Q

AR Ix

A
  • ECG (LVH, LV strain – lateral lead TWI)
  • Bloods (FBC, U&E, NT-proBNP, lipids, glucose, ESR, HLA-B27, ANA)
  • CXR (cardiomegaly, LVH, pul. oedema)
  • Echo ± doppler (severity, cause, LV function); severe AR:
     Jet width (>65% outflow tract)
     Regurgitant jet volume
     Premature closing of mitral valve
  • Coronary angiography
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15
Q

AR Mx

A

General same as AS (MDT, RF modification, Regular FU)

Medical
- reduce afterload using ACEi, BB, diuretics

Surgical

  • Vavle replacement before LV dilation and dysfunction:
  • — Pulse pressure >100mmHg
  • — ECG changes (TWI in lateral leads)
  • — LV enlargement on CXR or EF <50%
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16
Q

Mitral stenosis

  • peripheral
  • pulse
  • apex
  • HS
  • murmur
A

malar flush

  • irregular AF pulse
  • tapping apex (palpable S1)

HS
- loud S1 (early diastolic opeining snap) + loud S2 if pulmonary HTN

Murmur

  • mid diastolic murmur - in left lateral position at end expiration in apex
  • radiated to axilla
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17
Q

Severe MS S+S

A

malar flush, longer murmur, LVF

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18
Q

Evidence of pulmonary HTN

A

malar flush
raised JVP with large V waves
RV heave
Loud S2

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19
Q

MS Ix

A
  • ECG (P-mitrale, AF)
  • Bloods (FBC, U&E, NT-proBNP, lipids, glucose)
  • CXR (LA hypertrophy (splaying of carina), calcified mitral valve, pul. oedema)
  • Echo ± doppler (severity, cusp calcification, LV function, ? TOE); severe MS:
  • – Valve orifice <1cm2
  • – Pressure gradient >10mmHg
  • – Pul. artery SBP >50mmHg
  • Coronary angiography
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20
Q

Mitral stenosis Mx

A

General
- MDT, RF modification, regular FU

Medical

  • RhF prophylaxis (benxyylpenicillin)
  • AF - rate control and DOAC
  • diuretics for Sx relief

Surgical (indication = moderate severe MS symptomatic or non)
1st = balloon vavluloplasty
- valvotomy / commissutotomy (valve repair)
- valve replacement if repair not possible

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21
Q

Mitral regurgitation

  • pulse
  • apex
  • HS
  • murmur
A

irregular pulse (AF)

Apex displaced

Sounds - Soft S1 (Loud S2 if pulmonary HTN)

Murmur

  • pan systolic murmur
  • left lateral position at end expiration in apec
  • radiates to axilla
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22
Q

Severe MR S+S

A

LVF, AF

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23
Q

Mitral regurgitation Ix

A
  • ECG (P-mitrale, AF, LVH)
  • Bloods (FBC, U&E, NT-proBNP, lipids, glucose)
  • CXR (LA/LV hypertrophy, calcified mitral valve, pul. oedema)
  • Echo ± doppler (severity, cusp calcification, LV function); severe MR:
  • – Jet width >0.6cm
  • – Systolic pul. flow reversal
  • – Regurgitant volume >60mL
  • Coronary angiography
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24
Q

Mitral regurgitation Mx

A

General
- MDT, RF mod, regular FU

Medical
- AF (rate and rhythm control, anticoagulation)

(AR and MR medical mx is to reduce afterload)

Surgical (symptomatic)
- valve replacement / repair

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25
Q

Heart failure New York Heart Association Classification

A

1 – no limitation of activity

2 – comfortable at rest, dyspnoea on ordinary activity

3 – marked limitation of ordinary activity

4 – dyspnoea at rest

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26
Q

Normal EF

A

45-60%

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27
Q

HF Mx

A

BASHIeD up heart

BB
ACEi
Spironolactone
Hydralazine / Ivabradine 
Digoxin

1st line
BB + ACEi / ARB
(reduced EF - use BB or ACEi)
(preserved EF - use loop diuretic)

BB + Entresto (Sacubitril+valsartan) if ejection fraction <35%

2nd line
BB + ACEi/ ARB + spironolactone
– monitor K

3rd line
Ivabradine - EF <35%, sinus rhythm HR >75
Hydralazine+ nitrate - best for afro-caribbean
Cardiac resynchronisation therapy if patient has widened QRS
Digoxin

Repeat echo in 3 months after starting treatment

Pneumococcal and flu vaccines

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28
Q

Contraindicated drugs in HF

A

Thiozoladinediones

Verapamil (-ve inotrope)

NSAIDs (fluid retention)

Glucocorticoids (fluid retention)

Flecainide (-ve inotrope, arrhythmogenic)

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29
Q

Angina S+S

A

Sharp chest pain
Precipitated by physical exertion
Relieved by GTN spray within 5 min

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30
Q

Criteria for stable, atypical and non-anginal pain

A

Stable 3/3
Atypical 2/3
Non <1/3

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31
Q

Stable angina Ix

A

1st - CTCA – calcium score

2nd - non invasive functional imaging

  • MPS SPECT (Myocardial Perfusion Scintigraphy with single photon emission CT)
  • stress echo
  • first pass contrast enhanced MR perfusion
  • MR imaging for stress-induced wall motion abnormalities

3rd - coronary angiography

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32
Q

Stable angina Mx

A

Conservative
- stop smoking, weight loss, healthy diet

All receive aspirin + statin

1st
- GTN + BB / CCB

BB = atenolol 50-100mg OD
CCB = non-DHP, rate limiting e.g. verepamil, diltiazem

Increase to max dose

2nd
- GTN + BB + CCB

BB = Atenolol 50-100mg OD
CCB = DHP, non-rate limiting e.g. nifedipine, amlodipine

3rd- other options (instead of BB/CCB):

  • long acting nitrate e.g. ISMN 20-40mg BD or slow release nitrate Imdur 60mg OD
  • Ivabradine
  • Nicorandil
  • Ranolazine

if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

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33
Q

Secondary prevention of Angina

A
    • aspirin 75mg OD,
    • atorvastatin 80mh ON
    • ACEi
    • antihypertensives
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34
Q

Why can’t you give a BB with a non-DHP CCB

A

interacts with AVN conduction and can cause complete heart block

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35
Q

non-DHP CCB examples

A

Rate limiting

verapamil
diltiazem

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36
Q

DHP CCB examples

A

non rate limiting

amlodipine
nifedipine

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37
Q

BB CI

A

hypotension, bradycardia, asthma, HF

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38
Q

CCB CI

A

hypotension, bradycardia, peripheral oedema

DHP/ non rate limiting better than non-DHP for peripheral oedema

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39
Q

AF causes

A
  • ischaemic heart disease
  • rheumatic HD (MR, MS)
  • hyperthyroid
  • infection
  • PE
  • cardiomyopathy
  • alcohol
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40
Q

Types of AF

A

Acute <48h

Paroxysmal - self limiting, <7d, recurs

Persistent - >7d, may recur even after cardio version

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41
Q

Stroke + AF - medication

A

Anticoagulant e.g. apixaban

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42
Q

Stroke + no AF - medication

A

Antiplatelet e.g. clopidogrel / ticagrelor

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43
Q

AF Mx

use rhythm control if

A

reversible AF

coexistent HF

new onset AF

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44
Q

Rhythm control in AF

A

Acutely
Antgicoagulation required if onset 24-48 hours, for 4 weeks

1st - electrical cardio version (synchronised DC shocks)

2nd - pharmacological cardioversion

    • flecainide (young, no structural heart disease)
    • amiodarone (old, structural heart disease e.g. HF)

Long term:
1st - BB e.g. bisoprolol

Paroxysmal – ‘pill in pocket’ flecainide (not in structural HD), amiodarone

BB failed/ CI –> amiodarone

Pacing

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45
Q

Rate control in AF

A

1st - BB e.g. bisoprolol or rate limiting CCB/ non DHP e.g. verapamil (CI in peripheral oedema)

2nd - digoxin

3rd - amiodarone

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46
Q

Anticoagulation in AF

A

remember that antiplatelets are used in arterial causes for clots e.g. atheroma

anticoagulation in venous causes

CHASVASC 1+ anticoagulate in men, 2+ in women

AF<48h - LMWH until assessemtn

AF >48h - Apixaban > dabigatran/rivoroxaban/warfarin

    • for 3w before cardio version
    • for 4w after cardio version if Chadvasc low/ for LIFE if chadvasc high or paroxysmal
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47
Q

Severe HTN BP

A

> 180/110

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48
Q

Signs of severe HTN

Ix

A 
retinal haemorrhage 
pappiloedma 
confusion
AKI
chest pain

ADMIT

ECG, urine dip, blood tests,

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49
Q

HTN algorithm

A

If T2DM or <55 and not black

1) ACEi / ARB
2) ACEi/ARB + CCB/ thiazide like diuretic (indapamide)
3) ACEi/ARB + CCB + thiazide-like diuretic (indapamide)

4) spironolactone if K<4.5
a-blocker or BB if K>4.5

55+ or black

1) CCB
2) CCB + ACEi/ ARB/ thiazide-like diuretic
3) ACEi/ARB + CCB + thiazide like diuretic

4) spironolactone if K<4.5
a-blocker or BB if K>4.5

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50
Q

Who should we measure standing and sitting BP in?

A

People with

T2DM
people with sx of postural hypotension
80y+

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51
Q

BP targets

<80 and >80

A

<80
clinic BP <140/90
ABPM/HBPM <135/85

80 or more
clinic BP <150/90
ABPM/HBPM <145/85

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52
Q

What needs to be monitored before and during treatment with ACEi/ ARBs?

A

U+Es

increase up to 30% in creatinine is ok

increase in K up to 5.5mmol is ok

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53
Q

In which diseases are thiazides contradicted for use in HTN

A 
CKD 4 5 (eGFR<30)
DM
gout
dyslipidaemia
SLE
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54
Q

primary prevention statin

A

Atorvastatin 20mg OD

if 10y risk 10%+ or T1DM or CKD eGFR <60

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55
Q

Secondary prevention statin

A

Atorvastatin 80mg OD

IHD or CVD or PAD

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56
Q

Risk factors for infective endocarditis

A 
rheumatic heart disease
IVDU
Prostehtic valves
congenital heart defects
recent piercings
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57
Q

Valve affected in previously normal valves vs IVDU

A

normal – mitral valve

IVDU – tricuspid valve (first valve after venous circulation)

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58
Q

Organisms in IE

A

S aureus - IVDU, acute presentation

S epidermis - CoNS, prosthetic valves

S viridans - sub-acute presentation, developing world

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59
Q

culture negative organisms in IE and RF

A

RF
- prior abx, coxiella, bartonella, brucella, sub-acute presentation

HACEK

  • H influenzae
  • Actinobacillus
  • Cariobacterium
  • Eikenella corrodens
  • Kingella
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60
Q

Criteria for IE

A

Dukes criteria - BE FEVEER

2 major 
or 
1 major 3 minor
or
5 minor

Major criteria

  • Bacteraemia (2 cultures, 12 hours apart)
  • Echo (vegetation, new murmur, abscess, dehisced prosthetic valve)

Minor criteria

  • Fever >38
  • Echo findings
  • Vascular (embolus e.g. stroke PE, splinter haemorrhages, Janeway)
  • Evidence of immunological involvement (Osler nodes, Rtoh spots, glomerulonephritis, RF)
  • Evidence of microbiological involvement (1 culture +)
  • RF e.g. IVDU, predisposing heart condition
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61
Q

IE S+S

A

FROM JANE

Fever
Roth spots
Osler nodes
Murmur

Janeway lesions
Anaemia
Nail haemorrhage (splinter)
Emboli

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62
Q

IE Mx

blind therapy native / prosthetic valve

A

blind therapy
native valve
- amoxicillin
± gentamicin (low dose)

prosthetic valve
- vancomycin + rifampicin + LD gentamicin

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63
Q

IE Mx

Native valve, staphylococci

A

Flucloxacillin

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64
Q

IE Mx

Prosthetic valve, staphylococci

A

Flucloxacillin + rifampicin + LD gentamicin

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65
Q

IE Mx

Streptococci (fully sensitive)

A

benzylpenicillin

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66
Q

IE Mx

Streptococci (not fully sensitive)

A

Benzylpenicillin + LD gentamicin

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67
Q

IE Mx

if pen allergic or MRSA

A

Amoxicillin –> vancomycin + LD gentamicin

Flucloxacillin –> vancomycin + rifampicin

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68
Q

rheumatic fever/ heart disease aetiology

A

Group A β-haemolytic streptococcus (S. pyogenes; GAS)

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69
Q

rheumatic fever/ heart disease

latent interval

A

2-6 weeks after pharyngeal infection

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70
Q

rheumatic fever/ heart disease

S+S

A 
poly arthritis (tender joints, swelling)
pericarditis (endocarditis, myocarditis, pericarditis)
erythema marginatum

synenham;s chorea 2-6 months later

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71
Q

rheumatic fever/ heart disease chronic progression

A

MS

chronic progression in 60-80%

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72
Q

rheumatic fever/ heart disease

diagnostic criteria

A

Jones criteria

2 major or 1 major + 2 minor

Major = CASES

  • carditis
  • arthritis
  • Subcutaneous nodules
  • erythema marginatum
  • syndenham’s chorea

Minor = FRAPP

  • fever
  • raised ESR./ CRP
  • arthralgia
  • prolonged PR interbal
  • previous RF
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73
Q

rheumatic fever/ heart disease Ix

A

Bloods FBC ESR ASOT
ECG
Echo

74
Q

rheumatic fever/ heart disease Acute Mx

A

Acute

  • bed rest until CRP normal for 2 weeks
  • analgesia (NSAIDs, aspirin)
  • phenoxymethylpenicillin (penicillin V QDS 10/7) or azithromycin if pen-allergic

CCF/ cardiomegaly or 3rd degree heart block – corticosteroids

sydenhams chorea – haloperidol, diazepam,

75
Q

rheumatic fever/ heart disease prophylaxis

A

Once monthly IM benzylpenicillin or

BD PO 250mg phenozymethylpenicillin

± surgical valve repair/ replacement

76
Q

Pericarditis causes

A 
Viral - coxsackie
TB
uraemia (fibrinous pericarditis)
post MI, dressler's
hypothyroid 
Trauma 
Malignancy 
CTD
77
Q

Pericarditis S+S

A 
pleuritic chest pain
non productive cough
dyspnoea 
flu like sx
pericardial rub 
tachypnoea 
tachycardia
78
Q

Pericarditis Ix

A
  • ECG - widespread
    PR depression > saddle-shaped ST elevation
  • TTE
  • troponin (may/ may not be raised)
79
Q

Pericarditis Mx

A

Treat cause

1st - NSAIDs ± colchicine

80
Q

Aortic stenosis

Murmur
Location
Radiation
HS

A

Murmur = ejection systolic murmur

Location = R 2nd ICS parasternal

Radiation = to carotids

HS = Soft S2 ± S4

81
Q

Aortic regurgitation

Murmur
Location
Radiation
HS

A

Murmur = Early diastolic

Location = L 3rd ICS, parasternal, Erb’s point

Radiation - displaced apex

HS = Soft S2 ±S3

82
Q

Mitral stenosis

Murmur
Location
Radiation
HS

A

Murmur = mid diastolic murmur

Location = apex

Radiation = axilla

HS = loud S1

83
Q

Mitral regurgitation

Murmur
Location
Radiation
HS

A

Murmur = pansystolic

Location = apex displaced

Radiation = axilla

HS = soft S1 ± loud S2 (if pulmonary HTN)

84
Q

Cause of S1

A

mitral valve closure

85
Q

Cause of S2

A

Aortic valve closure

86
Q

Cause of S3

A

blood filling a compliant ventricle

Kentucky
gallop rhythm

87
Q

Normal causes of S3

A

young, athletes, pregnancy

88
Q

Abnormal causes of S3

A

Heart failure
Aortic regurgitation
MR/TR
dilated CM

89
Q

Cause of S4

A

blood filling a non-compliant ventricle

Tennesse

90
Q

Abnormal causes of S4

A

LVH - aortic stenosis or HTN
HOCM
restrictive cardiomyopathy

91
Q

Split S1 cause

A

M1 and T1 closure at different times

92
Q

Abnormal cause of split S1

A

RBBB

93
Q

Split S2 cause

A

A1 and P1 closure at different times

94
Q

Normal cause of split S2

A

Deep inspiration -non fixed

95
Q

Abnormal cause of split S2

A 
fixed
Atrial septal defect
Pulmonary HTN
RHF
BBB
96
Q

Causes of collapsing pulse (4)

A

AR
thyrotoxicosis
pregnancy
anaemia

97
Q

Causes of Absent radial pulse (5)

A 
trauma
dead
coarctation 
thromboembolic 
Takayasu's arteritis
98
Q

Causes of impalpable apex beat

A

COPD
Obese
pericardial effusion
dextrocardia

99
Q

Features of Pulmonary HTN (5)

A 
Raised JVP 
Left parasternal heave (RVH)
Ascites/ peripheral oedema 
Loud S2
Pulsatile hepatomegaly
100
Q

Types of cardiomyopathy

2 genetic
2 mixed
2 acquired

A

2 genetic

  • HOCM
  • Arrhythmogenic right ventricular dysplasia

2 mixed

  • dilated cardiomyopathy
  • restrictive cardiomyopathy

2 acquired

  • peripartum cardiomyopathy
  • takostubo cardiomyopathy
101
Q

Causes of dilated cardiomyopathy

A

alcohol
coxsackie B
wet beri beri
doxorubicin

102
Q

Causes of restrictive cardiomyopathy

A

Amyloidosis
post radiotherapy
Loeffler’s endocarditis

103
Q

How does dilated cardiomyopathy present

A

HF - transplant, ACEi, BB, family screen

Arrhythmia - ICD

Sudden death
stroke

LV: reduced EF and contractility

Must rule out MR, AR, CAD

104
Q

Primary cardiomyopathy must have absence of

A 
CAD
HTN
valvular disease
congenital heart disease
systemic disease
105
Q

Causes of secondary cardiomyopathy

A

Infective - coxsackie B, chagas disease

Infiltrative - amyloidosis

Storage - haemochromatosis

Toxicity - doxorubicin, alcohol

Inflammatory - sarcoidosis

Endocrine - DM, thyrotoxicosis, acromegaly

Neuromsucular - Friedrichs ataxia, Duchenne-Becker muscular dystrophy

Nutritional - beri beri

Autoimmune - SLE

106
Q

CYP inducers

A

BS CRAP

Barbiturates
Sulphonylurea

Carbamazepine
Rifampicin
Alcohol (chronic excess)
Phenytoin

107
Q

CYP inhibitors

A

ZAG DeViCES

Zoles - ketoconazole, fluconazole, omeprazole
Allopurinol
Grapefruit juice
Disulfiram 
Valproate
Ciprofloxacin
Ethanol (acute excess)
Sulphonamides
108
Q

Long QT causes

A

Congenital

  • Jervell Lange Nielson syndrome (deafness)
  • Romano Ward syndrome (no deafness)

Drugs METH CATS

  • Methadone
  • Erythromycin
  • Terfenadine
  • Haloperidol
  • Chloroquine/ clarithromycin
  • Amiodarone/ azithromycin
  • TCAs
  • SSRIs - citalopram
Other 
- Hypocalcaemia 
- Hypokalaemia 
- Hypomagnesaemia 
MI 
Myocarditis 
hypothermia 
SAH
109
Q

Torsades de Pointes Tx

A

IV magnesium sulphate

110
Q

Pulsus paradoxus is…

Seen in

A

> 10mmHg drop in systolic BP during inspiration causing faint or absent pulse in inspiration

severe asthma, cardiac tamponade

111
Q

Pulsus alternans is…

seen in

A

Regular alternation of the force of arterial pulse

in severe left ventricular failure

112
Q

slow rising pulse in

A

Aortic stenosis

113
Q

Collapsing pulse is in

A

Aortic regurgitation
PDA
Hyperkinetic states e.g. anaemia, thyrotoxicosis, fever

114
Q

Bisferiens pulse is

seen in

A

double pulse - two systolic peaks

in HOCM, mixed aortic valve disease

115
Q

Jerky pulse seen in

A

HOCM

116
Q

HOCM S+S

A

Asymptomatic

Sudden death (most commonly due to ventricular arrhythmias / VF), arrhythmias, heart failure, stroke, AF, VF (sudden cardiac death), VT (collapse)

Exertional: dyspnoea, angina, syncope (from hypertrophy of ventricular septum –> functional aortic stenosis)

Examination

  • jerky pulse
  • large ‘a’ waves
  • double apex beat
  • ESM (increases with Valsalva manoeuvre and decreases on squatting, PSM of mitral regurgitation from impaired mitral valve closure)
117
Q

HOCM Ix

A

Echo (MR SAM ASH)::
 Mitral regurgitation (MR)
 Systolic anterior motion (SAM) of the anterior mitral valve leaflet
 Asymmetric hypertrophy (ASH)

ECG:
	LVH
	Non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
	Deep Q waves
	AF (occasionally)
118
Q

HOCM mx

A 
ABCDE
o	Amiodarone
o	Beta-blockers / verapamil for symptoms
o	Cardioverter defibrillator
o	Dual chamber pacemaker
o	Endocarditis prophylaxis

o Septal reduction therapies for NYHA 3-4: Myomectomy/ alcohol septal ablation
o Drugs to avoid = nitrates, ACEi, inotropes

119
Q

What is coarctation of the aorta?

A

congenital narrowing of the aorta

120
Q

Coarctation of the aorta features in children and adults

General features

A

Children
Heart failure

Adults
HTN
Notching of the inferior border of ribs

General:

  • Mid systolic murmur, maximal over back
  • Apical click from aortic valve
121
Q

Coarctation of the aorta

Associations

A

Male > Females

Turner’s syndrome
Bicuspid aortic valve
Berry aneurysms
Neurofibromatosis

122
Q

Difference between unstable angina, STEMI and NSTEMI

A

Unstable angina
- troponin normal

NSTEMI

  • troponin raised
  • no ST elevation on ECG

STEMI

  • troponin raised
  • ST elevation
123
Q

PCI vs CABG

A

PCI
- for 1 or 2 vessel disease, NOT including LAD

CABG
- 2 or 3 vessel disease, including LAD

124
Q

Leads in an anteroseptal MI

which artery

A

V1-V4

LAD

125
Q

Leads in an inferior MI

which artery

A

II, III, aVF

Right coronary artery

126
Q

Leads in an anterolateral MI

which artery

A

V4-6, I, aVL

LAD or LCx

127
Q

Leads in a lateral MI

which artery

A

I, aVL ± V5-6

LCx

128
Q

Leads in a posterior MI

which artery

A

Tall R waves V1-2

Usually LCx, also RCA

129
Q

LAD leads

A

V1-4

130
Q

RCA leads

A

II, III, aVF

131
Q

Anterior leads

A

V3-4

132
Q

Septal leads

A

V1-2

133
Q

Inferior leads

A

II, III, aVF

134
Q

Lateral leads

A

I, aVL, aVR, V5-6

135
Q

Reversible causes of MI

A

4H and T

  • Hypothermia
  • Hypoxia
  • Hypovolaemia
  • Hypokaelamia, hyperkalaemia, hypoglycaemia, acideamie
  • Thrombosis
  • Tamponase
  • Tension pneumothorax
  • Toxins
136
Q

Classification for predicting prognosis of MI

A

Killip classification

137
Q

Complications of MI

A

DARTH VADER

Death

Arrhythmia

Rupture

Thrombus

Haemorrhage

Valvular heart disease

Aneurysm

Dressler’s syndrome / pericarditis

Embolism

Re-infarction

138
Q

types of arrhythmia post MI and Mx

A

o Heart block

  • —–inferior MI = atropine
  • —-anterior MI = temporary TC pacing –> permanent pacemaker

o Tachy/ Bradyarrhythmias
—–VF = most common cause of death post MI
Pacemaker

139
Q

Types of rupture post MI

A

o Acute / 3-5 days
- acute mitral regurgitation (papillary muscle rupture; RCA)
in 15-60% of MIs

o Acute / 3-5 days - ventricular septal rupture (LAD or RCA)
1-2% of MIs

o 5 days - 2 weeks
- Left ventricular free wall rupture (LAD):
3% of MIs

140
Q

MI Complication rupture:

Acute MR S+S, Mx

A

S+S

  • pulmonary oedema
  • hypotension
  • new pan systolic murmur (no thrill, soft murmur)

Mx
- inotropes/ vasopressors, surgery

141
Q

MI Complication rupture:

Ventricular septal rupture S+S, Mx

A

S+S

  • chest pain
  • biventricular failure (acute HF)
  • shock
  • new pan systolic murmur (thrill, harsh murmur)

Mx
- inotropes/ vasopressors, surgery

142
Q

MI Complication rupture:

Left ventricular free wall rupture
S+S, Mx

A

S+S

  • HF
  • tamponade – raised JVP, muffled HS, hypotension, pulses paradoxus (exaggerated fall of BP >10mmHg during inspiration)

Mx
- Pericardiocentesis + thoracotomy

143
Q

MI Complication aneurysm:

which wall
which vessel

A

left ventricular wall

LAD involvement

144
Q

MI Complication aneurysm:

S+S, Mx

A

S+S

  • SOB
  • persistent ST elevation
  • no chest pain
  • LVF –> thrombus

Mx
- anticoagulation

145
Q

MI Complication Dressler’s vs pericarditis time frames

A

pericarditis <48h

Dressler’s 2-6 weeks

146
Q

MI Complication Dressler’s and pericarditis

S+S, Mx

A

S+S

  • Fever
  • pleuritic pain
  • pericardial effusion
  • raised ESR

Mx
- NSAIDs

147
Q

What to use to tell fi there is a re-infarction

A

CK-MB because it only stays raised for 3-4d post MI

re-infarcts happen 4-10d after initial MI

148
Q

How long does troponin stay raised for

A

10d

149
Q

General Mx of acute MI

A

D MONABASH

Dual antiplatelet therapy
– aspirin and ticagrelor

Morphine

Oxygen

Nitrate

Anticoagulant

Beta blockers

ACEi (Longer term)

Statin (Longer term)

Heparin (enoxaparin or fondaparinux)

150
Q

Morphine in acute MI dose

+ M….? dose?

A
  • 5-10mg IV
  • repeat after 5 min if needed
    + metoclopramide 10mg IV
151
Q

when do you give oxygen in acute MI

A
  • if <94%
152
Q

when do you give nitrate in acute MI

A
  • GTN if HTN or acute LVF
153
Q

Anticoagulants given in acute MI

A

Angiography ± PCI <24h
–> enoxaparin (LMWH) or unfractionated heparin or bivalirudin

Fibrionlysis
–> enoxaparin or unfractionated heparin or fondaparinux

No intervention (low GRACE)
--> Fondaparinux
154
Q

Do not give ? if PCI is possible

A

Fondaparinux

155
Q

what do you always give in NSTEMI

A

Fondaparinux

156
Q

Acute MI dual anti platelet therapy

A

Aspirin 300mg PO
+
Ticagrelor 180mg PO

157
Q

Definitive Mx of STEMI
<12h
>12h

A

<12h
+ can give PCI <120min
–> PCI

<12h
+ cannot give PCI <120min
–> thrombolysis within 12h

– do ECG 60-90min post thrombolysis - if ST elevation persisting, do PCI

> 12h
- specialist advice + anticoagulation (fondaparinux or enoxaparin)

158
Q

Long term management after MI

A

ABCDS

ACEi

  • reduces RAAS cardiac remodelling
  • if S+S HF after MI consider sprionolactone

Beta blocker or verapamil/ diltiazem

Cardiac rehab

  • diet
  • exercise 20-30min / day until slightly breathless
  • sex after 4w

DAPT

  • ACS medically managed –> aspirin + ticagrelor (stop after 12m)
  • ACS PCI managed –> aspirin + prasugrel/ ticagrelor (stop after 12m)

Statin

159
Q

Management of acute STEMI

A

DaM Beta blockers –> PCI/ thrombolysis

D = DAPT

  • aspirin 300mg PO
  • ticagrelor 180mg PO

M = Morphine
- 5-10mg IV
+ anti-emetic metoclopramide 10mg IV

B = Beta blockers

PCI or Fibrinolysis

160
Q

Management of acute chest pain

A

MONA –> GRACE

M = Morphine 5-10mg IV + metoclopramide 10mg IV

O = Oxygen

N = GTN spray

A = aspirin 300mg PO

GRACE score
GRACE >3% >72h PCI

Haemodynamically unstable - immediate PCI

161
Q

Acute pulmonary oedema S+S

A

SOB at rest

acute onset

162
Q

Causes of severe pulmonary oedema

A

Cardiovascular
- LVF (post MI, valvular heart disease) –> elevated PAWP

ARDS (trauma, malaria, drugs).–> elevated PAWP

Fluid overload

Neurogenic (head injury)

163
Q

acute pulmonary oedema Mx

A

A-E –> AHF

1) Sit up. High flow O2
2) IV diamorphine 3mg + IV metoclopramide 10mg (careful in liver failure and COPD)
3) IV furosemide 40-80mg (larger dose in renal failure)
4) SL GTN spray x2 ( if SBP >100mmHg, use IV GTN)

5) further management:
- furosemide 40-80mg
- further nitrate infusion (maintain SBP >90)
- CPAP

164
Q

Pulmonary oedema once stable Mx

A
  • daily weight
  • repeat CXR
  • manage meds
  • change to oral furosemide
  • consider thiazide
  • ACEi (LV EF <40%), BB (LV EF <35%), spironolactone
165
Q

Causes of cardiogenic shock

A 
MI
Arrhythmias 
cardiac tamponade
PE
Tension pneumothorax 
Myocarditis 
Valve destruction 
Aortic dissection
166
Q

ECG of cardiogenic shock

A

electrical alternans

167
Q

Cardiogenic shock S+S (triad)

A

Becks triad

  • hypotension
  • raised JVP
  • muffled sounds
168
Q

Ix/ Mx of cariogenic shock/ cardiac tamponade

A
  • senior review
  • pericardiocentesis

ECG, ABG, CXR, Echo
U+E, troponin, BNP, UO (catheterise)

consider CVP + arterial lines
Swan Gantz catheter / pulmonary artery catheter

169
Q

Swan Gantz catheter / pulmonary artery catheter can measure

A
  • RA and RV pressure
  • PAWP
  • filling LA pressure
  • Cardiac output
170
Q

Normal central venous pressure

A

0-6mmHg

171
Q

Complications of CV line

A

NOW
- pneumothorax, arrhythmia, failure, air embolus, bleeding, perforation

Early
- bruise, infection, occlusion

Late
- thrombosis, Horners, phrenic nerve damage, sepsis, venous stenosis

172
Q

broad complex tachycardias

A

VT including Torsades de pointes

173
Q

narrow complex tachycardias

A

sinus tachycardia
SVT
AF/ flutter
atrial tachycardia

174
Q

Mx of VF

A

non synchronised DC shock

175
Q

Mx of VT (including TdP)

A

synchronised DC shock (synch to R waves)

Drugs

  • amiodarone
  • lidocaine
  • procainamide
176
Q

Mx of Torsades de points

A

Congenital - high dose beta blockers

Drug-induced - magnesium sulphate

177
Q

Mx of broad complex tachycardias (stable, regular rhythm)

A

IV amiodarone 300mg + 900mg over 24h, central line

178
Q

Mx of narrow complex tachycardias

A

vagal manoeuvres

IV adenosine 6mg, 12mg, 12mg

179
Q

When to use adrenaline and how much

A

PEA/ asystole = immediately

VF/pVT = after 3 shocks

1mg adrenaline / 10ml 1 in 10,000 IV

180
Q

Causes of bradycardia

A
  • physiological
  • cardiac e.g. post MI, sick sinus syndrome, aortic valve disease, cardiomyopathy, sarcoid
  • non-cardiac: vasovagal, hyperkalaemia, hypothermia, raised ICP, hypothyroid
  • drug induced e.g. BB, amiodarone, verapamil , diltiazem, digoxin
181
Q

Bradycardia Mx

A

atropine 500mcg / 0.5mg IV

If no satisfactory response, do one of:
- repeat atropine every 3-5 min. Max = 6 doses (3mg)

  • transcutaneous pacing (pads on chest giving small shocks) –> interventional radiology thread a catheter into the heart –> transvenous pacing
  • isoprenaline 5mcg/ min IVI
  • adrenaline 2-10mcg/ min IVI

Year 6 (8 decks)

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