Cardio Flashcards
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
ECG changes seen in a posterior MI?
what supplies the posterior territories?
V1-V3
horizontal ST depression
tall broad R waves
upright T waves
dominant R waves in V2
left circumflex and right coronary
which part of an ECG shows the lateral territory of the heart? What supplies it?
I, aVL +/- V5 and V6
Left cirucmflex
normal QRS and PR interval
QRS = 70-120ms (<3 small squares)
PR Interval = 120-200ms (3-5 small squares)
long QTc syndrome causes
loss of functioning K+ channels
long QTc syndrome
from the start of the QRS to the end of T
>12 in women, >11 in men
hypokalaemia ECG findings
small, absent or inverted T waves
prolonged PR interval
ST depression
long QTC
U waves
VF/VT Mx
deliver 1 shock immediately
if witnessed on cardiac monitoring: 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
PEA and Asystole Mx
1mg adrenaline ASAP
continuous CPR
repeat adrenaline 1mg every 3-5mins
supraventricular tachycardia Mx
adenosine
bradycardia Mx
only requires treatment when haemodynamically unstable
- IV atropine 500mcg -> can be given up to 3mg
- transcutaneous pacing
adenosine side effects
flushing
chest pain
abdominal discomfort
amiodarone monitoring
prior to treatment: TFTs, LFTs, U&Es, CXR
every 6 months: TFTs, LFTs
haemodynamically unstable AF (hypotension or HF present) management
DC cardioversion
stable AF (<48 hours) management
rate control
- bisoprolol or metoprolol
- verapamil or diltiazem
rhythm control
- DC cardioversion
- start heparin beforehand
stable AF presenting (>48 hours) management
rate control
- bisoprolol or metoprolol
- verapamil or diltiazem
elective DC cardioversion
- 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
alternative to anticoagulating for 3 weeks before cardioversion?
transoesophageal echo to exclude clots
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
features for rhythm control in AF
new onset
reversible cause
coexistent ♡ failure
features for urgent DC cardioversion in new onset AF
haemodynamic instability
- syncope
- acute pulmonary oedema
- MI or ischaemic chest pain
- systolic BP <90
- shock
♡ failure
- pulmonary oedema
- raised JVP
which drug is always contraindicated in VT?
verapamil
aortic regurgitation - associated connective tissue/inflammatory conditions
marfan’s syndrome
Ehler-Danlos syndrome
RA
SLE
ankylosing spondylitis
+ inferior MI = ascending aortic dissection
INR management
INR >8 with bleeding - IV Vit K
INR >8 no bleeding - Oral Vit K
INR 5-8 minor bleeding - IV Vit K
INR 5-8 no bleeding - withold 1 or 2 doses of warfarin
antibiotics which increase the INR
ciprofloxacin
clarithromycin
erythromycin
target INR in those with repeated PEs
3.5
how do we interperate Ferritin?
Low ferritin often indicated iron deficiency anaemia, high ferritin can be seen in inflammation, malignancy and liver disease
gallop rhythm (S3 heart sound) cause
early LV heart failure
how long should you anticoagulate after VTE or DVT when the patient has been pregnant within the last 3 months?
3 months
pregnancy is considered a provoking factor
drugs contraindicated in aortic stenosis
nitrates
most common cause of aortic stenosis
<65s = bicuspid aortic valve
>65s = calcification of the aorta
aortic valve replacement indications in aortic stenosis
stenosis is symptomatic or if the pressure gradient is >40mmHg
above what value is hyperkalaemia always considered bad enough for urgent treatment?
> 6.5
brugada syndrome
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
brugada syndrome management
Implantable Cardioverter Defibrillator
hypertrophic obstructive cardiomyopathy (hocm)
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)
hocm symptoms
exertional dyspnoea and syncope.
ejection systolic murmur which is increased by the Valsalva manoeuvre and decreased by squatting
+/- a pansystolic murmur of mitral regurg
hocm associated with
fredreich’s ataxia
wolff-parkinson’s white syndrome
ventricular arrythmias = sudden death
fondaparinux moa
activates antithrombin III
aortic regurg causes
rheumatic fever
endocarditis
ascending aortic dissection
ankylo spondyl
aortic regurg symptoms
early diastolic murmur
collapsing pulse
wide pulse pressure
nail bed pulsation
head bobbing
heart failure symptoms
mitral regurg
acute: early-mid systolic
chronic: pansystolic
aortic stenosis
ejection systolic murmur
splitting of second ♡ sound
aortic stenosis Mx
only if symptomatic or valvular gradient > 40 mmHg
low/medium operative risk patients: surgical AVR
high operative risk patients: transcatheter AVR
tricuspid regurg murmur
- high pitched pan-systolic murmur
mitral stenosis causes and Sx
rheumatic fever
- mitral facies
- AF
- haemoptysis
- pulmonary hypertension
- rumbling mid-late diastolic murmur best heard in expiration
non cardiac chest pain but ischaemic changes in ECG
CT coronary angiogram
stable angina Ix
contrast enhanced CT angiography
cardiac tamponade Sx
low BP
raised JVP (with absent Y descent) muffled heart sounds
pulsus paradoxus (a large drop in BP during inspiration)
cardiac tamponade Ix and Mx
Ix = Echo
Mx = urgent pericardiocentesis
cor pulmonale
right heart enlargement due to pulmonary pathology (of the lungs or vessels)
angina Mx
A B C
angina =
- beta blocker
- ca channel blocker
- monotherapy: non dihydropyridine
(diltiazem, verapamil) - dual therapy: dihydropyridine
(amlodipine, modified release nifedipine)
- nitrates: ivabradine, nicorandil, ranolazine
beta blockers contraindications
rate limiting calcium channel blockers
- verapamil
- diltiazem
(VD = Very Dangerous)
which of the 3rd line angina drugs is contraindicated by sildenafil usage?
Long Acting Nitrates
which NSTEMI patients get a coronary angiography (and PCI if indicated) within 72 hours?
GRACE score >3%
STEMI management if PCI can be done in <120 mins?
- PCI
- prasugrel
- during PCI give unfractionated heparin with glycoprotein IIb/IIIa inhibitor
STEMI management if PCI can not be done in <120 mins?
- fibrinolysis: alteplase or tenecteplase.
- aspirin
- ticagrelor
- 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
athletes normal variant ECG changes
1st degree heart block
2nd degree (Mobitz type I)
sinus bradycardia
junctional rhythm
commonest risk factor for aortic dissection?
hypertension
aortic dissection Mx
ascending aorta
- weak pulse & aortic regurgitation
- control BP (IV labetalol) + surgery
descending aorta
- control BP (IV labetalol)
acute pericarditis Sx
pleuritic chest pain
- worse on lying back
- relieved by sitting forward
- no productive cough
- dyspnoea and flu like Sx
- pericardial rub may be seen
acute pericarditis Ix and Mx
ECG: saddle shaped ST elevation and PR depression.
troponin: mildly raised
transthoracic echo
Mx = NSAIDs and Colchicine
how can we differentiate between cardiac tamponade and constrictive pericarditis?
cardiac tamponade: pulsus paradoxus (a large drop in BP on inspiration)
constrictive pericarditis: kussmaul’s sign (a rise in JVP on inspiration)
myocarditis
- new onset chest pain
- dyspnoea
- arrhythmias seen in previously well young people following a recent illness
myocarditis Ix and Mx
Ix
- raised inflammatory markers
- cardiac enzymes
- BNP
- ECG: tachycardia, arrhythmias and ST elevation/T wave inversion
Mx
- treat cause
can you get lung crackles/fever in PE?
yes
how do you detect a re-infarction after MI?
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?
can cause an increase in troponin due to hypoxia of the tissues (as there is a supply and demand mismatch)
left ventricular aneurysm
occurs 2 weeks after MI
mimics heart failure
persistent ST elevation
ventricular septal defect
post mi acute ♡ failure
pansystolic mumur
acute mitral regurg
post mi rupture of papillary muscles
widespread (early-mid) systolic murmur
hypotension
pulmonary oedema
dressler’s syndrome
pericarditis occurring post MI
should you worry about a new LBBB?
yes
always pathological and is suggestive of a STEMI
if you get a complete heart block following an MI where can you localise the lesion to
right coronary artery lesion
S3 and S4 heart sounds
S3: DCM (Dilated Cardiomyopathy)
S4: HOCM (Hypertrophic Obstructive Cardiomyopathy)
what should you do with an AF patient who has a CHA2Ds2-VASc score indicating there is no need for anti-coagulation?
ECHO to exclude valvular heart disease
valve abnormality associated with Marfan’s and Ehler’s Danlos
mitral valve regurgitation
postural hypotension causes
DM and PD can cause it secondary to autonomic dysfunction
hypovolaemia, drug and alcohol
what should you do if a CTPA is negative?
CTPA OR D-dimer is negative and Wells score =<4 stop anticoagulation treatment
CTPA is negative and Well’s Score >4 consider a proximal leg vein USS if you suspect DVT
when is CTPA contraindicated and what should you do instead
renal impairment or allergy to the contrast media.
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)
IE Mx if the causative organism is unknown?
amoxicillin
true or false, thiazide like diuretics can cause erectile dysfuncion?
true
rheumatic fever Sx
CASES
- carditis
- arthritis
- subcutaneous nodules
- erythema marginatum
- sydenham’s chorea
how often should you measure LFTs with statins?
pre-treatment
3 months
12 months
when should you stop Beta blockers in acute HF?
HR <50
2nd or 3rd degree heart block
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?
suspect a septal defect - most likely ASD
(OE: Ejection systolic murmur and a fixed splitting of S2)
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
aortic dissection classification on examination
type A
- associated with aortic regurg
- in type A there is a false lumen in the ascending aorta
type B
- normal heart sounds
- in type B there is a false lumen in the descending aorta
aortic dissection Mx
type A (ascending)
- IV labetalol and surgical repair
type B (descending)
- IV labetalol and supportive management
describe erythema marginitum?
ring like rash found on the trunk, arms and legs associated with mitral stenosis due to Rheumatic fever
pulmonary stenosis murmur
- harsh mid-ejection systolic murmur
- may be associated with carcinoid syndrome (Hedinger syndrome)
when should you give oxygen in ACS?
sats <94%
NSTEMI Mx
- aspirin and ticagrelor
- PCI planned (GRACE score >3%): unfractionated heparin
- PCI not planned: fondaparinux
How do thiazide like diuretics affect calcium?
They cause hypercalcaemia and hypocalciuria
takayasu’s arteritis?
unequal upper limb BP
absent/weak peripheral pulses
limb claudication
aortic regurg (an early diastolic decrescendo murmur)
carotid bruits
malaise/headaches seen in females.
Ix = MR or CT angiography
Mx = steroids
acute HF Ix
echocardiography
HF in Afro-Caribbeans who have not responded to :
- ACEis
- Beta-blockers
- K+ sparring diuretics
hydralazine and a nitrate
HF in non-Afro-Caribbean patients who have not responded to
- ACEi
- beta blockers
- K+ sparring diuretics
ivabradine
sacubitril
valsartan
digoxin
HF in patients with a widened QRS who have not responded to
- ACEi
- beta blockers
- K+ sparring diuretics
cardiac resynchronisation
What should you do in acute HF if the patient is hypotensive and at risk of cardiogenic shock?
Speak to HDU ?inotropic support
chronic HF Mx
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)
HTN stages
stage 1
- clinic: >=140/90
- abpm: 135/85
stage 2:
- clinic: >= 160/100
- abpm >= 150/95
severe:
- systolic >=180
- diastolic >=120
HTN specialist assessment admission criteria
new BP >180/120
+ any of new onset confusion, chest pain, symptoms of HF or AKI
when should you treat stage 1 HTN (BP >= 140/90 clinic or 135/85 ABPM)?
if patient is under 80 and:
- organ damage
- CVD
- renal disease
- DM
- QRISK >10%
diuretics usage in HTN and HF
HTN = thiazide like diuretics
HF = K+ sparring diuretics
the only CCB that can be used (e.g. to treat HTN) in HF patients?
amlodipine
thiazide like diuretics
indapamide
HTN in patients who have not responded to
- ACEi/ARBs
- CCBs
- thiazide like diuretics
look at K
- ABove 4.5 = Alpha/Beta blocker
- beLOw 4.5 = spiroNOlactone
Torsade’s de Points Mx
MgSO4
Primary and Secondary prevention of CVD?
Primary = 20mg Atorvastatin
Secondary = 80mg Atorvastatin
signs of RHF
raised JVP
ankle oedema
hepatomegaly
acs poor prognostic factors
age
♡ failure
pvd
reduced systolic bp
killip class
raised: creatinine, cardiac markers
cardiac arrest
st depression
loop diuretics
inhibits NaKCl cotransporter in thick ascending limb of the loop of Henle
reduces NaCl absorption
useful in ♡ failure
examples: furosemide, bumetanide
HTN in patients who have not responded to
- ACEi/ARBs
- CCBs
- thiazide sparring diuretics
look at K
- ABove 4.5 = Alpha/Beta blocker
- beLOw 4.5 = spiroNOlactone
statins contraindications
erythromycin/ clarithromycin
acute mitral regurg
post mi rupture of papillary muscles
widespread (early-mid) systolic murmur
hypotension
pulmonary oedema
