CARDIO Flashcards
On examination, he has a collapsing pulse and a laterally shifted apex beat. You also notice his head bobs in time with his pulse.
What would you expect to hear on auscultation of the precordium?
Aortic regurgitation typically causes an early diastolic murmur
murmur mitral regurgitation.
pansystolic murmur
patent ductus arteriosus murmur
continuous ‘machinery’ murmur
mitral stenosis murmur
late diastolic murmur
the vast majority of cases of bacterial endocarditis are caused by
gram positive cocci.
Common causes:
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
Pulmonary embolism ecg changes
SI QIII TIII (deep S wave in lead I, Q wave in III, inverted T wave in III).
A 71-year-old woman presents to the emergency department as her smartwatch ECG recorder has indicated that she has had atrial fibrillation for the last three days. She has become slightly short of breath on exertion in the previous 24 hours. On assessment, her heart rate is irregular, with a heart rate of 98 bpm. Her blood pressure is maintained at 130/72 mmHg. She is not known to have atrial fibrillation and only takes amlodipine for grade I hypertension.
What is the most appropriate treatment approach?
Discharge on bisoprolol and apixaban and arrange cardioversion in four weeks
Acute onset of atrial fibrillation: if ≥ 48 hours - rate control initially, then if considered for long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks
ecg changes in II, III, aVF
inferior, right coronary
ecg changes in V1-V4
anteroseptal, Left anterior descending
first line in treatment of venous thromboembolism (VTE) in pregnancy
low molecular weight heparin (LMWH)
NSTEMI (managed conservatively) antiplatelet choice?
high bleeding risk vs no high bleeding risk
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
indapamide - class of drug?
thiazide like
first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications
Bisoprolol
Wolff-Parkinson White management?
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol (should be avoided if there is coexistent atrial fibrillation)
amiodarone, flecainide
Acute pericarditis on ECG
widespread ST elevation but the most diagnostic feature of the ECG is the PR depression - this is very specific for pericarditis and makes the diagnosis clear.
SVT - present as a younger person with palpitations
tx?
Acute management
1. vagal manoeuvres:
Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe
carotid sinus massage
- intravenous adenosine
rapid IV bolus of 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mg
contraindicated in asthmatics - verapamil is a preferable option - electrical cardioversion
Prevention of episodes
beta-blockers
radio-frequency ablation
If angina is not controlled with a beta-blocker.. what next to add?
also if they are on montherapy but cant tolerate the add on what med to add?
a longer-acting dihydropyridine calcium channel blocker- amlodipine, nifedipine
if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs:
a long-acting nitrate
ivabradine
nicorandil
ranolazine
Bendroflumethiazide causes what electrolite imbalance?
hyponatraemia and hypokalaemia
Atrial fibrillation management prior and post 48 hours?
If the atrial fibrillation (AF) is definitely of less than 48 hours onset patients should be heparinised. Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation.
Otherwise, patients may be cardioverted using either:
electrical - ‘DC cardioversion’
pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease
more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion.
A 24-year-old attends her routine medical examination prior to starting her job as a professional footballer. She is fit and well with no significant family history.
On examination, her chest is clear and she has normal heart sounds. Her pulse is 62 beats per minute. Her ECG shows sinus rhythm with a prolonged PR interval of 215ms.
How should her ECG findings be managed?
First-degree heart block is a normal variant in an athlete. It does not require intervention
She has a prolonged PR interval; the normal range is 120-200 ms. A PR interval > 200ms (five small squares) is first-degree heart block.
Chronic heart failure: drug management
first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
Second-line treatment is an aldosterone antagonist : spironolactone and eplerenone
third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
vaccine for CHF?
offer annual influenza vaccine
offer one-off pneumococcal vaccine:
adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
knoen to have lon qt
presenting now- look at ecg
treatment?
iv mag sulphate
broad complex tachycardia at approximately 200 beats per minute. It is characteristic of ventricular tachycardia. At the beginning and end of the ECG trace, the amplitudes of the QRS complexes differ and are characterised as being polymorphic. This pattern is known as Torsades de Pointes (TdP).
adverse effects of Nicorandil?
anal ulcers, headache, flushing
Nicorandil is a vasodilatory drug used to treat angina.
Which scores measures the risk of stroke in someone with atrial fibrillation?
The CHA2DS2-VASc score is used to determine the need to anticoagulate a patient who has atrial fibrillation.
management for symptomatic bradycardia if atropine fails?
external pacing
Warfarin management for increased INR?
Major bleeding
INR>8.0 and minor bleeding
INR >8.0 and no bleeding
INR 5 to 8 and minor bleeding
INR 5 to 8 no bleeding
Major bleeding intacranial hemorrhage :
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
INR > 8.0 and Minor bleeding
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
INR > 8.0 and No bleeding
Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0
INR 5.0-8.0 and Minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
INR 5.0-8.0 and No bleeding
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
35-year-old male presents his general practice with pain in his foot and lower limb which is worse at night. He describes that the pain improves when he hangs his leg over the edge of the bed. On further questioning, he also notes that he has been getting ‘pins and needles’ in his fingers and they feel very cold. He has no past medical history but smokes 25 cigarettes per day.
diagnosis?
Young male smoker with symptoms similar to limb ischaemia - think Buerger’s disease aka thromboangiitis obliterans
primary hyperaldosteronism key features?
hypokalemia, htn
falsely low BNP result?
Being on ramipril for his blood pressure
percutaneous coronary intervention for an ST-elevation myocardial infarction.
After 12 hours he becomes pale, clammy, and bradycardic. The ECG shows complete disassociation between the atria and ventricles.
What coronary artery is most likely to have been affected?
RCA- complete heart block
scoring Acute pancreatitis
ranson criteria
Used to help assess the whether induction of labour will be required
bishop
assessment of suspected obstructive sleep apnoea
epsworth
Measure of disease activity in rheumatoid arthritis
DAS28
stoke medication?
Aspirin 300 mg daily for 2 weeks should be given immediately after an ischaemic stroke is confirmed by brain imaging.
clopidogrel 75 mg daily should be given long-term
chronic hypoxaemia- persistent low between pa02 7.3 or 7.3 to 8 secondary to polycythemia
child, runny nose last week, now coughing fits, occasional strange sounds when gasping for breath between coughs?
severe haemoptysis and nosebleeds, found to have renal failure? what could be causing this?
Granulomatosis with polyangiitis (GPA
aortic aneurysm - what size to inform DVLA?
larger then 6cm needs to be informed
6.5 cant drive
explain presentation of TOF?
most common cyanotic heart condition
large VSD, overriding aorta. blood shunted from RV to LV due to RV obstruction. cyanosed blood pumped.
squatting reduces obstruction and reducing the shunt r to l
turners syndrome- cold feet and caludication?
whats the issue?
coarctation of the aorta- narrowing so difficult to supply to the extremities
contraindication for ECG stress test
unstable angina, electrolyte inbalance, recent MI within last 2-7 days, AS, HF secondary and pulmonary oedema
digoxin ecg?
can be 1st degree heart blck, ST depression, Twave inversion
aortic dissection, imaing?
transthoracic echocardiograpthy
sick sinus syndrome?
sinus brady, postual drop on standing and lying BP
ventiruclar fib description
irregular rhythm, unidentifiable QRS complexes or p waves
polymorphic ventricular tachycardia description?
normal QT, AV dissociation , broad qrs
reason for pacemaker
bradycardia
