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Finals HH > Cardio > Flashcards

Cardio Flashcards

1
Q

Scoring system in percent for a stroke or M.I in next 10 years?

A

QRISK score

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2
Q

Side effects of statins?

A

Myopathy - muscle weakness and pain
Rhabdomyolysis
Type 2 diabetes
Haemorrhagic strokes

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3
Q

Cholesterol lowering drugs

A
  1. Statins (Atorvastatin)
  2. Ezetimibe

Specialist - PCSK9 inhibitors (evolucamab, alirocumab)

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4
Q

Secondary prevention of CVD Mx? (4 As)

A

4 A’s

  • Antiplatelet medication (aspirin, clopidogrel or ticagrelor)
  • Atorvostatin 80mg
  • Atenolol (or bisoprolol)
  • Ace inhibitor (ramipril)
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5
Q

What antiplatelets are offered after a stroke?

A

Aspirin for two weeks followed by clopidogrel

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6
Q

Difference between stable and unstable angina?

A

Stable angina is only on exertion and always relieved by GTN

Unstable angina comes on randomly at rest

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7
Q

What drug can be given in cardiac stress testing to stress the heart?

A

Dobutamine

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8
Q

Gold standard Ix for coronary artery disease?

A

Invasive coronary angiography

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9
Q

Acute, long term and secondary medical management of angina?

A

Immediate symptomatic relief -> GTN

Long-term symptomatic relief:
- B-blocker (Bisoprolol)
- CCB (Diltiazem or verapamil) [avoid in reduced EF HF)

Secondary prevention:
- Aspirin
- Atorvastatin
- Ace inhibitor (if diabetes, hypertesnion, CKD or heart failure Px)
- Already on a b-blocker

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10
Q

All options of long term symptomatic relief of angina?

A

Key:
- B-blocker
- CCB (Diltiazem or verapamil)

Other:
- Long-acting nitrates (isosorbide mononitrate)
- Ivabradine
- Nicorandil
- Ranolazine

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11
Q

ECG change in STEMI?

A

ST-segment elevation
New left bundle branch block

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12
Q

ECG change in NSTEMI?

A

ST segment depression
T wave inversion

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13
Q

Area of heart and artery of I, aVL, V3-6 STEMI?

A

Anterolateral - left coronary artery

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14
Q

Area of heart and artery of V1-4 STEMI?

A

Anterior - Left anterior descending

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15
Q

Area of heart and artery of I, aVL, V5-6 STEMI?

A

Lateral - Circumflex

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16
Q

Area of heart and artery of II, III, aVF STEMI?

A

Inferior - Right coronary artery

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17
Q

What do pathological Q waves on an ECG suggest?

A

Deep infarction involving full thickness of the heart muscle (transmural)

Appears 6 or more hours after onset of symptoms

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18
Q

What is needed for NSTEMI dx?

A

Raised troponin + either:
- A normal ECG
- ECG changes such as ST depression or T wave inversion

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19
Q

Alternative causes of raised troponin?

A

Chronic kidney disease
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism

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20
Q

Unstable angina dx?

A

Symptoms of ACS, normal troponin + either:
- Normal ECG
- ECG changes (ST depression or T wave inversion)

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21
Q

Mx of acute coronary syndrome mnemonic?

A

CPAIN

C - Call an ambulance
P - Perform an ECG
A - Aspirin 300mg
I - IV morphine + anti-emetic
N - Nitrate (GTN)

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22
Q

Mx of STEMI?

A

<2 hours -> PCI (percutaneous coronary intervention)
>2 hours -> thrombolysis (streptokinase, alteplase and tenecteplase)

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23
Q

Mx of NSTEMI mnemonic?

A

BATMAN

B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)

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24
Q

What does GRACE score give?

A

It gives a 6 month probability of death after having an NSTEMI

<3% = low risk
>3% = medium / high risk -> PCI within 72h

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25
Q

Secondary prevention of STEMI?

A

6 A’s

Aspirin 75mg
Another Antiplatelet (ticagrlor or clopidegrol) for 12mo
Atorvastatin 80mg OD
ACE inhibitors (ramipril)
Atenolol (or bisoprolol)
Aldosterone antagonist for those with clinical heart failure (eplerenone)

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26
Q

Dressler’s syndrome Px?

A

2-3 weeks post-M.I pericarditis:
- Pleuritic chest pain
- Low-grade fever
- Pericardial rub on auscultation

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27
Q

Mx of Dressler’s syndrome?

A

NSAIDs
If severe -> steroids +/- pericardiocentesis

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28
Q

Types of M.I?

A

Type 1 - acute coronary event
Type 2 - ischaemia secondary to increased oxygen demand
Type 3 - sudden cardiac death
Type 4 - Iatrogenic (PCI, stenting, CABG -> M.I)

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29
Q

Pericarditis Px?

A

Low-grade fever
Chest pain
Pericardial rub on auscultation

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30
Q

Pericarditis ECG changes?

A

Saddle-shaped ST-elevation
PR depression

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31
Q

Mx Pericarditis?

A
  • NSAIDs
  • Colchicine (for 3mo to reduce recurrence)

Severe or recurrent -> steroids
Significant pericardial effusion or tamponade -> pericardiocentesis

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32
Q

Causes of pericardial effusions?

A

Transudative effusion due to increased venous pressure:
- Congestive heart failure
- Pulmonary hypertension

Exudative effusion due to inflammatory process affecting pericardium:
- Infection
- Autoimmune
- Injury
- Uraemia
- Cancer
- Meds (methotrexate)

Blood -> rapid onset cardiac tamponade:
- M.I
- Aortic dissection (type A)
- Traum

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33
Q

Signs of pericardial effusion?

A
  • Quiet heart sounds
  • Hypotension
  • Raised JVP
  • Pulsus paradoxus (abnormal fall of BP during inspiration)
  • Pericarditis px
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34
Q

Dx of pericardial effusion?

A

Echo to dx pericardial effusion
Fluid analysis to dx underlying cause

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35
Q

What is cardiac output and stroke volume?

A

Cardiac ouput = volume of blood ejected by the heart per minute

Stroke volume = volume of blood ejected during each beat

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36
Q

Cardiac output calculation?

A

Stroke volume x heart rate

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37
Q

Signs of right-sided heart failure?

A

Raised JVP
Peripheral oedema

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38
Q

What is BNP and why is it used?

A

BNP is a hormone released when ventricles are stretched. It relaxes smooth muscle of blood vessels and reduces SVR.

Used to rule out heart failure (if negative). Is sensitive but not specific so can’t be used to dx heart failure.

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39
Q

What is the ejection fraction?

A

Percentage of blood in the left ventricle that is squeezed out with each ventricular contraction

> 50% = normal

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40
Q

Mx of acute left ventricular failure mnemonic?

A

SODIUM

Sit up
Oxygen
Diuretics (IV furosemide)
IV fluids should be stopped
Underlying causes need to be mx
Monitor fluid balance

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41
Q

When are inotropes used?

A

Patients with low cardiac output
- Acute heart failure
- Recent M.I
- Following heart surgery

Example is dobutamine

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42
Q

Causes of acute left ventricular failure?

A
  • Aggressive IV fluids
  • Myocardial infarction
  • Arrhythmias
  • Sepsis
  • Hypertensive emergency
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43
Q

What is heart failure with reduced and preserved ejection fraction?

A

Heart failure with reduced ejection fraction is when the ejection fraction is less than 50%

Heart failure with preserved ejection fraction is when someone has clinical features of heart failure but ejection fraction is greater than 50%. The clinical features are due to diastolic dysfunction as the left ventricle isn’t filling up with blood properly.

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44
Q

New York heart association classification?

A

Class I: No limitation on activity
Class II: Comfortable at rest but symptomatic with ordinary activities
Class III: Comfortable at rest but symptomatic with any activity
Class IV: Symptomatic at rest

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45
Q

Heart failure referral cirteria?

A

NT-proBNP of:
- 400 - 2000 -> within 6 weeks
- >2000 -> within 2 weeks

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46
Q

Medical management of chronic heart failure?

A

ABAL

Ace inhibitor (ramipril)
Beta-blocker (bisoprolol)
Aldosterone antagonist (spironolactone or eplerenone)
Loop diuretic (furosemide or bumetanide)

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47
Q

When is cardiac resynchronisation therapy given?

A

In severe heart failure with an ejection fraction of less than 35%

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48
Q

What is high blood pressure defined as?

A

Clinical blood pressure > 140/90
Ambulatory blood pressure >135/85

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49
Q

Secondary causes of high blood pressure mnemonic?

A

ROPED

R - Renal disease (renal artery stenosis)
O - Obesity
P - Pregnancy-induced
E - Endocrine (hyperaldosteronism)
P - Drugs (alcohol, NSAIDs, steroids, oestrogen and liquorice)

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50
Q

Hypertension stages?

A

Clinical Ambulatory/home
Stage 1 is >140/90 >135/85

Stage 2 is >160/100 >150/95

Stage 3 is >180/120

51
Q

What is the QRISK score?

A

Percentage risk a patient will have an M.I in the next 10 years

if >10%, offer statin

52
Q

Ix after hypertension Dx?

A

Looking for end stage organ damage:
Kidneys - Urine albumin: creatinine ratio + dipstick
Diabetes - HBA1C
Eyes - Fundus examination
LVH - ECG

53
Q

Mx of hypertension?

A
  1. Either:
    <55 or T2DM -> ACEi (ramipril)
    >55 or black African -> ARB (candesartan)
  2. Add CCB (amlodipine)
  3. Add Thiazide-like diuretic (indapamide)
  4. Either:
    Serum potassium <4.5 -> Spironolactone
    Serum potassium >4.5 -> Alpha blocker (doxazosin) or consider b-blocker (atenolol)
54
Q

Blood pressure targets?

A

Under 80 aim for <140 / <90
Over 80 aim for <150/ <90

55
Q

IV options in hypertensive emergency?

A

Sodium nitroprusside
Labetalol
GTN
Nicardipine

56
Q

What is malignant hypertension?

A

BP >180/120 with retinal haemorrhages or papilloedema

57
Q

First heart sound indicate?

A

Closing of atrioventricular valves
- Tricuspid & mitral

58
Q

Second heart sound indicate?

A

Closing of the semilunar valves
- Pulmonary and aortic valves

59
Q

Third heart sound when and indicates what?

A

0.1s before second heart sound

Indicates rapid ventricular filling -> chordae ringing before sound

Young = normal, healthy
Old = stiff, weak ventricles & chordae reaching limit faster than usual

60
Q

Fourth heart sound when and indicates what?

A

Directly before first heart sound

Always abnormal, indicates stiff or hypertrophic ventricles -> turbulent flow

61
Q

Pulmonary area?

A

2nd intercostal space, left sternal border

62
Q

Aortic area?

A

2nd intercostal space, right sternal border

63
Q

Tricuspid area?

A

5th intercostal space, left sternal border

64
Q

Mitral area?

A

5th intercostal space, mid clavicular line (apex area)

65
Q

What does mitral stenosis and atrial stenosis cause?

A

Mitral stenosis -> left atrial hypertrophy
Aortic stenosis -> left ventricular hypertrophy

Pushing against a stenotic valve -> muscle trying harder and hypertrophies

66
Q

What does mitral regurgitation and atrial regurgitation cause?

A

Mitral regurgitation > left atrial dilatation
Aortic regurgitation -> left ventricular dilatation

Leaky valves -> blood flowing back into the chamber stretching the cardiac muscle

67
Q

Aortic stenosis signs? (3)

A

Slow rising pulse
Narrow pulse pressure
Thrill in aortic area

68
Q

Aortic regurgitation signs? (4)

A

Collapsing pulse
Wide pulse pressure
Thrill in aortic area
Heart failure & pulmonary oedema

69
Q

Mitral stenosis murmur?

A

Mid-diastolic, low-pitched “rumbling”

70
Q

Aortic regurgitation murmur?

A

Early diastolic, soft murmur
“Rumbling” at apex

71
Q

Aortic stenosis murmur?

A

Ejection systolic, high-pitched murmur
Crescendo-decrescendo character
Radiates to carotids

72
Q

Mitral stenosis signs? (3)

A

Tapping apex beat
Malar flush
Atrial fibrillation

73
Q

Mitral regurgitation murmur?

A

Pan-systolic, high-pitched “whistling”
Radiates to left axilla
Possible third heart sound

74
Q

Mitral regurgitation signs? (3)

A

Thrill in mitral area
Signs of heart failure or pulmonary oedema
Atrial fibrillation

75
Q

Tricuspid regurgitation murmur?

A

Pan-systolic murmur
Split second heart sound

76
Q

Tricuspid regurgitation signs? (5)

A

Thrill in the tricuspid area on palpation
Raised JVP with giant C-V waves (Lancisi’s sign)
Pulsatile liver (due to regurgitation into the venous system)
Peripheral oedema
Ascites

77
Q

Pulmonary stenosis murmur?

A

Ejection systolic loudest in pulmonary area in expiration
Widely split second heart sound

78
Q

Pulmonary stenosis signs? (4)

A

Thrill in pulmonary area
Raised JVP with giant A waves (due to the right atrium contracting against a hypertrophic right ventricle)
Peripheral oedema
Ascites

79
Q

Causes of pulmonary stenosis?

A

Usually congenital:
- Noonan syndrome
- Tetralogy of Fallot

80
Q

Mitral stenosis cause?

A

Rheumatic heart disease
Infective endocarditis

81
Q

Causes of aortic stenosis and aortic regurgitation?

A

Idiopathic age-related calcification -> stenosis
Idiopathic age-relate weakness -> regurgitation

Bicuspid aortic valve

Connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome

82
Q

What causes infective endocarditis in prosthetic valve?

A

Gram-positive cocci:
- Staphylococcus
- Streptococcus
- Enterococcus

83
Q

Most common bacteria to cause infective endocarditis?

A

Staphylococcus aureus

84
Q

Px of infective endocarditis?

A

Fever
Fatigue
Night sweats
Muscle aches
Anorexia

85
Q

Signs of infective endocarditis?

A

New heart murmur
Splinter haemorrhages
Petechiae
Janeway lesions - painless red flat macules on palms of hands and soles of feet
Osler’s nodes - tender red/purple nodules on fingers and toes
Roth spots - Haemorrhages on the retina

86
Q

Ix of infective endocarditis?

A

Blood cultures Before antibiotics (three seperated by 6 hours from different sites)

ECHO

Transeosophageal ECHO > transthoracic ECHO

87
Q

Specialist Ix in patient with prosthetic heart valve?

A

18F-FDG PET/CT
SPECT-CT

88
Q

What scoring system to help diagnose endocarditis?

A

Modified Duke criteria

89
Q

Diagnosis of endocarditis requires?

A

One major plus three minor criteria OR
Five minor criteria

Major criteria are:
- Persistently positive blood cultures
- Specific imaging findings

Minor criteria are:
- Predisposition (PWID or heart valve pathology)
- Fever above 38°C
- Vascular phenomena (splenic infarction, intracranial haemorrhage and Janeway lesions)
- Immunological phenomena (Osler’s nodes, Roth spots and glomerulonephritis)
- Microbiological phenomena (positive cultures not qualifying as a major criterion)

90
Q

Infective endocarditis bacterial cause and Mx in PWID?

A

Cause - Staphylococcus aureus
Mx - Flucloxacillin

91
Q

Infective endocarditis bacterial cause and Mx in prosthetic valve?

A

Cause - Staph epidermis
Mx - IV Vancomycin & Gentamicin, then rifampicin PO

92
Q

Mx of infective endocarditis in native valve + sepsis + Rx of resistant pathogens

A

Vancomycin + Meropenem

93
Q

Unresponsive infective endocarditis with sepsis Mx?

A

IV Vancomycin + Gentamicin, followed by Rifampicin PO

94
Q

Signs of hypertrophic obstructive cardiomyopathy?

A

Ejection systolic murmur at lower left sternal border
Fourth heart sound
Thrill at lower left sternal border

AF
Mitral regurgitation
Heart failure

95
Q

What medications in hypertrophic obstructive cardiomyopathy?

A

Beta blockers

Avoid ACEi or nitrates

96
Q

Differential diagnosis of irregularly irregular pulse?

A

Atrial fibrillation
Ventricular ectopics

97
Q

ECG changes of AF?

A

Absent P waves
Narrow QRS complex tachycardia
Irregularly irregularly ventricular rhythm

98
Q

Suspected paroxysmal AF Ix:

A

24-hr ambulatory ECG (Holter monitor)
Cardiac event recorder

99
Q

When to give rhythm control in AF?

A

Rhythm control may be offered to patients with:
- A reversible cause for their AF
- New onset atrial fibrillation (within the last 48 hours)
- Heart failure caused by atrial fibrillation
- Symptoms despite being effectively rate controlled

100
Q

When not to give rate control first line in AF?

A
  • A reversible cause for their AF
  • New onset atrial fibrillation (within the last 48 hours)
  • Heart failure caused by atrial fibrillation
  • Symptoms despite being effectively rate controlled
101
Q

Rate control Mx in AF?

A

Either:
1. B-blocker
2. CCB (not in heart failure)
3. Digoxin

102
Q

When to immediately cardiovert in AF?

A

Present for less than 48 hours

Causing life-threatening haemodynamic instability

103
Q

Pharmacological cardioversion options?

A
  1. Flecainide
  2. Amiodarone (if structural heart disease)
104
Q

When to cardiovert if AF >48hours?

A

After three weeks of anticoagulation + rate control

In 48hrs, blood clot could have formed which may mobilise if cardioverted

105
Q

Paroxysmal AF mx?

A

Flecainide at onset of AF

Patient must have infrequent AF and not have structural heart disease

106
Q

Anti-coagulation in AF?

A
  1. DOAC
  2. Warfarin
107
Q

What scoring system used in AF to assess starting anticoagulation and scoring points?

A

CHA2DS2-VASc

C – Congestive heart failure
H – Hypertension
A2 – Age above 75 (scores 2)
D – Diabetes
S2 – Stroke or TIA previously (scores 2)
V – Vascular disease
A – Age 65 – 74
S – Sex (female)

> 1 consider anticoagulation
2 offer anticoagulation

108
Q

Scoring system for risk of major bleeding in patient with AF taking anticoagulation?

A

ORBIT score

O – Older age (age 75 or above)
R – Renal impairment (GFR less than 60)
B – Bleeding previously (history of gastrointestinal or intracranial bleeding)
I – Iron (low haemoglobin or haematocrit)
T – Taking antiplatelet medication

109
Q

Mx of SVT?

A
  1. Vagal manoeuvres
  2. Adenosine
  3. Verapamil or b-blocker
  4. Synchronised DC cardioversion

Severe -> DC cardioversion
+ IV amiodarone if unsuccessful

110
Q

Mx of recurrent SVT?

A

Options:
- Long-term medication (e.g., beta blockers, calcium channel blockers or amiodarone)
- Radiofrequency ablation

111
Q

ECG changes of Wolff-Parkinson-White syndrome?

A

Short PR interval, less than 0.12 seconds
Wide QRS complex, greater than 0.12 seconds
Delta wave - slurred upstroke in QRS complex

112
Q

Mx of Wolff-Parkinson-White syndrome

A

Radiofrequency ablation of the accessory pathway

Anti-arrhythmic medications (e.g., beta blockers, calcium channel blockers, digoxin and adenosine) are contraindicated. Increase risk of AF by slowing conduction through AV node which promotes conduction through accessory pathway.

113
Q

What are the shockable rhythyms?

A

Ventricular tachycardia
Ventricular fibrillation

114
Q

What are the non-shockable rhythyms?

A

Pulseless electrical activity
Asystole

115
Q

Causes of prolonged QT?

A

Long QT syndrome (genetic)

Medications, such as antipsychotics, citalopram, flecainide, sotalol, amiodarone and macrolide antibiotics

Electrolyte imbalances, such as hypokalaemia, hypomagnesaemia and hypocalcaemia

116
Q

Acute Mx of torsades de pointes?

A

Correcting the underlying cause (e.g., electrolyte disturbances or medications)

Magnesium infusion (even if they have normal serum magnesium)

Defibrillation if ventricular tachycardia occurs

117
Q

What is first-degree heart block?

A

PR interval > 0.2s

Delayed conduction through AV node

118
Q

What is second-degree heart block?

A

Some atria impulses don’t make it through AV node to ventricles

Includes:
- Mobitz type 1
- Mobitz type 2

119
Q

What is Mobitz type 1 heart block?

A

Increasing PR interval until a P wave is not followed by a QRS complex

120
Q

What is Mobitz type 2 heart block?

A

Pattern of for every x P waves, there is an absence of QRS complexes. Normal PR interval.

121
Q

What is third degree heart block?

A

No relationship between P waves and QRS complex

Significant risk of asystole

122
Q

Mx of unstable patient at risk of asystole? Bradycardic patients.

A

IV atropine
Inotropes (adrenaline)
Temporary cardiac pacing
Pacemaker

123
Q

Indications for a pacemaker?

A

Symptomatic bradycardias (e.g., due to sick sinus syndrome)
Mobitz type 2 heart block
Third-degree heart block
Atrioventricular node ablation for atrial fibrillation
Severe heart failure (biventricular pacemakers)

Finals HH (21 decks)

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