Cardio Flashcards
Long term Medical treatment of MI
ACEi
Beta blocker
Statin
Dual AP
Immediate treatment of MI
DAPT- 300mg aspirin, 180mg ticagrelor
Anticoagulate- LMWH
Morphine
BB- not if low BP/HR
PCI- <12 hrs and <120 mins of fibrinolysis
Fibrinolysis <12hours too
4Hs and 4Ts of cardiac arrest
Hypothermia
Hypokalaemia
Hypoxia
Hypovolaemia
Tension Pneumothorax
Thrombosis
Tamponade
Toxins
Posterior MI on ECG
Tall R V1-2
Or ST depression on anterior leads
When should you give PCI after thrombolysis
If ST elevation persists after 60 mins
NSTEMI with a GRACE score >3% management
CA within 72 hours
Contraindications to thrombolysis
ABC SHIP
Aortic dissection
Bleeding
Coag disorders
Stroke <3 months
Hypertension (severe)
Intracranial neoplasm/injury
Pregnancy
Which marker to use for assessing re-infarction
CK-MB
Treatment of HF
ACEi and Beta blocker- poor EF - <45
Furosemide- normal - 45-60
Add SGLT2 inhibitor
Add Entresto- angiotensin receptor-neprilysin inhibitor
Spironolactone added
Management of Acute pulmonary oedema
o (1) Sit them up high-flow O2 (if SpO2 decreased)
o (2) IV diamorphine (3mg) + IV metoclopramide (10mg) [caution in liver failure and COPD]
o (3) IV furosemide (40-80mg) [larger dose in renal failure]
o (4) SL GTN spray x2 [if SBP ≥100mmHg, use IV GTN]
Treatment of angina
BB
Aspirin
Artovostatin
GTN spray
Q risk score and statin dose
Q risk above 10%- offer
Above 20%
20mg artovostatin
Pericarditis sign and symptoms
Pericardial rub
Widespread PR depression
Saddle back
Trops raised
Previous Inf
LBBB on ecg
Wide QRS complez
W in V1
M in V6
ECG of hypokalaemia
U waves after T waves
T waves absent or sine like
Prolonged PR
Hypothermia ECG and shocks
J waves, bradycardia
Causes VF
Shock 3 times- then only when body temp >30
Management of VF/VT with adverse signs
Shock 3 times
Amiodarone 300mg IV
Management of SVT
Vagal manoeuvres
Adenosine- 6,12,18mg
May cause chest pain
Cause of Torsades de pointes
Macrolides
Amiodarone
Normal PR
120-200ms
3-5 small squares
Normal QRS
80-100ms
2-3 small squares
Normal QT interval
350-450ms
Step 4 intervention of HTN
Spironolactone if K <4.5
If K>4.5 BB or AB
Treatment of bradycardia
Atropine IV 0.5mg
Investigations and features of IE
3 blood culture
Echo
Urine dipstick
Splenomegaly
TIA, complete HB, HF, AKI
Positive RF
S3 vs S4 causes and sound
S3- normal if <30- Kentucky
Dilated- forced blood hitting compliant ventricle
S4- contracted- Tennessee
Non compliant ventricle- restrictive
Treatment of Rheumatic fever
IM benzene then Pen
Surgery if severe carditis/CF
Feature of mitral stenosis
RF big cause
Tapping beat - due to loud s1
Often in A fib
Open snap after s2- then decrescendo- crescendo
Loud s1- due to stiff valve
Features of aortic stenosis
Radiates to neck
Under 60- bicuspid
Require replacement
Forceful apex beat, non displaced
Severe
SAD- syncope, angina, dyspnoea
Feature of aortic dissection
Often hypertensive then shock
Widened mediastinum and dilated aorta
Can present with neuro deficits- compression of symp branch- horners
Type 1- ascending, arch, descending
2- ascending
3- descending
Takotsubo cardiomyopathy features
After stressor
Raised trops
ST eleveation in anterior leads
Octopus
Wellens syndrome features
LAD stenosis
Inverted/biphasic T waves
Chest pain
Self resolving
How MI can present in older patient
Without chest pain
Sweating
SOB
Tachycardia and pneoa
Tx of paroxysmal AF
AC even if short
CHADSVASc score
CHF
HTN
Age- 75-2 or 65-1
Diabetes
Stroke- or TIA 2
Vascular
Sex- female
If 1- consider if male
2- AC
Aortic regurgitation sx
Wide pulse pressure
Head nodding
Quinckes sign- nail pulse
Collapsing
Early diastolic
Displaced apex beat
Acute heart failure causes
CHAMP
ACS
HTN crisis
Arrythmia
Mechanical- valve
PE
AHF treatment
O2
Frusemide
Nitrites
Inotropes
NIV
Mx of cocaine induced ACS
Benzo to calm
GTN to dilate
Sodium bicarb if arrhythmic, or mgso4 for torsades
Left ventricular aneurysm sx and ix
HF symptoms - crackles- s3 +4
Persistent ST elevation after MI
Ix of stable angina
CT angiogram
Tx of aortic stenosis
MDT
RF modification- statin, AP, HTN
Treat if gradient >40mmHg or symptomatic
Surgical - TAVI- >75
SAVR- <75
Tx of Aortic regurg
MDT
RF Modification
Reduce afterload- ACEi, BB- less regurg
If symptomatic
Surgical- valve replacement before LV dilatation
Tx of Aortic regurg
MDT
RF Modification
Reduce afterload- ACEi, BB
Surgical- before LV dilatation
Tx of Mitral stenosis
Rhf Prophylaxis
AF rate and DOAC
If symptomatic
Surgical- moderate to severe- balloon valvuloplasty- not if calcified valve
ECG signs on mitral stenosis
Atrial fibrillation
P mitrale- left atrial enlargement- biphasic p wave
P pulmonale
Peaked/high p waves
Right atrium enlargement- increased pulmonary circulation pressure or pulmonary stenosis
Features of mitral regurg
Dyspnoea, AF
Left parasternal heave- RVH
Displaced Apex
CI drugs in HF
Glucocorticoids- fluid
NSAIDs- fluid
Verapamil
Thiozoladinediones- PPAR- fluid
Dukes criteria
BE FEVER- 2 major, 1 major 3 minor, 5 minor
Blood cultures- 2 12 hours
Echo- vegitation, new murmur
Fever
Echo- not major
Vascular- embolism, splinter, janeway
Evidence- immunological- osler, roth, GN, RF, micro- 1 culture
RF- IVDU
Rheumatic fever classification and path
GAS- s pyogenes
JONES
Joint, carditis, nodules, erythema marginatum, Sydenham chorea
Minor
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
1 major 2 minor
or 2 major
Tx of IE
Strep viridans- BP- sub acute
S aureus- flucloxacillin- acute- IVDU
Pericarditis Causes and Tx
Post MI, Viral, malignancy, uraemia, drugs, inflammatory- rheumatoid, SLE, Behcets, sarcoid
NSAIDs or Colchicine
Drugs that inhibit CYP- interactions
AAACDE V
Acute alcohol
Allopurinol
Azoles
Cipro/ cimetidine
Disulifram
Erythromycin
Valproate
Cause of long QT
Antipsychotic
Antibiotics- clarithromycin, erythromycin
Antidepressants- SSRI- citalopram, TCA
Amiodarone
Pacemaker vs ICD on CXR
ICD- thicker
Types of pacemaker
Single chamber- 1 lead in right atrium through vein- sinus node disease- problem with SA
Or ventricular- AV node
Dual chamber- right atrium and right ventricle- heart block
Bi-ventricular- 3 leads- left through coronary vein
Atrial lead not always needed
Pacemaker ECG
Sharp line before p- atrial
Before QRS- ventricular
Before both- dual chamber
What is Pulsus paradoxes and its causes
When inspiration causes a lower systolic BP
increase return- bulges into left- reducing outflow
Tamponade, severe asthma
Tx of angina
BB/CCB, statin and aspirin
If symptoms continue add in CCB/BB- if on BB add amlodipine
If on CCB and asthmatic add in long acting nitrate
If ACEi causes cough
Stop ACEi and prescribe ARB
Causes of Torsades de pointes
Long QT interval
Medications
TCA, AP, erythromycin,
Hypocalcaemia, hypomagnesium, hypokalaemia
Hypothermia
SAH
When to admit because of BP
> 180/120
AND
life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury
Infective Endocarditis Sx
Roth spots
Petechiae
Splenomegaly
Haematuria
Janeway lesions
Osler nodes
Rheumatic fever presentation over time
Acute- JONES
Chronic- hear valves- 20 years later
Why viridians affects mitral valve
Due to it being weak and can only affect damaged valve
What to see on CXR of mitral stenosis
left atrial dilatation
Splattered dense opacities - haemosiderin
Women presents with rosey cheeks and dyspnoea what does she have
Malar flush
Mitral stenosis
What is a tapping apex and what condition causes it
Due to high pressure in atrium when systole hits, slams it shut- causing it to be loud
Mitral stenosis
Causes of A fib
II HAEM
Infection
IHD
Hyperthyroidism
Alcohol
PE
Mitral stenosis
Present ECG
Rate
Rhythm
Axis
Determine axis of ECG
Lead 1 and aVF
If both positive- normal
If Lead 1 positive and aVF negative- LAD
1 negative and avF posiitve- RAD
If lead 1 + and 2 and 3 negative- LAD- inferior MI
Septal MI leads
V1 and V2
LAD complication
HF
Inferior infarct complication - right coronary artery
Rhythm disturbance
Can lead to posterior
Rhythm of 3rd degree HB
R waves are completely regular
Calculating rate in irregular rhythm
Rhythm strip
No. of r waves
x6
Tx of complete heart block and STEMI
Pacemaker and PCI
Treatment of cariogenic shock
Dobutamine
Causes of dilation and hypertrophy of the heart
Dilatation- fluid overload
AR, MR
Hypertrophy- growth inwards
HTN, AS
What can you see after treatment of SVT
If shows block
Can mean pre excitation in the opposing branch
For example- if see M in V1
Can eat pre excitation in left- WPW- need ablation
Third line for HF Tx
Hydralazine
ivabradine
SE for BB
Bronchoconstriction
Insomnia
ED
Murmur in ASD
Ejection systolic due to high flow right side
Greater with inspiration
JVP in pericarditis
Increases with inspiration due to poor compliance of heart
Normal JVP waves
Measures pressure in right atrium
2 pulses per heartbeat
Atrial contraction- a wave- pushes blood back up
C wave- start of systole- bulge of tricuspid causes small rise
V wave- atrial full of blood
Abnormal JVP waves
No A waves in AF- not coordinated contraction
Large A wave- due to atrial contracting hard- tricuspid stenosis, RVH (PLM HTN)
Large V wave- tricupid regurgitation
When are nitrates contraindicated
Hypotension <90
Types of shock and when to use
Unsync- VF or pulseless VT
Sync- if have pulse- pulse VT, unstable atrial fibrillation, atrial flutter, atrial tachycardia, and supraventricular tachycardias
Types of VT
Monomorphic
Polymorphic- torsades due to long QT or non- not long QT
Calcium affect on QT
Hypo- long
Hyper- short
How to determine whether LBBB or RBBB easily
Look at V1- if wide QRD
If upgoing- RBBB
if downing LBBB
Normal EF
50-70
Driving after MI
No driving for 4 weeks
Follow up After MI
Smoking cessation
Cardiac rehab
Post infarct clinic
Medications for HF
ACEi
BB
MCA- spironolactone
SGLT2
Start low but titrate up fairly fast
Can add sascubritil/valsartan- neprilysin inhibitor- breakdown naturetic peptides- stop ACEi if doing so
Invasive procedure for some HF and when indicative
Cardiac resynchronisation therapy
Since RV and LV are desynced
Only used if LBBB
Also give ICD
NSTEMI ECG
ST depression
Major T wave inversion
With chest pain
Mx of SVT after regained sinus rhythm
Conservative
Or SVT ablation
Mx of SVT after regained sinus rhythm
Conservative
Or SVT ablation
Place of insertion for PCI
Radial artery
Only liscensed CCB for HF
Amlodipine
NSTEMI vs posterior MI ECG
Posterior MI- tall R waves
HF with spironolactone and gynaec switch to what
Eplerenone
Ix of palpitations
ECG, bloods
Then holter monitor
Which drugs are CI in AS
Nitrites
Suspected HF what tests to order
NT BNP first
Echo 2nd
Sudden onset headache with loss of visual fields and hypotension
Pituitary apoplexy
Can present with adrenal insufficiency- like hypotension
Unstable patient with suspected dissection Ix
TOE
Target BP
<80
<140/90 clinic
<135/85- APBM
> 80
<150/90
<145/85
Types of heart block
Bifasicular block- RBB and LAFB/LPFB
Tri- incomplete- Bi + 1/2nd HB
Tri complete- Bi + 3rd
ECG of bifasicular block
RBBB + LAD
Types of murmurs in rheumatic fever
Acute- mitral regurg
Chronic- mitral stenosis
Acute rheumatic fever dx
Recent sore throat
Rash- marginatum- ring
Arthritis
Murmur
Stent used in PCI
Drug eluting stent
What type of branch block is always abnormal
New LBBB
Which antihypertensive should you avoid in poorly controlled DM
Thiazides
Worsen glucose tolerance
HF 5 days after MI with systolic murmur
Ventricle septal defect
Echo diagnoses
MOA of LMWH
Activated antithrombin 3
How often can you give adrenaline in ALS
Every 3-5 mins
When to give adrenaline or amiodarone in ALS
Give adrenaline for non shockable
Or after 3rd shock
Amiodarone and adrenaline after 3rd shock for VF and pulseless VT and 150 for 5 shocks
Digoxin toxicity sx
Lethargy, green vision, arrhythmia
Gynaecomastia
Factors causing digoxin toxicity
Hypokalaemia
Amiodarone
Alternate loop diuretic
Bumetanide
ECG changes for PCI/thrombo
> 2mm 2 small squares in 2 consecutive anterior leads
Or 1mm in inferior leads
Or new LBBB
MOA of alteplase
Converts plasminogen to plasmin
What do big QRS complexes mean
Hypertrophy
HOCM ECG
Hypertrophy- large QRS
Deep ST depression
T waves inversion
Left vs right hypertrophic changes
Left- large R waves in lateral sided leads
Right- deep S in lateral
Large R in septal
Actions required after thrombolysis
ECG after 60-90 mins
Urgent PCI if not resolved
Patient With chronic HF with new AF <48hrs tx?
Amiodarone
When to offer rate vs rhythm control first for AF
Rate normally
Rhythm if reversible cause- infection
Tx of aortic dissection
Type A- surgical but BP management whilst waiting
B- conservative- beta blocker IV and analgesia
How long do chronic subdural take to present
4-7 weeks
What drug can be used instead of amiodarone in ALD
Lidocaine
Notching of inferior border of ribs means
Aortic coarctation
Dilated vessels
Reversal agent of dabigatran
Idarucizumab
Anti 2
Reversal of apixiban
Adexanet alfa
Recombinant of X
Bleeding with warfarin
Check INR
If 5-8- withhold 1-2 doses
Give Vit K
Resart when <5
Tx of valvular AF
Warfarin
Pacing in bradyarrythmia and tachy
Mobitz 2 and Complete- require pacing
Permanent Brady caused by MI
Transcutaneous- if resistant to atropine
You pace in teaches if resistant to pharmo
Drug useful in AF with HF
Digoxin
When to give HF resynchronise or ICD
Give ICD if EF <35%, optimal medical therapy and good QoL
Give resync if sinus with prolonged QRS
Indications for surgery with Infective endocarditis
Haemodynamically unstable
Cardiac failure
Repeated emboli
Aortic valve abcess
Hypertrophic cardiomyopathy sx
Jerky pulse
Displaced apex
Ejection systolic murmur
Large QRS
Sign of digoxin on ECG
Downward sloping ST
If resistant HTN on 4 Anti hypertensives and has CKD what should the next step be
Refer to nephrology
Elderly patient with RF and sweating, trops are normal what should you do
Repeat trops as takes 2-3 hours to rise
Tx of HTN over 80
Stage 1- 140-150 - lifestyle
Stage 2- >150/95 abpm, 160/100 clinic- CCB
Burgers disease sx
Vasculitis young smokers
Claudication
Thrombophlebitis
Post MI, muffled heart sounds hypotension
Free ventricle ruputre
Post MI pan systolic murmur at apex
Acute Mitral regurg
If African- 2nd line intervention HTN
ARB >ACEi
Warfarin with big red patch on leg, what has happened
If Deranged INR- interaction with other meds?
If normal INR- skin necrosis
NSTEMI medical treatment
Aspirin and tica/clopi if high risk bleeding
Morphine
GTN spray
fondaparinux - unless risk of bleeding
GRACE score- if high- anagram within 96 hrs
Ix of pericarditis
All patients should have Transthoracic Echo
When to temporarily stop statins
If taking clarithromycin macrolide
Can cause myopathy
Ix of TIA
Usually just give aspirin
But if on AC- CT head
When to be assessed by TIA clinic
If TIA if last 7 days- 24 hours
>7 days- within 1 week
SE of furosemide
Hypokalaemia
Ototoxicity
Hypocalcaemia
If in VF and suspect PE what do you do
CPR with alteplase
Thiazide SE
Hypercalcaemia- due to sodium exchange
Hypokalaemia
Hyponatraemia
Gout
Impaired glucose tolerance
Which anti anginal do you develop resistance to and what should you do about it
Isosorbride mononitrate
Asymetric dosing regime
Nitrate free interval- take 2nd earlier or swap to once modified release
When do you not give fondaparinum in STEMI/NSTEMi
If PCI available
Treatment pathway for STEMI
Aspirin, O2 if hypoxic, Nitrates, Morphine
PCI if <120 mins, <12hours onset - prasugrel
Thrombolysis- antithrombin, after give ticagrelor
HOCM murmur
Systolic
Valsava increases
Squatting decreases
Ivabradine SE
Visual disturbances
How to differentiate between constrictive pericarditis and tamponade
Tamponade- pulsus paradoxus.
CP- Kussmaul’s sign, a paradoxical rise in JVP during inspiration.
PCI vs CABG
PCI- 1 or 2 vessels not including LAD
CABG- 2 or 3 including LAD
Papillary muscle rupture sx
After MI
Acute mitral regurg- early to mid systolic murmur
HF
Need surgical repair
When should BB be stoped in AHF
If HR <50
Second or third degree HB
or Shock
If in ITU with adequate fluid but hypotensive what do you give
Noradrenaline
SVCO sx and tx
Breathless, facial swelling, oedema
Dexamethasone and SVC stenting
How to remember hypokalaemia on ECG
U have no K or no T
But a long PR and QT
Hyperkalaemia ECG
Tinted T waves
Short QT but QRS prolongation
St depression
Long PR
Where should amiodarone be given and why
Central vein due to thrombophlebitis
Dressler syndrome sx and tx
Widespread ST
PR depression
Tx With aspirin
Severe aortic stenosis on echo
<1cm
Elevated pressure gradient >40
Needs replacing
If INR low and on warfarin mx
Increase warfarin dose and give LMWH until adequate
What can mobitz 2 progress to
3rd degree
SVT in asthmatics
Give verapamil
Coarctation murmur
ESM- AS
Drug to avoid in VT
Verapamil
Brugada tx
ICD
Brugada sx
St elevation V1-3
Negative T
Partial RBBB
What is pulmonary arterial pressure a measure of
Preload
Low preload, low CO and high vascular resistance shock
Hypovolaemic
High preload, low CO, high VP shock
Cardiogenic
Low PAP, high CO, low VP shock
Septic
When to admit BP
If 180/120 + retinal haemorrhage or papiloedema
Organism causing IE if <2m since valve surgery
Staph epidermis
Echo of alcoholic
LVEF- low, dilated LV
If allergic to atropine what to give in acute setting of bradycardia
Adrenaline infusion
If on AP and start AF what should you do
Give AC and stop AP
When to admit with chest pain
Current in last 12 hours- with abnormal ecg- admit emergency
Pain 12-72 horsed ago- same day assessment
>72 hours- full assess, trips, decide
Pacing on ECG
See spike before p or qrs depending if atrial or ventricle
After acutely treating HF what other things do you need to do to monitor the patient
Catheter- urine output
Fluid balance, daily weight
U+E review- ARF due to diuretics
Review- heart failure nurse
What do you have to do if you are going to cardiovert AF that started >48 hours ago
TOE
To assess if left atrial appendage
What condition is associated with coarctation
Turners
If need to give adrenaline for ALS but cant access vein what do you do
Intaosseosu via tibia
If acute HF not responding to furosemide what next tx
CPAP
VT with pulse tx
Amiodarone
How can diabetic patients with MI present
Without chest pain
If muffled heart sounds, raised JVP after MI what has happened
Free ventricle wall rupture- causing tamponade
Third line for HF
Ivabradine- HR >75, LECF <35
Sacubitril-valsartan- <35%
Cardiac resync- wide QRS
If had ablation of AF do they still need AC
Yes through their CHADVASC
How long should CPR be continued for If given thrombolytic drugs
60-90 mins
HOCM associated cardio pathology and its ecg
WPW
PR <120
QRS >120
Pulmonary HTN ascultation
Loud S2
Cause of splitting H1
Inspiration
Due to high venous return
AF treatment algorithm
BB- if >65 or hx of IHD
Second line digoxin
If no- fleccanide
2nd amiodarone
Third line for HF in afro
Hydralazine with nitrate
When to give morphine in ACS
Severe pain- give paracetamol otherwise
CHAD score of 0 with AF Ix
Arrange echo
RBBB + LAD vs RBBB + RAD
RBBB + LAD- left ant block - bifascular
RBBB + RAD- post block - bifasicular
Tri- RBBB + LAD/RAD + 1st degree HB
Pericarditis vs myocarditis sx
Peri- movement changes pain- ST changes
Myo- T wave inversion
Ix for someone having collapse at rest
Holter monitor
NSTEMI anti platelet choice after PCI
Oral AC- clopidogrel
Not- ticagrelor or prasugrel
Atypical angina classication
Constricting , aided by GTN, precipitated by physical exertion
Causes of Aortic regurg
Bicuspid
Connectvie diseases- RhA, SLE, Marfans, Ehler
Tertiary syphillis
Cause of rasised BNP
Cardiac failure and renal failure
Due to stress of the LV
BNP- can increase water excretion
Neprilysin degrades these- so inhibitors are good
Pedunculated heterogeneous mass on echocardiogram
Atrial myxoma
ASD signs
Systolic murmur radiating through to the back with fixed S2 splitting
Stroke with DVT
When to start diabetic on ACE
If ACR >3
Medication for orthostatic hypotension
Fludrocortisone
Witnessed arrest on monitor mx
3 successive shocks before CPR
V7-9 shows what STEMI
Inferior and Posterolateral
Tamponade on ECG
Electrical alternans
Digoxin therapy ecg
Scoped ST depression
Atrial flutter ecg
Saw like
Might be 2 in-between QRS
Most important RF of aortic dissection
HTN
Only BBs to improve mortality in HF
Bisoprolol and cavediol
PEA features and tx
Sinus rhythm with no pulse
CPR- adrenaline
PEA features and tx
Sinus rhythm with no pulse
CPR- adrenaline
When are long acting nitrates CI
Isosorbide mononitrate is CI if on sildenafil
Sawtooth pattern irregular rhythm on ECG
Atrial flutter with variable block
Confusion, syncope, ECG shows long QT, tx
IV calcium gluconate for hypoclaaemia
What should all patients with CKD be given
Statin
