Cardio Flashcards
How do you manage haemodynamically unstable AF (hypotension or HF present)?
DC cardioversion
How do you manage stable AF presenting in the 1st 48 hours?
Rate control (bisoprolol or metoprolol // verapamil or diltiazem) OR Rhythm control (DC cardioversion, start heparin beforehand)
How do you manage stable AF presenting after the 1st 48 hours?
Rate control (bisoprolol or metoprolol // verapamil or diltiazem) OR Elective DC Cardioversion (must be anticoagulated for at least 3 weeks)
If medical treatment fails and catheter ablation is required, do you still need to anticoagualte?
Yes if they were already being anticoagulated! Stroke risk does not change
What is the cause of congenital long QTc syndrome? When is QTc considered long?
Loss of functioning K+ channels
From the start of the QRS to the end of T, >12 in women, >11 in men
Which drug is always contraindicated in VT?
Verapamil
Name the ECG findings in hypokalaemia?
Small, absent or inverted T waves
Prolonged PR interval
ST depression
Long QTC
U waves
What is the normal QRS and PR interval?
QRS = 70-120ms (<3 small squares)
PR Interval = 120-200ms (3-5 small squares)
Is there an alternative to anticoagulating for 3 weeks before cardioversion?
Yes, Transoesophageal echo to exclude clots
Which connective tissue/inflammatory conditions are associated with aortic regurgitation?
Marfan’s Syndrome, Ehler-Danlos syndrome, RA, SLE and ankylosing spondylitis
Name 3 antibiotics which increase the INR?
Ciprofloxacin, clarithromycin and erythromycin
What is a gallop rhythm (S3 heart sound) a sign of?
Early LV heart failure
Which patients presenting >48 hours after AF begins will we offer elective DC cardioversion to?
<65s who are symptomatic or for whom this is the first presentation of AF
>65s or those with a history of IHD should be treated with rate control
How long should you anticoagulate after VTE or DVT when the patient has been pregnant within the last 3 months?
3/12. Pregnancy within the last 3 months is considered a provoking factor
Which drugs are contraindicated in aortic stenosis?
Nitrates
What is the most common cause of aortic stenosis?
<65s = bicuspid aortic valve
>65s = calcification of the aorta
What is the target INR in those with repeated PEs?
3.5
When should you replace the aortic valve in aortic stenosis?
If the stenosis is symptomatic or if the pressure gradient is >40mmHg
A patient presents with new onset AF. They are deemed to need urgent DC cardioversion. Which features may be present?
Haemodynamic instability (syncope, acute Pulmonary oedema, MI or ischaemic Chest pain, systolic BP <90, shock)
Heart failure (pulmonary oedema or raised JVP)
Above what value is hyperkalaemia always considered bad enough for urgent treatment?
> 6.5
How do we interperate Ferritin?
Low ferritin often indicated iron deficiency anaemia, high ferritin can be seen in inflammation, malignancy and liver disease
What is Brugada Syndrome?
An AD cause of sudden cardiac death.
ECG changes seen when giving flecainide = ST segment elevation in V1-V3 then negative T waves and a partial RBBB
How do we manage Brugada Syndrome?
Implantable Cardioverter Defibrillator
True or false, a large PE can cause a LBBB on ECG?
False! It can cause a RBBB
Mx of Chronic HF?
1st line = ACEi and Beta blocker
2nd line = spironolactone
If there is reduced EF a SGLT-2 inhibitor can be used to reduce hospital admissions (providing there is not severe renal failure)
What is Hypertrophic Obstructive Cardiomyopathy?
AD cause of sudden cardiac death (the most common in young people)
ECG = Left ventricular hypertrophy (tall R waves in I, aVL and V4-V6, increased S wave depth in III, aVR and V1-V3 and Left axis deviation)
What symptoms are seen in Hypertrophic Obstructive Cardiomyopathy?
Exertional dyspnoea and syncope.
Ejection systolic murmur which is increased by the Valsalva manoeuvre and decreased by squatting
+/- a pansystolic murmur of mitral regurg
Which part of an ECG shows the anteroseptal territory of the heart? What supplies it?
V1-V4
LAD
Which part of an ECG shows the inferior territory of the heart? What supplies it?
II, III, aVF
R coronary
Which part of an ECG shows the anterolateral territory of the heart? What supplies it?
V1-V6, I and aVL
LAD
Which part of an ECG shows the lateral territory of the heart? What supplies it?
I, aVL +/- V5 and V6
Left cirucmflex
Where are ECG changes seen in a posterior MI? What additional changes are seen and what supplies the posterior territories?
V1-V3
Plus horizontal ST depression, tall broad R waves, upright T waves and dominant R waves in V2
Left circumflex and right coronary
Name 2 causes of and the symptoms of aortic regurg?
Rheumatic fever and Endocarditis
Early diastolic murmur, collapsing pulse, wide pulse pressure, nail bed pulsation, head bobbing and heart failure symptoms
Sx of cardiac tamponade?
Low BP, Raised JVP (with absent Y descent) and muffled heart sounds
Also pulsus paradoxus (a large drop in BP during inspiration)
Ix and Mx of cardiac tamponade?
Ix = Echo
Mx = urgent pericardiocentesis
What is Cor Pulmonale?
Right heart enlargement due to pulmonary pathology (of the lungs or vessels)
Mx of Angina?
1st line = Beta blocker OR Verapamil/Diltiazem
2nd line = Beta blocker AND Amlodipine/MR Nifedipine
3rd line = Long Acting Nitrate/Ivabradine/Nicorandil/Ranolazine
Which of the 3rd line angina drugs is contraindicated by sildenafil usage?
Long Acting Nitrates
How do we manage poorly controlled hypertension (when A/C/D drugs have already been given)?
If K+ >4.5 = Alpha or Beta blockers
If K+ <4.5 = spironolactone
What is the first line Ix for stable angina?
Contrast enhanced CT angiography
When must you admit a HTN for specialist assesment?
If there is a new BP >180/120 with any of new onset confusion, chest pain, symptoms of HF or AKI
Which NSTEMI patients get a coronary angiography (and PCI if indicated) within 72 hours?
Those who have a GRACE score >3%
How do you treat STEMI if PCI can be done in <120 mins?
Do PCI
Give Prasugrel.
During PCI give unfractionated heparin with glycoprotein IIb/IIIa inhibitor
How do we treat STEMI if PCI can not be done in <120 mins?
Fibrinolysis e.g. alteplase or tenecteplase.
Give Aspirin, Ticagrelor and Fondaparinux/LMWH
Repeat ECG 60-90 mins after Fibrinolysis, if MI persists consider for PCI
When should you use GTN with caution in ACS?
If the patient has a low BP
What is the most common cause of mitral stenosis? What are the symptoms?
Caused by rheumatic fever
Sx = mitral facies, AF, haemoptysis, pulmonary hypertension and a rumbling mid-late diastolic murmur best heard in expiration
What are some ECG changes which can be considered normal variants in athletes?
1st degree heart block, 2nd degree (Mobitz type I), sinus bradycardia and junctional rhythm
What is the only CCB that can be used (e.g. to treat HTN) in HF patients?
Amlodipine
What is the commonest risk factor for aortic dissection?
Hypertension
Sx of Acute Pericarditis?
Pleuritic chest pain worse on lying back and relieved by sitting forward, no productive cough, dyspnoea and flu like Sx. Pericardial rub may be seen
Ix and Mx of Acute Pericarditis?
ECG = saddle shaped ST elevation and PR depression.
Troponin is mildly raised
Also do a transthoracic echo
Mx = NSAIDs and Colchicine
Which diuretic is best used to manage HTN and which is best used to manage HF?
HTN = thiazide like diuretics
HF = K+ sparring diuretics
How can we differentiate between cardiac tamponade and constrictive pericarditis?
In cardiac tamponade there is pulsus paradoxus (a large drop in BP on inspiration)
In constrictive pericarditis there is Kussmaul’s sign (a rise in JVP on inspiration)
Describe Myocarditis?
New onset chest pain, dyspnoea and arrhythmias seen in previously well young people following a recent illness
Ix and Mx of Myocarditis?
Ix = raised inflammatory markers, cardiac enzymes and BNP are seen. ECG may show tachycardia, arrhythmias and ST elevation/T wave inversion
Mx = treat cause
True or false, you can not get lung crackles/fever in PE?
False, you can! If you are suspicious that PE is the most likely diagnosis (e.g. breathlessness, pleuritic chest pain and tachycardia) still suspect in the presence of lung crackles/fever!
How do you detect a re-infarction after MI?
Use CK-MB if it occurs in the first 4-10 days as troponin T can stay high for 10 days after insult
How can sepsis affect troponin?
It can cause an increase in troponin due to hypoxia of the tissues (as there is a supply and demand mismatch)
How does fondaparinux work?
It activates antithrombin III
How does a Left Ventricular Aneurysm present?
Occurs 2 weeks after MI, it mimics heart failure alongside persistent ST elevation
What is Dressler’s syndrome?
Pericarditis occurring post MI
Should you worry about a new LBBB?
YES!! It is always pathological and is suggestive of a STEMI
Describe the stages of HTN?
Stage 1: Clinic reading >=140/90 or ABPM >= 135/85
Stage 2: Clinic reading >= 160/100 or ABPM >= 150/95
Severe: Systolic >=180 or Diastolic >=120
If you get a complete heart block following an MI where can you localise the lesion to
Right coronary artery lesion
What should you do with an AF patient who has a CHA2Ds2-VASc score indicating there is no need for anti-coagulation?
Do an ECHO to exclude valvular heart disease
Which valve abnormality is associated with Marfan’s and Ehler’s Danlos?
Mitral valve regurgitation
Name some causes of postural hypotension?
DM and PD can cause it secondary to autonomic dysfunction
Hypovolaemia, drug and alcohol can also cause it
What should you do if a CTPA is negative?
If CTPA OR D-dimer is negative and Wells score =<4 stop anticoagulation treatment
If CTPA is negative and Well’s Score >4 consider a proximal leg vein USS if you suspect DVT
When is CTPA contraindicated? What should you do instead
If there is renal impairment or allergy to the contrast media.
Here do a V/Q (Ventilation-Perfusion) scan
What should you do in IE with congestive HF?
Urgent valve replacement (will most likely be the tricuspid valve)
What is the first line Mx of IE if the causative organism is unknown?
Amoxicillin
True or false, thiazide like diuretics can cause erectile dysfuncion?
True!
Sx of Rheumatic fever?
CASES
Carditis, Arthritis, Subcutaneous nodules, Erythema Marginatum, Sydenham’s Chorea
How often should you measure LFTs with statins?
Pre-treatment, at 3 months and at 12 months
How do you treat raised INR?
If >8 give vitamin K, if active bleed give IV if no active bleed give orally
If 5-8 give IV vitamin K if there is a bleed, if no bleed just withhold the next few warfarin doses
When should you stop Beta blockers in acute HF?
If the HR <50, if there is 2nd or 3rd degree heart block or if the patient is shocked
What should you consider if there is evidence that a peripheral clot (e.g. from a leg DVT) has travelled to the brain? What may you see on examiantion?
Suspect a septal defect (most likely ASD)
OE: Ejection systolic murmur and a fixed splitting of S2
How do we manage warfarin in patients requiring emergency surgery?
If the surgery can wait 6-8 hours give IV vitamin K, if they can not wait give 25-50 units/kg four factor prothrombin complex
True or false, Turner’s syndrome is associated with coarctation of the aorta?
True!
When do you hear the S3 and S4 heart sound?
S3 heart sound is heard in DCM (Dilated Cardiomyopathy)
S4 heart sound is heard in HOCM (Hypertrophic Obstructive Cardiomyopathy)
What is Hypertrophic Obstructive Cardiomyopathy frequently associated with?
Fredreich’s ataxia and wolff-parkinson’s white syndrome
When is ejection fraction considered reduced?
<40%
What should you do with the Wells score?
=<4 arrange a D-dimer
>4 do an immediate CTPA
Which antibiotics must you stop a statin to give?
Clarithromycin or Erythromycin
How can you localise aortic dissection on clinical exam?
Associated with normal heart sounds = Type B (there is a false lumen in the descending aorta)
Associated with aortic regurg = Type A (there is a false lumen in the ascending aorta)
Mx of Aortic dissection?
Type A (ascending) = IV labetalol and surgical repair
Type B (descending) = IV labetalol and supportive management
Describe erythema marginitum?
A ring like rash found on the trunk, arms and legs associated with mitral stenosis due to Rheumatic fever
Describe the Pulmonary stenosis Murmur?
A harsh mid-ejection systolic murmur which may be associated with carcinoid syndrome (Hedinger syndrome)
Describe the Tricuspid Regurg murmur?
High pitched pan-systolic murmur
When should you give oxygen in ACS?
When sats are <94%
Mx of NSTEMI?
Give Aspirin and Ticagrelor
If PCI is planned (GRACE score >3%) give unfractionated heparin
If PCI is not planned give fundaparinux
True or false, aortic dissection can cause a neurological defect?
TRUE!
How do thiazide like diuretics affect calcium?
They cause hypercalcaemia and hypocalciuria
Describe Takayasu’s arteritis?
Unequal upper limb BP, absent/weak peripheral pulses, limb claudication, aortic regurg (an early diastolic decrescendo murmur), carotid bruits and malaise/headaches seen in females.
Ix = MR or CT angiography
Mx = steroids
When should you treat stage 1 HTN (BP >= 140/90 clinic or 135/85 ABPM)?
If the patient is under 80 and there is one of:
Organ damage, CVD, renal disease, DM and a QRISK >10%
What is the treatment recommended to Afro-Caribbean patients who have HF which has nor responded to ACEis, Beta-blockers or K+ sparring diuretics)?
Hydralazine and a nitrate
What is the 3rd line Mx of HF in non-Afro-Caribbean patients? (after ACEi, beta blockers and K+ sparring diuretics have failed)
Ivabradine, Sacubitril, Valsartan and Digoxin
What is the 3rd line Mx of HF in patients with a widened QRS? (after ACEi, beta blockers and K+ sparring diuretics have failed)
Cardiac resynchronisation
Mx Torsade’s de Points?
MgSO4
Primary and Secondary prevention of CVD?
Primary = 20mg Atorvastatin
Secondary = 80mg Atorvastatin
What should you do in acute HF if the patient is hypotensive and at risk of cardiogenic shock?
Speak to HDU ?inotropic support
ALS Mx of Shockable Rhythms (VF or VT)?
Deliver 1 shock immediately, if witnessed on cardiac monitoring (e.g. on CCU) give up to 3 initial shocks
Deliver CPR for 2 mins before shocking again
After 3 shocks give 1mg adrenaline and 300mg amiodarone
Repeat 1mg adrenaline every 3-5 mins
After 5 shocks give 150mg amiodarone
If amiodarone is not available give lidocaine
ALS Mx for Non-Shockable Rhythms (PEA and Asystole)?
1mg Adrenaline ASAP then continuous CPR
Repeat adrenaline 1mg every 3-5mins
