Cardio Flashcards
what is beck’s triad?
- muffled/absent heart sounds
- low systolic BP
- distended neck veins
associated with cardiac tamponade
Which ECG leads represent the inferior aspect of the heart?
II, III and AVF
Which ECG leads represent the lateral aspect of the heart?
I, AVL, V5 and V6
Which ECG leads represent the anterior / septal aspect of the heart?
V1-V4 (V1-2 septal, V3-4 anterior)
Which ECG leads represent the anterolateral aspect of the heart?
I, avL, V3-6
The inferior part of the heart is supplied by?
right coronary artery
The lateral part of the heart is supplied by?
left circumflex
The septal/anterior part of the heart is supplied by?
left anterior descending / bundle branches
ECG finding for hypercalcaemia?
short QT interval
Hypertension <55Y or type 2 diabetic first line management?
ACE inhibitor e.g. ramipril
or
ARB (when ACE not tolerated) e.g. candesartan
Hypertension >/=55Y or black african / african Caribbean first line management?
Calcium channel blocker e.g. amlodipine
Second line for hypertension?
Add ACE/ARB or Calcium channel blocker depending on what patient is already taking
OR
thiazide-like diuretic e.g. indapamide
Third line for hypertension?
Dependant on patient already taking - add ACE/calcium channel blocker/thiazide diuretic - whatever patient is not yet taking.
Management of resistant hypertension if K+ <4.5mmol/l?
spironolactone
Management of resistant hypertension if K+ >4.5mmol/l?
alpha or beta blocker e.g. Bisoprolol
Which conditions must be met before you would cardiovert someone with AF?
patient must be anticoagulated
or
have symptoms <48h
First line drug for rate control of AF?
beta-blocker
or
rate -limiting calcium channel blocker e.g diltiazem
Which antibiotic would you avoid in long QT syndrome?
erythromycin
HOCM inheritence type?
autosomal dominant
Hypokalaemia ECG findings?
U waves
small/absent T waves
prolonged PR
ST depression
Long QT
angina (stable) management?
- Aspirin + statin + lifestyle modification
- sublingual GTN
- beta-blocker or calcium channel blocker (rate limiting such as verapamil/diltiazem)
1st line management of Heart failure with reduced ejection fraction?
- loop diuretics for symptomatic relief e.g. furosemide
- ACE inhibitor + beta-blocker (e.g. bisoprolol, carvedilol, and nebivolol)
NOTE: ARB can be used if ACE not tolerated.
2nd line management of heart failure with reduced ejection fraction?
- aldosterone antagonist (e.g. spironolactone and eplerenone)
- consider SGLT2 inhibitor (e.g. Dapagliflozin and empagliflozin)
ACE inhibitors + aldosterone antagonists - which adverse effect is important to consider?
hyperkalaemia (monitor K+)
Investigations for heart failure?
NT-proBNP
ECG
Echo
Consider CXR, Bloods, urinalysis, peak flow or spirometry
NT-proBNP cut offs and indications?
<400 ng/l - HF not confirmed, consider other causes
400-2000ng/l - refer to specialist services within 6 weeks
> 2000ng/l - refer urgently to be seen within 2 weeks
Which drug may be started if a patient has HF + AF?
Digoxin
which 3rd line option would you consider for patients with HF who are symptomatic on ACE/ARB?
sacubitril-valsartan
3rd line drug for HF for patients who are Afro-Caribbean?
Hydralazine in combination with nitrate
HF + widened QRS (e.g. LBBB) - what treatment would you consider?
cardiac resynchronisation therapy
3rd line HF - sinus rhythm >75bpm + left ventricular fraction <35% - which drug?
ivabradine
Most common cause of endocarditis?
staph aureus
most common cause of endocarditis if <2m post valve surgery?
staph epidermis
Endocarditis with poor dental hygiene/following a dental procedure?
staph viridans
AF pharmacological cardioversion drug options?
flecanide
amiodarone (indicated if structural heart disease)
Hyperkalcaemia ECG findings?
Tall-tented T waves
small P waves
widened QRS leading to a sinusoidal pattern and asystole
Hyperkalcaemia management?
- 10ml of 10% calcium gluconate (or chloride) over 10 mins
- Intravenous insulin (10U soluble insulin) in 25g glucose
- Nebulised salbutamol
investigations for aortic dissection?
CT angio - diagnostic
ECG
echo
CXR
Bloods - raised troponin + D-dimer
investigations for stable angina?
- CT coronary angiography - 1st line
- myocardial perfusion
- stress echo
- MRI
- coronary angiogram
management of SVT?
- vagal manoeuvre
- adenosine (6mg -> 12mg -> 18mg)
- electrical cardioversion
when is adenosine contraindicated + what would you use instead?
asthmatics - use verapamil instead
which drug should not be used in VT?
Verapamil - may cause severe hypotension, cardiac arrest and v fib
Differences in presentation in right sided HF vs left-sided HF?
right - raised JVP, peripheral oedema, hepatosplenomegaly and ascites.
left - SOB on exertion, paroxysmal nocturnal dyspnoea and orthopnoea.
ECG axis - lead I up, lead II up?
normal
ECG axis - lead I up, lead II down?
left axis deviation
ECG axis - lead I down, lead II up?
right axis deviation
Persistent ST elevation following recent MI, no chest pain = ?
left ventricular aneurysm
XRAY findings in heart failure?
Alveolar oedema (bat’s wings)
Kerley B lines (interstitial oedema)
Cardiomegaly
Dilated prominent upper lobe vessels
Effusion (pleural)
ECG sign of cardiac tamponade?
electrical alternans
Management of cardiac tamponade?
urgent pericardiocentesis
How do you diagnose orthostatic hypotension?
when there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing
Management of orthostatic hypotension?
midodrine or fludrocortisone
secondary causes of hypertension (ROPE)?
renal - if non responsive to treatment then consider renal artery stenosis
Obesity
Pregnancy
Endocrine - consider hyperaldosteronism
Investigations for diagnosis of hypertension?
two measured BP >140/90 + ambulatory BP monitoring or home blood pressure monitoring.
What classification is used for heart failure and what are the stages?
New york heart association classification
class 1 - no limitations
class 2 - mild symptoms
slight limitation of physical activity
class 3 - moderate symptoms
marked limitation of physical activity - asymptomatic at rest
class 4 - severe symptoms
unable to carry out any physical activity without discomfort - symptomatic at rest
Management of STEMI?
- aspirin 300mg
- establish if PCI available with 120mins
if YES then PCI (Prasugrel if not already on anti-coagulant or clopidogrel if on anticoagulant)
if NO then thrombolysis / fibrinolysis with alteplase + ticagleror
Management of NSTEMI?
- aspirin 300mg
- offer antithrombin (Fondaparinux) unless bleeding risk or immediate PCI.
- assess GRACE 6-month mortality risk
LOW risk (<3%) - ticagrelor + aspirin OR clopidogrel + aspirin if bleeding risk
HIGH risk - PCI (+ prasugrel/ticagrelor or clopidogrel)
What screening is available for AAA?
Single USS at age 65y
What are the screening result principles for AAA?
- Small AAA (3-4.4cm) – offered yearly repeat ultrasound
- Medium AAA (4.5-5.4cm) – offered repeat ultrasound every 3 months
- Large AAA (>5.5cm) – surgery generally recommended.
What are the indications for repair of AAA?
Size >5.5cm or rapid expansion (increase in diameter >5mm over a 6 month period or >10mm over one year)
Surgical repair options for AAA?
Open repair OR Endovascular Aneurysm repair (EVAR).
Intracranial haemorrhage on warfarin management?
Give IV vitamin K 5mg + prothrombin complex concentrate
Torsades de pointes management?
IV magnesium sulphate
What is an aortic dissection?
a tear in the tunica intima of the aorta creates a false lumen whereby blood can flow between the inner and outer layers of the walls of the aorta.
Risk factors for aortic dissection?
Hypertension
Connective tissue disease e.g. Marfan’s syndrome
Valvular heart disease
Cocaine/amphetamine use
Difference between aortic dissection type A and B?
A - involves ascending aorta, arch of aorta
B - involves descending aorta
‘tearing’ chest pain which radiates to the back = ?
aortic dissection
Investigations for aortic dissection?
CT angiogram - Diagnostic
ECG - pericardial effusion and aortic valve involvement.
echo - pericardial effusion and aortic valve involvement.
CXR - widened mediastinum
bloods - troponin and d-dimer may be raised
Management of aortic dissection?
Resus
cardiac monitoring
strict blood pressure control (IV metoprolol)
Type A - surgical e.g. aortic graft
Type B - conservative, if evidence of organ failure then repair
QRISK score >10% = ?
statin e.g. atorvastatin
tachyarrhythmia, a systolic BP < 90 mmHg → ?
DC cardioversion
Which drug improves survival in chronic congestive heart failure?
ACE inhibitors
Anterolateral MI - which artery?
left coronary
Management for the different types of heart block?
type 1 - no treatment
type 2 mobitz I - no treatment
type 2 mobitz 2 - pacemaker
complete - pacemaker
Management of haemodynamically unstable patient with fast AF?
immediate DC cardioversion
Scoring system to decide if patient with AF needs anti-coagulation?
CHADS2VASc score:
C: 1 point for congestive cardiac failure.
H: 1 point for hypertension.
A2: 2 points if the patient is aged 75 or over.
D: 1 point if the patient has diabetes mellitus.
S2: 2 points if the patient has previously had a stroke or transient ischaemic attack (TIA).
V: 1 point if the patient has known vascular disease.
A: 1 point if the patient is aged 65-74.
Sc: 1 point if the patient is female.
How do you interpret the CHADS2VASc score?
Males who score 1 or more or females who score 2 or more should be anticoagulated.
rSR’ pattern in V1-3 (‘M’ shaped QRS complex) = ?
Right bundle branch block
What would you see on ECG for right bundle branch block?
- broad QRS > 120 ms
- rSR’ pattern in V1-3 (‘M’ shaped QRS complex)
- wide, slurred S wave in the lateral leads (aVL, V5-6)
How do you differentiate between RBBB and LBBB?
- LBBB there is a ‘W’ in V1 and a ‘M’ in V6
- RBBB there is a ‘M’ in V1 and a ‘W’ in V6
Causes of RBBB?
- normal variant - more common with increasing age
- right ventricular hypertrophy
- chronically increased right ventricular pressure - e.g. cor pulmonale
- PE
- MI
- atrial septal defect (ostium secundum)
- cardiomyopathy or myocarditis
Complete heart block following MI - which artery?
Right coronary artery lesion (supplied AV node in 90% of people)
Familial hypercholesterolaemia inheritence type?
Autosomal dominant
Which drugs for patient’s after MI (no AF)?
Aspirin 75mg
clopidogrel or ticagrelor
Surgical management of unstable angina?
PCI
CABG
NSTEMI ECG findings?
ST segment depression
T wave inversion
STEMI ECG findings?
ST elevation
new LBBB
What is troponin?
A protein found in cardiac muscle and skeletal muscle - a rise is consistent with myocardial ischaemia.
What is cardiac tamponade?
The pericardial effusion large enough to raise the intra-pericardial pressure - This increased pressure squeezes the heart and affects its ability to function. It reduces heart filling during diastole, decreasing cardiac output during systole.
Investigations for pericarditis?
- raised inflammatory markers (WBC, CRP and ESR)
- ECG - saddle-shaped ST-elevation, PR depression
Management of pericarditis?
NSAIDs + Colchicine (3 month course to reduce risk of recurrence)
Steroids - 2nd line, in recurrent cases + associated with inflammatory conditions
What is acute left ventricular failure?
when acute events result in the left ventricle being unable to move blood efficiently through the left side of the heart and into the circulation. This results in a backlog of blood and causes an increase in volume and pressure which results in pulmonary oedema.
What can trigger acute left ventricular failure?
usually a result of Decompensated chronic heart failure
- Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function)
- Myocardial infarction
- Arrhythmias
- Sepsis
- Hypertensive emergency (acute, severe increase in blood pressure)
Presentation of acute left ventricular failure?
- Acute SOB - worse on lying flat / improves with sitting up
- type 1 resp failure
- cough with frothy white/pink sputum
- reduced oxygen sats
- 3rd heart sound
- bilateral basal crackles
How do you assess acute left ventricular failure?
ABCDE
ECG - ischaemia and arrhythmias
Bloods - anaemia, infection, kidney function, BNP, and consider troponin if suspecting myocardial infarction
Arterial blood gas (ABG)
Chest x-ray
Echocardiogram
Management of acute left ventricular failure?
S - sit up
O - oxygen
D - diuretics
I - IV fluids should be stopped
U - underlying causes need to be identified and treated
M - monitor fluid balance
Signs and symptoms of aortic stenosis?
- ejection systolic, high pitched murmur (crescendo-decresendo character), radiates to carotids
- thrill in aortic area
- slow rising pulse
- narrow pulse pressure
- exertional syncope
Causes of aortic stenosis?
Idiopathic age-related calcification (by far the most common cause)
Bicuspid aortic valve
Rheumatic heart disease
Signs and symptoms of aortic regurgitation?
- early diastolic, soft murmur
- thrill in aortic area
- collapsing pulse
- wide pulse pressure
- heart failure and pulmonary oedema
Causes of aortic regurgitation?
Idiopathic age-related weakness
Bicuspid aortic valve
Connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome
Signs and symptoms of mitral stenosis?
- mid-diastolic, low pitched ‘rumbling’ murmur
- loud S1
- opening snap after S2
- tapping apex beat
- malar flush - due to rise in CO2
- AF
Causes of mitral stenosis?
Rheumatic heart disease
Infective endocarditis
Signs and symptoms of mitral regurgitation?
- can cause congestive HF
- pan-systolic, high pitched ‘whistling’ murmur
- murmur radiates to left axilla
- 3rd heart sound
- thrill in mitral area
- signs of HF and pulmonary oedema
- AF
Causes of mitral regurgitation?
Idiopathic weakening of the valve with age
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome
Signs and symptoms of tricuspid regurgitation?
- pan-systolic murmur
- split 2nd heart sound
- thrill in tricuspid area
- raised JVPA
- pulsatile liver
- peripheral oedema
- ascites
Causes of tricuspid regurgitation?
- Pressure due to left-sided heart failure or pulmonary hypertension (“functional”)
-Infective endocarditis
-Rheumatic heart disease
-Carcinoid syndrome
-Ebstein’s anomaly
-Connective tissue disorders, such as Marfan syndrome
Signs and symptoms of pulmonary stenosis?
- ejection systolic murmur loudest in pulmonary area in expiration
- widely split 2nd heart sound
- thrill
- raised JVP
- peripheral oedema
- ascites
Causes of pulmonary stenosis?
Usually congenital -
- Noonan syndrome
- Tetralogy of Fallot
What does tetralogy of fallot consist of?
Ventricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy
Most common cause of endocarditis?
Staphylococcus aureus
Signs and symptoms of infective endocarditis?
- fever
- fatigue
- night sweats
- muscle aches
- anorexia
- new/changing heart murmur
- hand signs - splinter haemorrhages, Janeway lesions, osler’s nodes
- petechiae
- roth spots (haemorrhages on retina)
Investigations for infective endocarditis?
- blood cultures (before antibiotics) - 3 samples, usually separated by 6 hours and taken from different sites.
- Echo - TOE is more sensitive/specific than transthoratic but transthoratic is 1st line.
Which criteria is used to diagnose infective endocarditis?
Modified Duke criteria
A diagnoses requires either:
- 1 major + 3 minor
- 5 minor
Major - +ve blood cultures, specific imaging findings
Minor - predisposition, fever >38, vascular phenomena, immunological phenomena, microbiological phenomena
Management of infective endocarditis?
Admission
IV broad-spectrum antibiotics (usually amoxicillin + gentamicin) - then change antibiotics depending on causative bacteria
Surgical repair
Indications for surgical repair in infective endocarditis?
- severe valvular incompetence
- aortic abscess (often indicated by a lengthening PR interval)
- infections resistant to antibiotics/fungal infections
- cardiac failure refractory to standard medical treatment
- recurrent emboli after antibiotic therapy
what are the components of the CHA2DS2-VASc score?
1 point for:
Congestive heart failure
Hypertension (controlled or uncontrolled)
Age of 65-74 years
Diabetes
Vascular disease
Female sex
2 points for:
An age of 75 years or over
Prior stroke or thromboembolism.
ST depression in leads V1,V2,V3 and tall R waves in V1 and V2 = ?
Posterior myocardial infarction
Critical vs acute limb ischaemia?
Critical limb ischaemia - pain at rest for greater than 2 weeks, often at night, not helped by analgesia
acute - ‘6 P’s’ (pale, pulseless, pain, paralysis, paraesthesia, perishingly cold)
widespread systolic murmur + hypotension + pulmonary oedema post STEMI - likely diagnosis?
acute mitral regurgitation due to papillary muscle rupture
Which drugs should patients with peripheral arterial disease be taking?
Statin + anti-platelet (e.g. clopidogrel)
