Cardio Flashcards
INR target for replacement aortic valve
3.0
INR target for replacement mitral valve
3.5
which pathway timing is most affected by warfarin
PT
as predominately affects factor VII
Initial blind therapy for native valve endocarditis
amoxicillin
consider adding low-dose gentamicin
Initial blind therapy If penicillin allergic, MRSA or severe sepsis in endocarditis
vancomycin + low-dose gentamicin
Initial blind therapy If prosthetic valve endocarditis [3]
vancomycin + rifampicin + low-dose gentamicin
Native valve endocarditis caused by staphylococci : treatment
Flucloxacillin
Native valve endocarditis caused by staphylococci treatment if pen allergic or MRSA
vancomycin + rifampicin
Prosthetic valve endocarditis caused by staphylococci: treatment
Flucloxacillin + rifampicin + low-dose gentamicin
Prosthetic valve endocarditis caused by staphylococci: treatment if pen allergic or MRSA [3]
vancomycin + rifampicin + low-dose gentamicin
Endocarditis caused by fully-sensitive streptococci (e.g. viridans) treatment
Benzylpenicillin
Endocarditis caused by fully-sensitive streptococci (e.g. viridans) treatment if pen allergic
vancomycin + low-dose gentamicin
Endocarditis caused by less sensitive streptococci
Benzylpenicillin + low-dose gentamicin
Endocarditis caused by less sensitive streptococci if pen allergic
vancomycin + low-dose gentamicin
CHADS-VASC components
Congestive Heart Failure
Hypertension
Age
Diabetes
Stroke, TIA, thromboembolism hx
Vascular disease
Sex
SADCHAVS
which components of CHADS-VASC score 2 points
Age >75
and
previous stroke, TIA, thromboembolism
normal QRS
80-120 ms
normal QTc
<450 female
<430 male
normal PR
120-200 ms
indication for cardiac resynchronisation therapy in heart failure
a widened QRS (e.g. left bundle branch block) complex on ECG
vaccines offers in heart failure
offer annual influenza vaccine
offer one-off pneumococcal vaccine
summary of drugs in HF [4]
BASH
beta blockers
ace inhibitors
spirinolactone
hydralazine, SGLT-2 and co
Modified Dukes Criteria for Infective Endocarditis
A useful mnemonic to remember the criteria is ‘BE FIVE PM’:
Major Criteria:
- Blood Cultures (2 cultures, 12 hours apart)
- Evidence of Endocardial Involvement: Echo shows new murmur; abscess
Minor Criteria:
- Fever >38
- Immunological phenomena: Roth spots, splinter haemorrhages or Olser’s nodes
- Vascular phenomena
- Echocardiogram minor criteria
- Predisposing features: valvular disease, IVDU, prosthetic valves
- Microbiological evidence that does not meet major criteria.
For a definitive diagnosis of IE two major criteria, or one major and three minor criteria, or all five minor criteria must be present.
5 medications that need to be started post MI
2 antiplatelets (aspirin + ticagrelor if medically managed)
ACEi
Beta blocker
Statin
might use prasugrel after PCI
reduced ejection fraction (HF-rEF) percentage
<35-40%
4 causes of Systolic dysfunction HF
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Arrhythmias
4 causes of Diastolic dysfunction HF
Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis
which type of ejection fraction do
- systolic HF
- diastolic HF
have?
HF-rEF in systolic HF
HF-pEF in diastolic HF
signs of LVHF
pulmonary oedema:
dyspnoea
orthopnoea
paroxysmal nocturnal dyspnoea
bibasal fine crackles
signs of RVHF
peripheral oedema
ankle/sacral oedema
raised jugular venous pressure
hepatomegaly
weight gain due to fluid retention
anorexia (‘cardiac cachexia’)
causes of high output cardiac failure (normal heart with not enough blood to pump to meet metabolic needs) [6]
anaemia
arteriovenous malformation
Paget’s disease
Pregnancy
thyrotoxicosis
thiamine deficiency (wet Beri-Beri)
pulse pressure in aortic regurg
wide
pulse pressure in aortic stenosis
narrow
which murmur has an opening snap
mitral stenosis
in which murmurs is S3 likely to be heard
mitral regurgitation
aortic regurgitation
where is S4 likely to be heard
aortic stenosis
main ECG findings in pericarditis
main: PR depression
ST elevation everywhere
which murmur has a displaced apex heart sound
aortic regurgitation
aortic regurgitation murmur
end diastolic on LLSE (Erb’s point)
signs of severe aortic regurg [3]
collapsing pulse
wide pulse pressure
LVF
chronic causes of aortic regurgitation [4]
bicuspid aortic valve
RHD
CTD
ankylosing spondylitis
acute causes of aortic regurg [2]
infective endocarditis
aortic dissection
heart sounds in mitral stenosis
comment on the apex beat
loud S1 due to opening snap
tapping apex beat
murmur in mitral stenosis
mid diastolic in left lateral position at end expiration radiates to the axilla
low pitch rumbling
low pitch= low velocity
causes of mitral stenosis [2]
RHD
Austin-flint murmur
1st line surgical treatment of mitral stenosis (symptomatic)
balloon valvuloplasty
CI: LAA thrombus, calcified valve
murmur in mitral regurgitation
pan systolic murmur in left lateral position on end expiration radiates into axilla
chronic causes of mitral regurgitation [4]
mitral valve prolapse
RHD
calcification
CTDs
how can AR and MR be medically manageed
reduce the after load e.g. rate control and BP reduction, fluid reduction with diuretics
management of heart failure [4 lines]
1st line:
ACEi or Beta blocker (HFrEF)
Diuretic (HFpEF)
2nd line:
Spironolactone
SGLT-2 inhibitor (for HFrEF)
3rd line:
Hydralazine + nitrate
(other: ivabradine, digoxin, sacubitirl-valsartan)
4th:
cardiac resychronisatfon therapy
1st line treatment of stable angina
beta blocker or non-DHP CCB (along with GTN)
non DHP CCB e.g. verapamil or diltiazem
2nd line treatment of stable angina
beta blocker AND DHP CCB (along with GTN)
DHP CCB: amlodipine, nifedipine as these can be given with beta blcokcers
never prescribe non-DHP CCBs with beta blockers
3rd line options for stable angina [4]
long acting nitrate
ivabradine
nicorandil
ranolazine
1st line investigation of stable angina
CT coronary angiography
treatment of stroke without AF
antiplatelets i.e. clopidogrel (+ statin)
treatment of stroke with AF
anti coagulant i.e. DOAC
NICE guidelines (2021) suggest all patients with AF should have rate control as first-line, except with: [4]
- 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
i.e. all of these people need rhythm control
1st line rate control option for AF
beta blocker (bisoprolol or atenolol)
or
non DHP CCB (diltiazem or verapamil)
contraindication for CCB [2]
peripheral oedema, heart failure
2nd line rate control of AF
digoxin
3rd line rate control of AF
amiodarone
which patients need rhythm control [4]
- have a reversible cause of AF
- have heart failure with AF
- new onset AF
- inadequately managed by rate control
1st line rhythm control of AF
electrical cardioversion (synchronised)
2nd line rhythm control of AF
pharmacological cardio version
depends on presence of structural heart disease
pharm rhythm control in someone with structural heart problems
amiodarone
pharm rhythm control in someone with NO structural heart disease
flecainide
two methods of rhythm control
cardio version (immediate or delayed) and long term drugs
2 types of immediate cardioversion
electrical and pharmacological
indications for immediate cardio version [2]
Present for less than 48 hours
Causing life-threatening haemodynamic instability
when is delayed cardio version used. How it is done.
if the atrial fibrillation has been present for more than 48 hours and they are stable.
The patient should be anticoagulated for at least 3 weeks before delayed cardioversion.
They are rate controlled whilst waiting for cardioversion.
1st line long term rhythm control
Beta blockers
2nd line long term rhythm control
Dronedarone
second-line for maintaining normal rhythm where patients have had successful cardioversion
3rd line long term rhythm control
Amiodarone
is useful in patients with heart failure or left ventricular dysfunction
1st line investigation of hypertension
ambulatory BP monitoring
what BP is severe hypertension requiring admission; what are the signs [5]
> =180/110
retinal haemorrhage
papilloedema
confusion
AKI
chest pain
example of thiazide LIKE diuretic
indapamide
what needs to be monitoring before and during ACEi treatment
U&Es
most commonly affected valve in infective endocarditis
mitral
most commonly affected valve in infective endocarditis caused by IVDU
tricuspid
treatment approach for paroxysmal AF
pill in pocket with flecainde
Paroxysmal atrial fibrillation refers to episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm. These episodes can last between 30 seconds and 48 hours.
Investigation for suspected paroxysmal AF [2]
24-hour ambulatory ECG (Holter monitor)
Cardiac event recorder lasting 1-2 weeks
most common causative agent of infective endocarditis
staph aureus
Key investigations in infective endocarditis [3]
1) blood cultures: x3, 6hr apart
2) trans-oesophageal echo
3) 18F-FDG PET/CT for prosthetic heart valve
what replaces amoxicillin in infective endocarditis treatment if pen-allergic or MRSA
vancomycin and Low dose gentamicin
what replaces flucloxacillin in infective endocarditis treatment if pen-allergic or MRSA
vancomycin and rifampicin
treatment duration of native valve infective endocarditis
4 weeks
treatment duration of prosthetic valve infective endocarditis
6 weeks
causative organism of rheumatic fever
group A beta haemolytic strep i.e. strep pyogenes
2 histological findings in rheumatic heart disease
Anitschkow myocytes and Aschoff bodies
Rheumatic fever major criteria: CASES
C- carditis
A- Arthritis
S- Sucutaneous nodules
E- Erythema marginatum
S- Syndenham’s chorea (presents 2-6m later)
Rheumatic fever minor criteria: FRAPP
F- Fever
R- Raised ESR/CRP
A- Arthralgia
P- Prolonged PR
P- Previous rheumatic fever
diagnostic investigations of rheumatic fever [3]
throat culture and rapid streptococcal antigen test
ISO titre
management of rheumatic fever [3]
- bed rest
- analgesia (NSAIDs for joint painand aspirin for carditis)
- phenoxymethylpenicillin (Pen V, for sore throat, 10 days)
prophylactic antibiotic for rheumatic fever
IM benzathine penicillin or PO phenoxymethylpencillin
infective causes of pericarditis [4]
HIV
TB
coxsackie
EBV
autoimmune causes of pericarditis [2]
SLE
RA
investigations for pericarditis [3]
bloods for inflammatory markers
ECG
Echo for effusion
acute management of pericarditis and long term management
NSAID e.g. aspirin or ibuprofen
steroids in severe cases
colchicine (longer term to reduce reoccurrence)
which patients are at risk of silent MI
diabetics
ECG changes in stemi [2]
ST-segment elevation
New left bundle branch block
ECG changes in NSTEMI [2]
ST segment depression
T wave inversion
can be normal just like in unstable angina but will have raised crops
ECG leads representing the Left coronary artery
I, aVL, V3-6
ECG leads representing the Left anterior descending
V1-4
ECG leads representing the Circumflex
V5-6, I, aVL
ECG leads representing the Right coronary artery
II, III, aVF
two options for a STEMI presenting within 12 hours
Percutaneous coronary intervention (PCI) (if available within 2 hours of presenting)
Thrombolysis (if PCI is not available within 2 hours)
medication given before PCI
aspirin and prasugrel
what are angiography, angioplasty and stent
catheter into the patient’s radial or femoral artery (radial is preferred), feeding it up to the coronary arteries under x-ray guidance and injecting contrast to identify the area of blockage (angiography).
Blockages can be treated using balloons to widen the lumen (angioplasty) or devices to remove or aspirate the blockage.
Usually, a stent is inserted to keep the artery open.
examples of fibrinolytic used in thrombolysis [3]
streptokinase, alteplase and tenecteplase.
BATMAN management of NSTEMI
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 GRACE score is considered low risk
<=3%
what GRACE score is considered medium to high risk
how are they treated
> 3%
angiography with PCI within 72 hours
how are unstable NSTEMI patients treated
angiography
which CCB must ivabradine not be given with
verapamil (rate limiting CCB) as it can lead to bradycardia
4H’s and 4T’s of reversible causes of PEA
hypovolaemia, hypoxia, hyper/hypokalaemia, hyper/hypothermia, toxicity, tension pneumothorax, tamponade, thromboembolism
how can aortic dissection have neuro deficits
due to involvement of the carotid artery
in which type of dissection is chest pain more common
Type A
in which type of dissection is upper back pain more common
Type B
treatment of acute pulmonary oedema
IV loop diuretics e.g. furosemide or bumetanide
treatment of heart failure with respiratory failure
add CPAP
when should GTN be given in acute heart failure [3]
normally not routinely given
only if there is concurrent myocardial ischaemia, severe hypertension or AR/MR
what is pulsus paradoxus
causes of pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
severe asthma, cardiac tamponade
cause of slow rising pulse
aortic stenosis
causes of collapsing pulse [4]
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
what is Pulsus alternans
cause of Pulsus alternans
regular alternation of the force of the arterial pulse
severe LVF
what is Bisferiens pulse
cause of bisferiens pulse
double pulse’ - two systolic peaks
mixed aortic valve disease, HOCM occasionally (a jerky pulse)
investigation of choice in aortic dissection
CT angio of chest, abdo pelvis
Transoesophageal echocardiography (TOE) more suitable for unstable patients who are too risky to take to CT scanner
1st line investigation in aortic dissection
Chest X-ray
shows widened mediastinum
treatment of Type A dissection
IV labetalol aim for 100-120 systolic and surgery
treatment of Type B dissection
IV labetolol and conservative
ECG feature of cardiac tamponade
electrical alternans (QRS big small big small)
which ejection systolic murmurs are heard louder on expiration [2]
aortic stenosis and HOCM
which ejection systolic murmurs are heard louder on inspiration [2]
ASD and pulmonary stenosis
which murmur is associated with carcinoid heart disease (Hedinger syndrome).
mid-ejection systolic murmur due to pulmonary stenosis
what drug can make clopidogrel less effective
PPI
lansoprazole should be okay tho
what are the risk factors for asystole in bradycardia [4]
complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds
treatment of bradycardia
initially atropine 500mcg
atropine, up to a maximum of 3mg
transcutaneous pacing
isoprenaline/adrenaline infusion titrated to response
transvenous pacing if no response to the above
contraindications for thrombolysis [8]
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
severe hypertension
MoA of thrombolytic drugs
convert plasminogen to plasmin, plasmin degrades fibrin that makes up the thrombus
difference between aortic sclerosis and aortic stenosis
aortic sclerosis produced an ejection systolic murmur that does not radiate to the carotids and produces a normal ECG
what finding would suggest an ascending aorta dissection over a descending
new early diastolic murmur suggesting aortic valve involvement
ST elevation requirement in anterior leads and inferior leads in order to do PCI or thrombolysis
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of > 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
cause of inverted T waves [6]
myocardial ischaemia
digoxin toxicity
subarachnoid haemorrhage
arrhythmogenic right ventricular cardiomyopathy
pulmonary embolism (‘S1Q3T3’)
Brugada syndrome
features of takayasu arteritis [6]
systemic features of a vasculitis e.g. malaise, headache
unequal blood pressure in the upper limbs
carotid bruit and tenderness
absent or weak peripheral pulses
upper and lower limb claudication on exertion
aortic regurgitation (around 20%)
investigation and management of takayasu arteritis
Investigations
vascular imaging of the arterial tree -either magnetic resonance angiography (MRA) or CT angiography (CTA)
Management
steroids
which vessel is typically affected in Takayasu
aorta
which antibiotic should statins not be co-prescribed with
macrolides due to risk of rhabdomyolysis
what is Kussmaul’s sign and where is it seen
JVP will rise on inspiration
seen in constrictive pericarditis
which diuretic can worse glucose tolerance
thiazides
Beck’s Triad in cardiac tamponade
hypotension
raised JVP
muffled heart sounds
other features: pulsus paradoxus - an abnormally large drop in BP during inspiration
in acute heart failure, when are inotropes and vasopressors used
in severe hypotension/ cardiogenic shock
Following basic ABC assessment, patients are classified as being stable or unstable according to the presence of any adverse signs:
shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
syncope
myocardial ischaemia
heart failure
monitoring of amiodarone
- before treatment
- during treatment
before: TFT, LFT, U&E, CXR prior to treatment
during: TFT, LFT every 6 months
normal QRS in seconds
0.12-0.20
4 causes of raised JVP
- heart failure
- fluid overload
- constrictive pericarditis
- cardiac tamponade
management of WPW Syndrome
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation
which drug is contraindicated in VT
verapamil
can precipitate cardiac arrest.
atorvastatin dose in primary prevention of MI
20mg
what three things make up a trifasicular block
RBBB +left anterior or posterior hemiblock (ventricular strain) + 1st-degree heart block
features of 2 level Wells score
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative)
what makes the ejection systolic murmur in HOCM quieter and louder
Increases with Valsalva manoeuvre and decreases on squatting
which two conditions is HOCM associated with
Friedreich’s ataxia
Wolf-Parkinson White
anti-anginal associated with GI ulceration
nicorandil
anti-anginal at risk of developing tolerance
what should be done if this happens
isosorbide mononitrate
patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
what does the opening snap in MS indicate
valve is still mobile
which anti anginal can cause cold peripheries
beta blockers
age threshold for ACEi/ARB in hypertension
< 55
causative agent of endocarditis in post prosthetic valve op patients ( < 2 months)
staph epidermidis
causative agent of endocarditis associated with colorectal cancer
strep bovis
causative agent of endocarditis associated with poor dental hygiene
step viridans
which abx can precipitate torsade de pointes
macrolides
ECG features of HOCM [4]
- left ventricular hypertrophy
- non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
- deep Q waves
- atrial fibrillation may occasionally be seen
when can consecutive shocks be given in defibrillation
if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend ‘up to three quick successive (stacked) shocks’, rather than 1 shock followed by CPR
when is a further dose of amiodarone given in defibrillation
a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
First degree heart block
constantly prolonged PR interval
there is delayed conduction through the atrioventricular node. Despite this, every atrial impulse leads to a ventricular contraction, meaning every P wave is followed by a QRS complex.
Second degree heart block
some atrial impulses do not make it through the atrioventricular node to the ventricles. There are instances where P waves are not followed by QRS complexes. There are two types of second-degree heart block:
Mobitz type 1 (Wenckebach phenomenon)
Mobitz type 2
Mobitz type 1
what is the pathophysiology and what is the ECG finding
conduction through the atrioventricular node takes progressively longer until it finally fails, after which it resets, and the cycle restarts.
increasing PR interval until a P wave is not followed by a QRS complex.
Mobitz type 2
what is the pathophysiology and what is the ECG finding
Intermittent failure of conduction through the atrioventricular node, with an absence of QRS complexes following P waves.
The PR interval remains normal.
what is the complication of Mobitz type 2 and third degree heart block
risk of asystole
Third degree heart block
There is no observable relationship between the P waves and QRS complexes
3 causes of sudden cardiac death in the young
most common: HOCM
2nd most common : Arrhythmogenic right ventricular cardiomyopathy (ARVC, also known as arrhythmogenic right ventricular dysplasia or ARVD
Brugada syndrome (common in Asians)
inheritance of ARVC/ARVD
autosomal dominant pattern with variable expression
Naxos disease
an autosomal recessive variant of ARVC
a triad of ARVC, palmoplantar keratosis, and woolly hair
pathology in ARVC
right ventricular myocardium is replaced by fatty and fibrofatty tissue
investigations for ARVC [3]
ECG
abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex
echo
changes are often subtle in the early stages but may show an enlarged, hypokinetic right ventricle with a thin free wall
magnetic resonance imaging
is useful to show fibrofatty tissue
treatment of ARVC [3]
drugs: sotalol is the most widely used antiarrhythmic
catheter ablation to prevent ventricular tachycardia
implantable cardioverter-defibrillator
curative treatment for patients who get atrial flutter
radiofrequency ablation of the tricuspid valve isthmus is curative for most patients
where do atrial myxomas develop
75% occur in left atrium, most commonly attached to the fossa ovalis
more common in females
most common ASD found in adulthood
what ECG finding?
ostium secundum
ECG: RBBB with RAD
features of ASD [2]
ejection systolic murmur
fixed splitting of S2
ECG changes in Brugada syndrome [2]
administration of which medications make these changes more apparent
-convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
- partial right bundle branch block
the ECG changes may be more apparent following the administration of flecainide or ajmaline - this is the investigation of choice in suspected cases of Brugada syndrome
management of Brugada syndrome
implantable cardioverter-defibrillator
treatment of HOCM
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
drugs to avoid in HOCM
nitrates
ACE-inhibitors
inotropes
drug causes of Long QT (METH CATS)
Methadone
Erythromycin
Terfenadine
Haloperidol
Clarithromycin / chloroquine
Amiodarone / Azithromycin
TCAs
SSRIs (esp. citalopram) / Sotolol
ECG findings in dextrocardia [3]
inverted P wave in lead I
right axis deviation
loss of R wave progression
how is asymptomatic mitral stenosis treated
observation every 6-12 months with echo
side effects of beta blockers [5]
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
Long QT syndrome: what channel is the issue
loss of function of K+ channels
which murmur can present with haemoptysis
mitral stenosis
due to pulmonary pressures and vascular congestion
may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins
which medication is contraindicated in treating breathlessness associated with aortic stenosis
nitrates
theoretical risk of profound hypotension
management of AF post TIA and stroke: when is a DOAC started
post TIA- immediately once haemorrhage has been excluded
post stroke- if not haemorrhage, after 14 days of aspirin
what BP is defined as severe hypertension
180 sys or 120 dia
which conditions are associated with coarctation of the aorta
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
features of coarctation of the aorta
infancy: heart failure
adult: hypertension
radio-femoral delay
mid systolic murmur, maximal over the back
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
ECG features in hypothermia
bradycardia
‘J’ wave (Osborne waves) - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
common cause of aortic stenosis in young patients
bicuspid aortic valve
stage 1 HTN: clinic and ABPM
clinic >= 14//90
ABPM >=135/85
stage 2 HTN: clinic and ABPM
clinic >=160/100
ABPM >=150/95
when are LFTs monitored with statins
at baseline, 3 months then 12 months
reversal agent for dabigatran
idarucizumab
reversal agent for heparin
protamine
reversal agent for DOAC
andexanet alfa
treatment of subclavian steal syndrome
percutaneous transluminal angioplasty or a stent.
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
+fondaparniux
which type of heart failure are SGLT-2 inhibitors used for
HFrEF
features of a bifascicular block
the combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
indication for emergency valve replacement surgery in infective endocarditis
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
adverse effects of thiazide diuretics
dehydration
postural hypotension
hypokalaemia
due to increased delivery of sodium to the distal part of the distal convoluted tubule → increased sodium reabsorption in exchange for potassium and hydrogen ions
hyponatraemia
hypercalcaemia
the flip side of this is hypocalciuria, which may be useful in reducing the incidence of renal stones
gout
impaired glucose tolerance
impotence
Rare adverse effects
thrombocytopaenia
agranulocytosis
photosensitivity rash
pancreatitis
treatment of aortic stenosis:
- asymptomatic
- symptomatic
- young person
- high risk operative
- not fit for valve replacement
- asymptomatic: observe unless valve gradient >40 –> consider valve replacement
- symptomatic: valve replacement
- young person : surgical AVR
- high risk: transcatheter AVR
- not fit for valve replacement: balloon valvuloplasty
for how long can’t you drive post mi
4 WEEKS
unless angioplasty done, then its one week
Wellen syndorme
ECG pattern that is typically caused by high-grade stenosis in the left anterior descending coronary artery.
biphasic or deep T wave inversion in V2-3
minimal ST elevation
no Q waves
management of AF with mitral stenosis
warfarin
