Cardio Flashcards
Atherosclerosis is
Athermatous plaques forming in artery walls
Atherosclerosis plaques result in (3)
Stiffening
Stenosis
Plaque rupture
Stiffening in atherosclerosis leads to
HTN
Stenosis in atherosclerosis leads to
Angina
Plaque Rupture in atherosclerosis leads to
MI etc
Start a statin first check
LFTs
Statin ADRs
Myopathy, rhabdomyolysis
After a MI, offer patients
Dual antiplatelets
Aspirin 75 mg
Clopidogrel or Ticagrelor
Generally for 12 months
Angina is stable when
Symptoms come on with exertion only, and always relieved by rest or GTN
Angina is unstable when
Symptoms appear randomly whilst at rest
- type of acute coronary syndrome and require immediate management
Patients with angina should have which investigations (6)
Physical examination (cardio, BP, BMI), ECG, blood tests
Cardiac stress testing
CT coronary angiography
Invasive coronary angiography (gold standard)
GTN ADRs
dizziness and headaches
long-term symptomatic relief of stable angina medications (2)
B-blocker (bisoprolol)
CCB - diltiazem or verapamil - avoid in HF
MI prevention thrombus med
Aspirin
Surgical interventions for angina
Percutaneous coronary intervention, Coronary artery bypass graft.
Three types of acute coronary syndrome
Unstable angina
STEMI
NSTEMI
ACS Investigations
Troponin, baseline bloods
ECG
CXR
Echocardiogram - once stable - to assess functional damage to the heart.
Troponin specific?
Troponin is a non-specific marker, meaning that a raised troponin does not automatically imply acute coronary syndrome. The alternative causes of a raised troponin include:
Chronic kidney disease
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
STEMI management
PCI (within 2 hrs)
Thrombolysis
Complications of MI
Death
Rupture
oEdema (Heart failure)
Arrhythmia
Dressler’s syndrome
Dressler’s syndrome
2-3 weeks after acute MI, localised immune response resulting in inflammation of pericardium - pericarditis.
Pleuritic chest pain, low grade fever, pericardial rub on auscultation.
Dressler’s syndrome complications
Pericardial effusion and rarely pericardial tamponade
Dressler’s syndrome management
NSAIDs, steroids, pericardiocentesis if needed.
Pericarditis
idiopathic, infective - viral mostly.
Also autoimmune (RA, SLE), injury, uraemia, cancer
Pericarditis complication
Pericardial effusion & pericardial tamponade
Pericarditis symptoms
Chest pain, low-grade fever
Chest pain is sharp, worse with inspiration (pleuritic), worse on lying down, better on sitting forward.
Pericarditis examination
Pericardial friction rub alongside heart sounds
Pericarditis investigations
Blood tests, ECG (saddle shaped ST elevation), PR depression
Echo can diagnose pericardial effusion
Management of pericarditis
NSAIDs
Colchicine taken longer term e.g. 3 months to reduce risk of recurrence.
Steroids second line
Pericardiocentesis if needed
Pacemakers incompatible with
MRI scans, diathermy
Indications for a pacemaker
symptomatic bradycardia, some types of heart block, , AV node ablation for atrial fibrillation, severe heart failure
ECG changes pacemaker
Sharp vertical line on all leads before P wave and/or before QRS
Acute left venticular failure symptoms
Pulmonary oedema
Triggers of acute left ventricular failure
Iatrogenic - e.g. agressive IV fluids
MI
Arrhythmias
Sepsis
Hypertensive emergency
Right sided HF findings
Raised JVP
Peripheral oedema
Assessment of patients with acute left ventricular failure
ECG - ischaemia & arrhythmias
Bloods - anaemia, infection, kidneys, BNP, troponin
Arterial blood gas
Chest X-ray
Echo
BNP sensitive but not specific - can also be
tachycardia, sepsis, PE, renal impairment, COPD
BNP represents myocardial
stretch
acts on smooth muscle in blood vessels to reduce systemic vascular resistance
LVEF normal value
if above 50%
CXR findings HF
Cardiomegaly, pleural effusion, kerley B lines, upper lobe diversion
Management Acute left ventricular failure
S - sit up
O - oxygen
D - diuretics
I - intravenous fluids STOP
U - underlying cause identified and treated
M - monitor fluid (urine output, Us&Es, body weight)
Management Acute left ventricular failure
- acronym
SODIUM
Causes chronic heart failure
Ischaemic heart disease, valvular heart disease - commonly aortic stenosis, hypertension, arrhythmias - commonly atrial fibrillation, cardiomyopathy
Chronic heart failure treatment - medications
ABAL
Ace Inhibitor
B blocker
Aldosterone antagonist (if A&B not adequate)
Loop diuretic
ACE inhibitors and aldosterone effect on K
Can cause hyperkalaemia
Secondary causes of hypertension acronym
ROPED
Secondary causes of hypertension
R - renal disease - e.g. renal artery stenosis
O - obesity
P - pregnancy
E - endocrine
D - drugs
Sleep apneoa
HTN increases the risk of
Ischaemic heart disease, cerebrovascular accident, vascular disease, retinopathy, nephropathy, vascular dementia, left ventricular hypertrophy, heart failure.
New HTN diagnosis investigations
Urine dipstick, bloods - HbA1c, renal function, lipids, fundus examination, ECG
HTN management
Lifestyle
Ace inhibitor (not if african), B blocker, CCB e.g. amlodipine, Diuretic (thiazide), ARB
HTN meds - monitor
K+ (Us & Es)
Spironolactone - K sparing
bendroflumethiazide - hypokalaemia
Malignant hypertension
BP > 180/120
with retinal haemorrhages or papilloedema
bad - end organ damage - give labetalol, GTN
Aortic stenosis affect on heart
Left ventricular hypertrophy
Mitral stenosis affect on heart
Left atrial hypertrophy
Mitral regurgitation affect on heart
Left atrial dilation
Aortic regurg affect on heart
Left ventricular dilation
causes of aortic stenosis
idiopathic calcification age related, bicuspid aortic valve, rheumatic heart disease
Aortic regurg causes
Bicuspid valve, idiopathic age related, marfan syndrome, ehlers-danlos syndro,e
Mitral Stenosis causes
Rheumatic heart disease, infective endocarditis
Mitral Regurgitation causes
Idiopathic age, ischaemic heart disease, rheumatic hear disease, IE, marfan or ehlers danlos syndrome
Pan systolic
Mitral regurg
Tetralogy of fallot - may cause pulmonary stenosis
Ventricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy
Aortic valve click replaces
S2
Mitral valve click replaces
S1
Three major complications of mechanical heart valves:
-Thrombus formation
-Infective endocarditis
-Haemolysis causing anaemia
TAVI
Transcatheter Aortic Valve implantation
- treatment for severe aortic stenosis, if patients don’t tolerate open surgery.
Bioprosthetic valve therefore do not typically require warfarin
Infective endocarditis caused by
Staph Aureus most common, strep viridans, enterococcus faecalis
Infective endocarditis risk factors
IV drug use, structural hearth pathology (valvular heart disease, congenital heart disease, hypertrophic cardiomyopathy, prosthetic valve, implantable cardiac devices e.g. pacemakers), CKD, immunocompromised, history of infective endocarditis
Types of IE (3)
Acute, subacute, chronic
IE area of heart affected
Endothelium, most commonly the heart valve
IE symptoms
Fever, fatigue, night sweats, muscle aches, anorexia (loss of appetite)
IE examination findings
- New or changing murmur
- splinter haemorrhages
- petechiae
- janeway lesions, osler’s nodes
- finger clubbing
IE investigations
Blood cultures
Echo - look for vegetations
IE diagnosis criteria
Modified duke criteria
IE management
Admission
IV broad spectrum ABx - e.g. amoxicillin and optional gentamicin
Becomes more specific once causative organism identified.
Continue treatment 4 weeks for with native heart valves
6 weeks for patients with prosthetic heart valves
May need surgery if HF, not responding
Complications IE
Valve damage, HF, emboli, glomerulonephritis
IE prophylaxis
in especially high risk patients give ABx before dental procedures
HOCM stands for
Hypertrophic obstructive cardiomyopathy
HOCM increases risk of
HF, MI, arrhythmias and sudden cardiac death
HOCM genetics
Autosomal dominant
HOCM Presentation
Mostly asymptomatic - may have SOB, fatigue, dizziness, syncope, chest pain, palpitations
Severe may present with HF
Family history of heart disease and sudden death
HOCM examination findings
Ejection systolic murmur at lower left sternal border
HOCM investigations
ECG - left ventricular hypertrophy
CXR - usually normal
Echo - for diagnosis
Genetic testing
HOCM management
B-blockers
Surgical myectomy
Heart transplant
Avoid intense exercise, heavy lifting & dehydration
ACE inhibitors and Nitrates avoids
LVOT
Left ventricular outflow tract obstruction - in HCOM
AFib increased risk of
Stroke
HF
Most common causes of AFib
SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension
Most common causes of Afib acronym
SMITh
Irregularly irregular pulse differentials
AFib, ventricular ectopic
Ventricular ectopics differ from afib how
Disappear when Heart rates gets above certain threshold
Ectopics also called
Premature ventricular contractions
AFib investigations
ECG
Echo for differentials
Types of AF
Paroxysmal - less than 48 hrs
Persistent
Permanent
AFib management principles (2)
Rate & rhythm control
Anticoagulation
Rate control Afib meds
B-blocker, CCB
Rhythm control Afib meds
Cardioversion - amiodarone, flecainide
Electrical cardioversion
B blocker
Ablation
Anticoagulation Afib meds
DOACs first line - dabigatran, rivaroxaban
Warfarin if DOAc contraindicated e.g. valve?
How to determine if need anticoagulation Afib?
CHA2DS2VASc
+ bleeding risk - hasbled
Supraventricular tachycardia
Abnormal electrical signals from above the ventricles cause a fast heart rate
Electrical signal re-enter the atria from the ventricles - self-perpetuating electrical loop without an end point
SVT narrow or broad
Narrow QRS
Narrow complex tachycardia differentials (4)
SVT, Sinus tachycardia, Atrial fibrillation, atrial flutter
Sinus tachycardia how tell
Normal PQRST pattern
AFib how tell
Absent P waves, tachycardia, irregularly irregular ventricular rhythm
Atrial flutter atrial rate
300 bpm
Adenosine
Interrupts the AV node - reset sinus rhythm
Paroxysmal SVT management
B blocker, CCB, amiodarone
Radiofrequency ablation
Shockable rhythms
Ventricular tachycardia, ventricular fibrillation
Non-shockable rhythms
Pulseless electrical activity, asystole
Broad complex tachycardia length
QRS more than 120 ms
Atrial flutter treatment
Anticoagulation based on CHADS-Vasc, radiofrequency ablation
QT prolongation length
From start of QRS to end of T wave more than 440
Torsades de points associated with
QT prolongation
Looks like ventricular tachycardia but qrs twisting around baseline
QT prolongation meds
Antipsychotics, citalopram, flecainide, amiodarone
Hypokalaemia, hypomagnesaemia, hypocalcaemia
Ventricular ectopics are
Premature ventricular beats caused by random electrical discharges outside the atria
ECG - isolated random abnormal QRS complexes on an otherwise normal ECG
Heart block 1st degree
PR consistently longer
Usually benign
PR interval should be
120-200 ms
Heart block second degree type 1 wenckebach
PR longer and longer until drops qrs and restarts
Usually fine
Heart block second degree type 2
PR interval normal, intermittent qrs failure
Bad
Heart block third degree
Complete P waves and QRS no relationship
Risk of asystole
Bradycardia causes
Athletes, meds e.g. B blockers, heart block, sick sinus syndrome
Asystole risk in
2nd degree type 2 & 3rd degree heart block
Pacemaker
Pacemaker indications
2nd degree type 2 & 3rd degree heart block, Bradycardia if symptomatic, severe heart failure
ECG changes with pacemaker
Sharp vertical line on all leads
Pericarditis ECG
Saddle shaped ST elevation
STEMI Management
Aspirin, clopidogrel, heparin, nitrites, morphine and controlled oxygen.
PCI
