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Its the final countdown > Cardio > Flashcards

Cardio Flashcards

1
Q

Define postural hypotension

A

recurrent drop in systolic blood pressure ≥ 20 mmHg (risk of syncope and falls).

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2
Q

what waves are found on ECGs in hypothermia

A

J waves = osbourne waves

(hypothermia - body temp <35 degrees)

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3
Q

In IE
- what side of the heart are IVDUs more at risk of gettign valve disease

A

Right side

IVDU: predisposition to Staph. aureus infection and right-sided valve disease e.g. tricuspid endocarditi

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4
Q

what triad is found in cardiac tamponade

A

Becks triad
- hypotension
- muffled heart sounds
- raised JVP

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5
Q

difference between SOB & orthopnoea

A

orthopnoea = SOB on lying down

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6
Q

which valve condition gives the following findings on auscultation:
a diastolic decrescendo murmur
best heard at the left sternal border
and a wide pulse pressure.

A

aortic regurgitation

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7
Q

which valve condition gives the following findings on auscultation:
low-pitched, diastolic rumble at the apex with an opening snap.

A

Mitral stenosis

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8
Q

which valve condition gives the following findings on auscultation:
harsh systolic murmur

A

Aortic stenosis

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9
Q

which valve condition gives the following findings on auscultation:

holosystolic murmur at the apex, radiating to the axilla.

A

mitral regurgitation

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10
Q

which valve condition gives the following findings on auscultation:
holosystolic murmur at the left lower sternal border, which increases with inspiration.

A

tricuspid regurgitation

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11
Q

Define SVT (bpm & QRS width on ECG

A

SVT -any narrow complex tachycardia (100bpm & QRS width <q20ms)

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12
Q

give examples of SVTs

A

AF
AV re-entry tachcardia (AVRT)
AV Nodal Re-entry Tachycardia (AVNRT)

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13
Q

Management of SVt in pts with adverse features is….

A

synchronised DC cardiovesion

HISS - HF, Ischaemia, Shocj and syncope afre the 4 adverse features of SVT

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14
Q

1st and 2nd line of management in SVT with a regular rhythym

A

1 regular vagal manoeuvres (e.g/ carotoid sinus massage)

2 IV Adenosine 6mg

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15
Q

what conditions cause
- arterial ulcers
- venous ulcers
- mixed ulcers

A

arterial - peripheral artery disease

venous - venous insufficiency, causes pooling of blood & waste products

mixed - arterial and venous disease

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16
Q

which of arterial or venous ulcers occur at the on the toes/dorsum of foot

A

arterial ( these affect more peripheral places first)

venous - gaiter area ( top of foot to bottom of calf uscle)

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17
Q

which type of ulcer is small deep with well-defined borders

A

arterial - “punched out” look

venous - larger, irregular border, more superficial, more likely to bleed

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18
Q

a pt presents complaining of left leg pain. upon inspection, they have an ulcer, what is this ulcer most liekly to appear as

A

punched out appearance ( deep, small, regular border) - arterial ulcer

these are painful
worse when lying/elevating leg)

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19
Q

what investigation is appropriate in a patient with a leg ulcer

A

ABPI - ankle-brachial pressure index (ratio of systolic blood pressure (SBP) in the ankle (around the lower calf) compared with the systolic blood pressure in the arm.)

this tests for arterial disease but is used in both
Normal: 0.9 - 1.2. Values
Arterial disease: <0.9 (or >1.3 - e.g. in diabetics due to calcification of ulcers )
critical ischaemia : <0.3

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20
Q

1st line Mx in arterial ulcer

A

the management of peripheral artery disease - referral to vascular - consider revascularisation

( do not use compression/debridement)

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21
Q

Mx in venous ulcers

A

Most important: Compression therapy

Pentoxifylline ( orally - improves healing).

Abx in infection, analgesia (NOT NSAID) in pain)

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22
Q

what is intermittent claudication

A

crampy, achey paiun in muscle due to fatigue following ischaemia which occurs during exertion.

it is relieved by rest

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23
Q

what is critical limb ischaemia

A

end-stage peripheral arterial disease, with pain at rest, non-healing ulcers, gangrene

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24
Q

what are the 6 s&s of critical limb ischaemia

A

6 Ps
* Pain
* Pallor
* Pulseless
* Paralysis
* Paraesthesia (abnormal sensation or “pins and needles”)
* Perishing cold

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25
Q

Mx in peripheral arterial disease ( medical and surgical)

A

Medical treatments:
* Atorvastatin 80mg
* Clopidogrel 75mg once daily (aspirin if clopidogrel is unsuitable)
* Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

Surgical options:
* Endovascular angioplasty and stenting
* Endarterectomy – cutting the vessel open and removing the atheromatous plaque
* Bypass surgery – using a graft to bypass the blockage

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26
Q

what are the 4 rhythms that may occur in a pulseless patients, which ones are shockable and which are non-shockable

A

Shockable :
Ventricular tachycardia
Ventricular fibrillation

Non-shockable :
* Pulseless electrical activity (everything but VF/VT, incl. sinus rhythm without a pulse)
* Asystole

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27
Q

what is the size of a normal QRS complex ( small squares/ seconds

A

small squares - 3

seconds - 0.12

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28
Q

give 4 main differentials of narrow complex tachycardia

A

narrow complex tachycardia
sinus tachycardia
Supraventricular tachycardia
atrial fibrillation
atrial flutter

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29
Q

broad complex tachycardia is defined as

A

fast HR w/ broad QRS (>0.12s/ 3small squares)

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30
Q

give 4 types of broad complex tachycardia

A

Ventricular tachycardia - tx I

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31
Q

what causes atrial flutter

A

a re-entrant rhythm in either atrium: extra electrical pathway

atrial rate is approx 300 bpm - conduction typically ina 2:1 ratio - but can be more ( so atria 300bpm, ventricles, 150bpm)

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32
Q

how does Atrial flutter appear on an ECG (x3)

A

Sawtooth appearance

repeated Pwave approx. 300/min

Narrow complex tachycardia (QRS<3 small boxes/ 0.12s)

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33
Q

Tx for atrial flutter

A

Rate/rhythm control ( as with AF)
plus anticoagulation (based on CHA2DS2-VASc score)

Permaent solution - radiofrequency ablation of re-entrat rhythm

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34
Q

QT interval

  • what section does it measure
  • what is QTc
  • what is a prolonged QT interval in men/women
A

QT - from start of Q wave to end of T wave

QTc = corrected QT interval if the HR were 60 bpm

prolonged
>440ms in men
>460 ms in women

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35
Q

give 3 electrolyte imbalances which cause prolonged QT

A

hypokalaemia, hypomagnesaemia hypocalcaemia

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36
Q

Ventricular ectopics are premature ventricular beats which occur in all ages/health status. How does it appear on an ECG?

A

as isolated, random, abnormal, broad QRS complexes on an otherwise normal ECG.

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37
Q

Whats is Bigeminy

A

when every other beat is a ventricular ectopic

ECG: normal beat (P wave, QRS complex and T wave), followed immediately by an ectopic beat, then a normal beat, then an ectopic, repeated

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38
Q

Management options in ventricular ectopics

A
  1. reassurance (no tx) in otherwise health people

2.Specialist advice: underlying heart disease/ concerning Sx ( chest pain/ syncope), FHx heart disease/ sudden death

B-Blockers ( Sx Mx)

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39
Q

how many types of heart block are there

A

4

1st degree - delayed conduction to AVN, so PR interval prolonged ( >200 ms)
otherwise, everthing present, regular rhythm

2nd degree type 1 ( Wenckebach)
Progressive prolongation of PR interval, until QRS drops, then repeats

2nd degree type 2 (Mobitz 2)
Pwave present, fixed PR interval, regular, but regular non-conducted Pwave, so dropped QRS wave . The intermittent failure of AVN conduction is at a set ratio ( e.g. 3:1)
3rd degree (complete heart block) - completely unrelated P waves and QRS complexes - Pwaves regular

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40
Q

give 3 potential causes of bradycardia

A

meds ( B-blockers)
heart block
sick sinus syndrome (any condition causing SAN dysfunction)

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41
Q

in which type of heart block is there a risk of asystole

A

3rd degree heart block

AND

2nd degree type 2

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42
Q

stepwise management of bradycardic patients who are unstable/ at risk of asytole

A

1st line - 500mcg IV atropine
2 Inotropes (e.g. adrenaline)
3. temporary cardiac pacing
(transcutaneous - e.g. pads/ transvenous e.g. catheter for direct stimulation of the heart)
4. permanent pacemenker

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43
Q

500mcg IV atropine is the 1st line in unstable bradycardic patients, what are its side effects? (x4)

A

Atropine - antimuscarinic
so inhibits parasympathetic nervous system

pupil dilation, dry mouth, urinary retention, contstipation

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44
Q

give 4 risks factors a for asystole in a bradycardic patient

A
  • complete heart block with broad complex QRS
  • recent asystole
  • Mobitz type II AV block
  • ventricular pause > 3 seconds
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45
Q

what ECG leads can be used to Dx bundle branch block

A

V1 and V6 (WiLLiaM MaRRoW)

the QRS complex is also wde in both (>120)

46
Q

an ejection systolic murmur which radiates to the carotids is associated with which heart murmur

A

Aortic stenosis

47
Q

closure of which valves cause S1?

A

atrioventricular (mitral, tricuspid)

48
Q

give 3 causes of aortic stenosis

A

calcification ( most common in developed countries - >65yo)

congenital abnormality

rheumatic disease

others :

  • bicuspid aortic valve (most common cause in younger patients < 65 years)
  • William’s syndrome (supravalvular aortic stenosis)
  • subvalvular: HOCM
49
Q

give 3 examination findings which indicate aortic stenosis

A

Ejection systolic murmur ( loudest at aortic region)
radiates to the carotids
manouevre: loudest on expiration when pt siting forwards

50
Q

narrow pulse pressure, slow rising pulse, LVH/ failure are indicative of the severe form of which murmur?

A

aortic stenosis

51
Q

Mx in aortic stenosis

if asymptomatic
if symptomatic
if symptomatic, with chest pain & pulmonary oedma - whilst awaiting referral

A

1 - asymptomatic, watch and wait

2 Sx - valve replacement

3- furosemide

52
Q

what cardiac medication should NOT be given in AS

A

nitrites are contraindicated - risk of profound hypotension

53
Q

ACEi may impair renal function and cause hyperkalaemia. What is the cut off for switching the ACEi for another anti-hypertensive in hyperkalaemia?

A

6.0mmol/l

( normal 3.5 - 5.0mmol/l)

54
Q

give 4 S/E ACEi

A

cough ( raised bradykining)

angiooedema

hyperkalaemia

first-dose hypotension ( more common in diuretics pts)

55
Q

ACEi cautions and contraindications in …

  • pregnancy and breastfeeding
  • renovascular disease -
  • aortic stenosis
  • starting ACEi in potassium >= 5.0 mmol/L
A
  • pregnancy and breastfeeding - avoid
  • renovascular disease - may result in renal impairment
  • aortic stenosis - may result in hypotension ( same reason why GTN should be avoided in AS)
  • hereditary of idiopathic angioedema
  • specialist advice should be sought before starting ACE inhibitors in patients with a K+ >= 5.0 mmol/L
56
Q

what is a potential adverse effect of prescribing ACEi to a pt on high-dose diuuretic ( e.g. furosemide 80mg/day)

A

hypotension

57
Q

90% of HTN cases are essential HTN, what are the causes of secondary htn?

A

ROPED

  • R – Renal disease*** most common cause of secondary HTN
  • O – Obesity
  • P – Pregnancy-induced hypertension or pre-eclampsia
  • E – Endocrine ( e.g. hyperaldosteronism)
  • D – Drugs (e.g., alcohol, steroids, NSAIDs, oestrogen and liquorice)
58
Q

what are the cut offs ( clinic reading and ambulatory readings) for

stage 1
stage 2
stage 3

HTN

A

stage 1
>140/90, 135/85

stage 2
160/100, 150/95

stage 3
180/120

59
Q

what are the 5 groups of medication used in HTN Mx

A

ABCD, ARB
* A – ACE inhibitor (e.g., ramipril)
* B – Beta blocker (e.g., bisoprolol)
* C – Calcium channel blocker (e.g., amlodipine)
* D – Thiazide-like diuretic (e.g., indapamide)
* ARB – Angiotensin II receptor blocker (e.g., candesartan)

A –> A+C/A+D –> A+C+D –> IF K+ <4.5 - spironolactone, if >4.5 -a/b blocker (doxazosin/ atenolol) –> specialist

60
Q

what potassium diuretic can be used in the 4th stage of HTN Mx

A

spironolactone

61
Q

U&E monitoring is essential in HTN mx what 3 groups of drugs in HTN can cause electrolyte disturbances

A

Spironolacton - potassium sparing diuretic –> hyperkalaemia
ACEi –> hyperkalaemia
Thiazide-like diuretics –> hypokalaemia

62
Q

what is Accelerated/ malignant hypertension,

A

BP >180/120, with retinal haemorrhages or papilloedema.

so regular fundoscopy is important

63
Q

Mx in accelerated HTN

A

same day referral

64
Q

what is the typical cause of an ACS

A

thrombus ( from atherosclerotic plaque, made up of mainly of patelets ) blocking coronary artery

65
Q

what are the 3 types of ACS

A

STEMI, Unstable angina, NSTEMI

(ACS SUN )

66
Q

name the 4 main coronary arteries

A

right coronary artery (R side & under heart)

left coronary artery (LCA - splits into circumflex & LAD)

circumflex artery ( splits off LCA, round the top ant and posterior left heart)

Left anterior descending (middle of heart)

67
Q

what areas of the heart are supplied by the right coronary artery?

A

Right atrium
Right ventricle
inferior left ventricle
posterior septal area

68
Q

what areas of the heart are supplied by the circumflex artery

A

left atrium
posteriori left ventricle

69
Q

what areas of the heart are supplied by the left anterior descending artery

A

left ventricle
anterior septum

70
Q

how long should sx continue, at rest, to be classed as ACS

A

at least 15 mins

71
Q

how does a STEMI present on an ECG (x2)

A

ST-segment elevation

new LBBB

72
Q

how does an NSTEMI present on an ECG

A

ST segment depression

T wave inversion

diagnosis of NSTEMI is made when troponin high and either normal ECG/ pathological ECG

73
Q

in ACS, pathologiucal Q waves typically appear >6hrs post symptom onset. What does their present indicate?

A

deep infarction - transmural ( full muscle) involvement

74
Q

what ECG leads correspond to the Left anterior descending artery

A

LAD = V1-4 (anterior region)

75
Q

what ECG leads correspond to the circumflex artery

A

V5-6, I, aVL

76
Q

what ECG leads correspond to the right coronary artery

A

II, III, aVF

77
Q

troponin levels are required to diagnose what type of ACS?

A

NSTEMI

STEMIs can be dx using clinical findings and ECG findings

78
Q

a high/ raisinng troponin ( on 3-hr repeat test) indicates what ACS?

A

NSTEMI

79
Q

what are alternative causes of raised troponin

A
  • Pulmonary embolism
  • Chronic kidney disease
  • Sepsis
  • Myocarditis
  • Aortic dissection
    *
80
Q

3 features used to diagnose unstable angina

A

ACS Sx but

troponin normal
ECG - normal / ST depression / T wave inversion

in chest pain where troponin & ECG are normal - think unstable angina or other cause, (e.g. MSK chest pain)

81
Q

what are the 5 steps which form the initial management in ACS

A

CPAIN
Call ambulance
Perform ECG
Aspirin 300mg
IV morphine
Nitrate

refer to hospital, same-day assessmrent

82
Q

STEMI mx

A

present
<12 hrs

refer for PCI (within 2 hrs of presenting)

Thrombolysis (if PCI not available within 2 hrs)

83
Q

Mx NSTEMI

A

BATMAN
Base decision about angiography & PCI on GRACE score ( or in haemodynamically unstable pt)
Aspirin 300mg stat
Ticagrelor 180mg stat
Morphine
Antithrombin therapy w/ fondaparinux ( unlss bleeding risk )
Nitrate

O2 if sats <95%

(ACS – CPAIN, NSTEMI – BATMAN, STEMI - PIC/ thrombolysis, 6As for secondary prevention )

84
Q

secondary prevention in ACS

A

6As

Aspirin 75mg OD
Another antiplatelet (ticagrelor/ clopidogrel) 12 months
Atorvastatin 80mg OD
ACEi (ramipril, high dose/0
Atenolol ( or other B-blocker e.g. bisoprolol)
Aldosterone antagonist ( in clinical heart failure e.g. eplerenone 50mg OD)

85
Q

Give 5 complications of an MI

A

“DREAD”
* D – Death
* R – Rupture of the heart septum or papillary muscles
* E – “oEdema” (heart failure)
* A – Arrhythmia and Aneurysm
* D – Dressler’s Syndrome (2-3 weeks post MI, local immune response –> pericardium inflamation –> pericarditis): pleuritic chest pain, low-grade fever, pericardial rub ( footsteps on snow)

86
Q

what are 3 options for m in dresslers syndrome

A

NSAIDS
Steroids 9 e.g. pred - if mrore severe)
Pericardocentesis ( if needed in significant pericardial effusion)

87
Q

Sudden onset chest pain, maximal at onset with neurological symptoms indicates what condition?

A

aortic dissection

88
Q

how does the pain in aortic dissection differ to that in ACS

A

Both can be central pain

but ACS - crushing/tight pain
aortic dissection - sharp pain

89
Q

in what layers of the aorta does aortic dissection occur

A

intima ( inner layer, the media & adventitia are maintained but blood pools between the intima and media )

90
Q

what are the 2 most common locations for aortic dissection

A

ascending aorta & aortic arch - most commons

91
Q

what are the risk factors for aortic dissection

A

same as CVD ( age, male sex, smoking, etc)

big risk factor: HTN
a dramatic increase in BP ( heavy /cocaine use) can trigger it

Conditions/procedures e.g.
* Bicuspid aortic valve
* Coarctation of the aorta
* Aortic valve replacement
* Coronary artery bypass graft (CABG)

Connective tissue disease:
* Ehlers-Danlos Syndrome
* Marfan’s Syndrome

( typical exams: man approx 60 yo w/ PMHx HTN who presents with sudden onset tearing chest pain = aortic dissection.

remember Marfan’s and Ehlers-Danlos syndrome are for MCQ exam).

92
Q

Sx in aortic dissection

A

sudden onset, severe, “ripping” or “tearing” chest pain.

pain: anterior chest (ascending aorta) or back ( descending aorta) - may migrate over time

Other features:
* Hypertension
* Diff. in BP between the arms (>20mmHg)
* Radial pulse deficit (in one arm decreased or absent and does not match the apex beat)
* Diastolic murmur
* Focal neurological deficit (e.g., limb weakness or paraesthesia)
* Chest and abdominal pain
* Collapse (syncope)
* Hypotension as the dissection progresses

93
Q

diagnostic investigations in aortic diseaction

A

CTA - initial confirmatory, can be done quickly

MRI angiogram - better detail

94
Q

Mx in aortic dissection

A

surgical emergence

type A - midline sternotomy , remove and relace damaged area of aorta

type B - TEVAR ( thoracic endovascular aortic repair)

Stanford classification
type A - ascending aorta, 2/3 of cases
type B - descending aorta, distal to left subclavian origin, 1/3 of cases

95
Q

give 6 potential complcations of aortic diseaction

A

MI, Stroke, paraplegia, cardiac tamponade, aortic valve regurgitation
death

96
Q

Stable pt with an NSTEMI can be given aspirin and fondaparinux . what alternative medication should be administered if they are getting immediate angiography

A

aspirin and unfractionated heparin .

97
Q

give 3 types of syncope

A

reflex syncope*
orthostatic syncope **
cardiac syncope**

  • most common in all age groups

** progressively more common with age

98
Q

what are the vasovagal, situational and vascular triggers of reflex syncope

A

Reflex syncope
= neurally mediated
* vasovagal: emotion, pain, stress
* situational: cough, micturition, gastrointestinal
* vascular: carotid sinus syncope

99
Q

what are the triggers of orthostatic syncope

A
  • primary autonomic failure: Parkinson’s disease, Lewy body dementia
  • secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
  • drug-induced: diuretics, alcohol, vasodilators
  • volume depletion: haemorrhage, diarrhoea
100
Q

causes of cardiac syncope

A

*arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (SVT, VT)
* structural: valvular, MI, hypertrophic obstructive cardiomyopathy
* others: pulmonary embolism

101
Q

what Ix/ Examinations should be conducted in syncope?

A

*CV exam
* postural BP : fall in SBP> 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg
* ECG

  • other tests depend on clinical features

In pts with typical features, no postural drop and a normal ECG –> no further Ix required

102
Q

an eldery patient presents with light headedness and lying/standing BP shows postural hypotension. Which causes of this would also give a compensatory tachycardia on standing up

A

‘4Ds’ of postural hypotension with compensatory tachycardia.

Deconditioning.
Dysfunctional heart: aortic stenosis.
Dehydration: disease (acute illness, adrenal insufficiency), dialysis, drugs (diuretics, narcotics).
Drugs: anti-anginals, anti-parkinsonian medications (levodopa), antidepressants, antipsychotics, anti–benign prostatic hyperplasia drugs (tamsulosin).

103
Q

what score is used to calculate the 6-monthly risk of death followign an NSTEMI

A

GRACE score

<3% - low risk
>3% - med/ high risk ( give early angiography / PCI in 72hours)

104
Q

what score is used to decise giving an angiography/ PCI in NSTEMI

A

Grace score
global registry of acute coronary events

Hx - age, cardiac arrest at Presentation
Ex : HR & BP, signs of HF
Bedside tests: ECG changes
Lab tests: troponin & creatinine conc

105
Q

Secondary prevention after coronary event

A

6As

Aspirin 75mg OD - permanent
Another Antiplatelet - 12 months
Atorvastatin 80mg OD
ACEi
Atenolol ( or other b-blocker)
Aldosterone antagonis( if clinical HF e.g/ eplerenon)

106
Q

give 5 complications of an MI

A

DREAD

Death
Rupture of heart septum/ papillary muscles
E- oedema
Arrhythmia/ aneurosym
Dresslers syndorme ( post-MI syndrome)

107
Q

how long after an MI might dressler’s syndrome occur

A

3 weeks

MI –> immunie response –> pericarditis ( pleuritic chest pain, low-grade fever, pericardial rub )

108
Q

In dressler’s syndrome, what would the following investigations show

ECG
Echo
inflammatory markers

A

dresslers syndrome = post-MI pericarditis

ECG - global ST elevation, T wave inversion
Echo - pericardial effusion
inflammatory markers - raised

109
Q

Mx in dresslers syndrome

A

NSAIDS ( aspirin/ ibuprofen)

If more severe - steroids
If significant effusion - pericardiocentesis

110
Q

what are the types of MI

A

There are 4 types

Type 1 - traditional MI ( acute coronary event)
2 - Ischaemic MI ( increased demand and reduced supply of O2 - e.g. anaemia, hypotension, tachycardia)
3 - sudden cardiac death/ arrest ( ischaemic event)
4 - Iatrogenic ( PCI, stenting, CABG)

  • Type 1: A – ACS-type MI
  • Type 2: C – Can’t cope MI
  • Type 3: D – Dead by MI
  • Type 4: C – Caused by us MI
111
Q
A

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