Cardio Flashcards
Scoring system in percent for a stroke or M.I in next 10 years?
QRISK score
Side effects of statins?
Myopathy - muscle weakness and pain
Rhabdomyolysis
Type 2 diabetes
Haemorrhagic strokes
Cholesterol lowering drugs
- Statins (Atorvastatin)
- Ezetimibe
Specialist - PCSK9 inhibitors (evolucamab, alirocumab)
Secondary prevention of CVD Mx? (4 As)
4 A’s
- Antiplatelet medication (aspirin, clopidogrel or ticagrelor)
- Atorvostatin 80mg
- Atenolol (or bisoprolol)
- Ace inhibitor (ramipril)
What antiplatelets are offered after a stroke?
Aspirin for two weeks followed by clopidogrel
Difference between stable and unstable angina?
Stable angina is only on exertion and always relieved by GTN
Unstable angina comes on randomly at rest
What drug can be given in cardiac stress testing to stress the heart?
Dobutamine
Gold standard Ix for coronary artery disease?
Invasive coronary angiography
Acute, long term and secondary medical management of angina?
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
All options of long term symptomatic relief of angina?
Key:
- B-blocker
- CCB (Diltiazem or verapamil)
Other:
- Long-acting nitrates (isosorbide mononitrate)
- Ivabradine
- Nicorandil
- Ranolazine
ECG change in STEMI?
ST-segment elevation
New left bundle branch block
ECG change in NSTEMI?
ST segment depression
T wave inversion
Area of heart and artery of I, aVL, V3-6 STEMI?
Anterolateral - left coronary artery
Area of heart and artery of V1-4 STEMI?
Anterior - Left anterior descending
Area of heart and artery of I, aVL, V5-6 STEMI?
Lateral - Circumflex
Area of heart and artery of II, III, aVF STEMI?
Inferior - Right coronary artery
What do pathological Q waves on an ECG suggest?
Deep infarction involving full thickness of the heart muscle (transmural)
Appears 6 or more hours after onset of symptoms
What is needed for NSTEMI dx?
Raised troponin + either:
- A normal ECG
- ECG changes such as ST depression or T wave inversion
Alternative causes of raised troponin?
Chronic kidney disease
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
Unstable angina dx?
Symptoms of ACS, normal troponin + either:
- Normal ECG
- ECG changes (ST depression or T wave inversion)
Mx of acute coronary syndrome mnemonic?
CPAIN
C - Call an ambulance
P - Perform an ECG
A - Aspirin 300mg
I - IV morphine + anti-emetic
N - Nitrate (GTN)
Mx of STEMI?
<2 hours -> PCI (percutaneous coronary intervention)
>2 hours -> thrombolysis (streptokinase, alteplase and tenecteplase)
Mx of NSTEMI mnemonic?
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)
What does GRACE score give?
It gives a 6 month probability of death after having an NSTEMI
<3% = low risk
>3% = medium / high risk -> PCI within 72h
Secondary prevention of STEMI?
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)
Dressler’s syndrome Px?
2-3 weeks post-M.I pericarditis:
- Pleuritic chest pain
- Low-grade fever
- Pericardial rub on auscultation
Mx of Dressler’s syndrome?
NSAIDs
If severe -> steroids +/- pericardiocentesis
Types of M.I?
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)
Pericarditis Px?
Low-grade fever
Chest pain
Pericardial rub on auscultation
Pericarditis ECG changes?
Saddle-shaped ST-elevation
PR depression
Mx Pericarditis?
- NSAIDs
- Colchicine (for 3mo to reduce recurrence)
Severe or recurrent -> steroids
Significant pericardial effusion or tamponade -> pericardiocentesis
Causes of pericardial effusions?
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
Signs of pericardial effusion?
- Quiet heart sounds
- Hypotension
- Raised JVP
- Pulsus paradoxus (abnormal fall of BP during inspiration)
- Pericarditis px
Dx of pericardial effusion?
Echo to dx pericardial effusion
Fluid analysis to dx underlying cause
What is cardiac output and stroke volume?
Cardiac ouput = volume of blood ejected by the heart per minute
Stroke volume = volume of blood ejected during each beat
Cardiac output calculation?
Stroke volume x heart rate
Signs of right-sided heart failure?
Raised JVP
Peripheral oedema
What is BNP and why is it used?
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.
What is the ejection fraction?
Percentage of blood in the left ventricle that is squeezed out with each ventricular contraction
> 50% = normal
Mx of acute left ventricular failure mnemonic?
SODIUM
Sit up
Oxygen
Diuretics (IV furosemide)
IV fluids should be stopped
Underlying causes need to be mx
Monitor fluid balance
When are inotropes used?
Patients with low cardiac output
- Acute heart failure
- Recent M.I
- Following heart surgery
Example is dobutamine
Causes of acute left ventricular failure?
- Aggressive IV fluids
- Myocardial infarction
- Arrhythmias
- Sepsis
- Hypertensive emergency
What is heart failure with reduced and preserved ejection fraction?
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.
New York heart association classification?
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
Heart failure referral cirteria?
NT-proBNP of:
- 400 - 2000 -> within 6 weeks
- >2000 -> within 2 weeks
Medical management of chronic heart failure?
ABAL
Ace inhibitor (ramipril)
Beta-blocker (bisoprolol)
Aldosterone antagonist (spironolactone or eplerenone)
Loop diuretic (furosemide or bumetanide)
When is cardiac resynchronisation therapy given?
In severe heart failure with an ejection fraction of less than 35%
What is high blood pressure defined as?
Clinical blood pressure > 140/90
Ambulatory blood pressure >135/85
Secondary causes of high blood pressure mnemonic?
ROPED
R - Renal disease (renal artery stenosis)
O - Obesity
P - Pregnancy-induced
E - Endocrine (hyperaldosteronism)
P - Drugs (alcohol, NSAIDs, steroids, oestrogen and liquorice)
Hypertension stages?
Clinical Ambulatory/home
Stage 1 is >140/90 >135/85
Stage 2 is >160/100 >150/95
Stage 3 is >180/120
What is the QRISK score?
Percentage risk a patient will have an M.I in the next 10 years
if >10%, offer statin
Ix after hypertension Dx?
Looking for end stage organ damage:
Kidneys - Urine albumin: creatinine ratio + dipstick
Diabetes - HBA1C
Eyes - Fundus examination
LVH - ECG
Mx of hypertension?
- Either:
<55 or T2DM -> ACEi (ramipril)
>55 or black African -> ARB (candesartan) - Add CCB (amlodipine)
- Add Thiazide-like diuretic (indapamide)
- Either:
Serum potassium <4.5 -> Spironolactone
Serum potassium >4.5 -> Alpha blocker (doxazosin) or consider b-blocker (atenolol)
Blood pressure targets?
Under 80 aim for <140 / <90
Over 80 aim for <150/ <90
IV options in hypertensive emergency?
Sodium nitroprusside
Labetalol
GTN
Nicardipine
What is malignant hypertension?
BP >180/120 with retinal haemorrhages or papilloedema
First heart sound indicate?
Closing of atrioventricular valves
- Tricuspid & mitral
Second heart sound indicate?
Closing of the semilunar valves
- Pulmonary and aortic valves
Third heart sound when and indicates what?
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
Fourth heart sound when and indicates what?
Directly before first heart sound
Always abnormal, indicates stiff or hypertrophic ventricles -> turbulent flow
Pulmonary area?
2nd intercostal space, left sternal border
Aortic area?
2nd intercostal space, right sternal border
Tricuspid area?
5th intercostal space, left sternal border
Mitral area?
5th intercostal space, mid clavicular line (apex area)
What does mitral stenosis and atrial stenosis cause?
Mitral stenosis -> left atrial hypertrophy
Aortic stenosis -> left ventricular hypertrophy
Pushing against a stenotic valve -> muscle trying harder and hypertrophies
What does mitral regurgitation and atrial regurgitation cause?
Mitral regurgitation > left atrial dilatation
Aortic regurgitation -> left ventricular dilatation
Leaky valves -> blood flowing back into the chamber stretching the cardiac muscle
Aortic stenosis signs? (3)
Slow rising pulse
Narrow pulse pressure
Thrill in aortic area
Aortic regurgitation signs? (4)
Collapsing pulse
Wide pulse pressure
Thrill in aortic area
Heart failure & pulmonary oedema
Mitral stenosis murmur?
Mid-diastolic, low-pitched “rumbling”
Aortic regurgitation murmur?
Early diastolic, soft murmur
“Rumbling” at apex
Aortic stenosis murmur?
Ejection systolic, high-pitched murmur
Crescendo-decrescendo character
Radiates to carotids
Mitral stenosis signs? (3)
Tapping apex beat
Malar flush
Atrial fibrillation
Mitral regurgitation murmur?
Pan-systolic, high-pitched “whistling”
Radiates to left axilla
Possible third heart sound
Mitral regurgitation signs? (3)
Thrill in mitral area
Signs of heart failure or pulmonary oedema
Atrial fibrillation
Tricuspid regurgitation murmur?
Pan-systolic murmur
Split second heart sound
Tricuspid regurgitation signs? (5)
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
Pulmonary stenosis murmur?
Ejection systolic loudest in pulmonary area in expiration
Widely split second heart sound
Pulmonary stenosis signs? (4)
Thrill in pulmonary area
Raised JVP with giant A waves (due to the right atrium contracting against a hypertrophic right ventricle)
Peripheral oedema
Ascites
Causes of pulmonary stenosis?
Usually congenital:
- Noonan syndrome
- Tetralogy of Fallot
Mitral stenosis cause?
Rheumatic heart disease
Infective endocarditis
Causes of aortic stenosis and aortic regurgitation?
Idiopathic age-related calcification -> stenosis
Idiopathic age-relate weakness -> regurgitation
Bicuspid aortic valve
Connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome
What causes infective endocarditis in prosthetic valve?
Gram-positive cocci:
- Staphylococcus
- Streptococcus
- Enterococcus
Most common bacteria to cause infective endocarditis?
Staphylococcus aureus
Px of infective endocarditis?
Fever
Fatigue
Night sweats
Muscle aches
Anorexia
Signs of infective endocarditis?
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
Ix of infective endocarditis?
Blood cultures Before antibiotics (three seperated by 6 hours from different sites)
ECHO
Transeosophageal ECHO > transthoracic ECHO
Specialist Ix in patient with prosthetic heart valve?
18F-FDG PET/CT
SPECT-CT
What scoring system to help diagnose endocarditis?
Modified Duke criteria
Diagnosis of endocarditis requires?
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)
Infective endocarditis bacterial cause and Mx in PWID?
Cause - Staphylococcus aureus
Mx - Flucloxacillin
Infective endocarditis bacterial cause and Mx in prosthetic valve?
Cause - Staph epidermis
Mx - IV Vancomycin & Gentamicin, then rifampicin PO
Mx of infective endocarditis in native valve + sepsis + Rx of resistant pathogens
Vancomycin + Meropenem
Unresponsive infective endocarditis with sepsis Mx?
IV Vancomycin + Gentamicin, followed by Rifampicin PO
Signs of hypertrophic obstructive cardiomyopathy?
Ejection systolic murmur at lower left sternal border
Fourth heart sound
Thrill at lower left sternal border
AF
Mitral regurgitation
Heart failure
What medications in hypertrophic obstructive cardiomyopathy?
Beta blockers
Avoid ACEi or nitrates
Differential diagnosis of irregularly irregular pulse?
Atrial fibrillation
Ventricular ectopics
ECG changes of AF?
Absent P waves
Narrow QRS complex tachycardia
Irregularly irregularly ventricular rhythm
Suspected paroxysmal AF Ix:
24-hr ambulatory ECG (Holter monitor)
Cardiac event recorder
When to give rhythm control in AF?
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
When not to give rate control first line in AF?
- 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
Rate control Mx in AF?
Either:
1. B-blocker
2. CCB (not in heart failure)
3. Digoxin
When to immediately cardiovert in AF?
Present for less than 48 hours
Causing life-threatening haemodynamic instability
Pharmacological cardioversion options?
- Flecainide
- Amiodarone (if structural heart disease)
When to cardiovert if AF >48hours?
After three weeks of anticoagulation + rate control
In 48hrs, blood clot could have formed which may mobilise if cardioverted
Paroxysmal AF mx?
Flecainide at onset of AF
Patient must have infrequent AF and not have structural heart disease
Anti-coagulation in AF?
- DOAC
- Warfarin
What scoring system used in AF to assess starting anticoagulation and scoring points?
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
Scoring system for risk of major bleeding in patient with AF taking anticoagulation?
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
Mx of SVT?
- Vagal manoeuvres
- Adenosine
- Verapamil or b-blocker
- Synchronised DC cardioversion
Severe -> DC cardioversion
+ IV amiodarone if unsuccessful
Mx of recurrent SVT?
Options:
- Long-term medication (e.g., beta blockers, calcium channel blockers or amiodarone)
- Radiofrequency ablation
ECG changes of Wolff-Parkinson-White syndrome?
Short PR interval, less than 0.12 seconds
Wide QRS complex, greater than 0.12 seconds
Delta wave - slurred upstroke in QRS complex
Mx of Wolff-Parkinson-White syndrome
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.
What are the shockable rhythyms?
Ventricular tachycardia
Ventricular fibrillation
What are the non-shockable rhythyms?
Pulseless electrical activity
Asystole
Causes of prolonged QT?
Long QT syndrome (genetic)
Medications, such as antipsychotics, citalopram, flecainide, sotalol, amiodarone and macrolide antibiotics
Electrolyte imbalances, such as hypokalaemia, hypomagnesaemia and hypocalcaemia
Acute Mx of torsades de pointes?
Correcting the underlying cause (e.g., electrolyte disturbances or medications)
Magnesium infusion (even if they have normal serum magnesium)
Defibrillation if ventricular tachycardia occurs
What is first-degree heart block?
PR interval > 0.2s
Delayed conduction through AV node
What is second-degree heart block?
Some atria impulses don’t make it through AV node to ventricles
Includes:
- Mobitz type 1
- Mobitz type 2
What is Mobitz type 1 heart block?
Increasing PR interval until a P wave is not followed by a QRS complex
What is Mobitz type 2 heart block?
Pattern of for every x P waves, there is an absence of QRS complexes. Normal PR interval.
What is third degree heart block?
No relationship between P waves and QRS complex
Significant risk of asystole
Mx of unstable patient at risk of asystole? Bradycardic patients.
IV atropine
Inotropes (adrenaline)
Temporary cardiac pacing
Pacemaker
Indications for a pacemaker?
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)
