cardio Flashcards
What condition may cause a double pulse
HOCM
mixed aortic valve disease
Management of stable CVD with AF
stop platelets and start anticoagulant
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l
add alpha or beta blocker
What is the MOA of alteplase
activates plasminogen to form plasmin, which degrades fibrin
What medications inhibit the conversion of fibrinogen to fibrin
heparin/direct thrombin inhibitors
ECG + artery: anteroseptal
V1-V4 + LAD
ECG + artery: inferior
II, III, aVF + right coronary
ECG + artery: Lateral
I, aVL, V5-6 + left circumflex
Why do you get pulmonary oedema in MI
- rupture of papillary muscle
- acute mitral regurgitation causing backflow leading to pulmonary hypertnesion
persistant myocardial ischamia following fibrinolysis
PCI
stable angina
- aspirin/statin
- GTN spray
- CCB/BB
ECG change in WPW
shortened PR interval (early depolarisation)
What medication should be avoided with HOCM
ace-inhibitors
When should statins be stopped
if serum transaminase concs rise to persist 3x upper limit
what is seen on chest x-ray wit aortic dissection
widened mediastinum
j waves
hypothermia
complete heart block following inferior MI
atropine (if anterior, pacing)
what cardiac abnormalities are associated with carcinoid syndrome
pulmonary stenosis and tricuspid insufficiency
most common cause of endocariditis
- staph aureus
- staph epidermis if < 2 months valve replace
cardiac tamponade following MI
left ventricular free wall rupture
persistent ST elevation following MI
left ventricular aneurysm
causes of torsades de pointes
hypothermia, hypocalcamia, hpokalamia, hypomagnesemia
What investigation should be done post fibinolysis
ECG
What is a contraindication to adenosine
asthma
DVLA advice post MI
cannot drive for 4 weeks
hypokalaemia ecg
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
AF pharmacological cardioversion meds
amiodarone
flecainide (if no structural heart disease)
what NSAID is contraindicated in al CVD
diclofenac
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination
ventricular septal defect
normal QRS
0.08-0.10
chronic heart failure vaccine
annual influenza
one off pneumococcal
what antibiotic can cause torsades de pointes
macrolides
Long Qt causes
Electrolytes:
Hypocalcaemia
Hypomagnesaemia
Hypokalaemia
- Drugs:
Antiarrhythmics (e.g. amiodarone, sotalol)
Antibiotics (e.g. erythromycin, clarithromycin, ciprofloxacin)
Psychotropic drugs (e.g. serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents)
third heart sound
caused by diastolic filling of the ventricle
considered normal if < 30 years old (may persist in women up to 50 years old)
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
raised vs low BNP causes
Raised
- myocardial ischaemia or valvular disease
-reduced excretion in patients with chronic kidney disease.
reduce BNP
- ACE inhibitors, angiotensin-2 receptor blockers and diuretics.
what murmur may be present with HOCM
ejection systolic murmur, louder on performing Valsalva and quieter on squatting
how to differentiate ascending vs descending aortic dissection
new murmur = aortic regurg = ascending
ascending: chest pain whilst descending is back pain and distal to subclavian vein
what diabetes drug should be stopped in MI
metformin: risk of lactic acidosis
what should be done before using flecinide
echo: look for structural heart disease
If a patient has been in AF for more than 48 hours…
- anticoagulation for at least 3 weeks prior
- perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy….
2 weeks after to prevent hemorrhagic transformation
PAD investigation
- handheld arterial Doppler examination
- ABPI
ACS initial management
- Morphine
- oxygen (if <94%)
- nitrates (unless hypotensive)
- Aspirin 300mg
STEMI management
- MONA
- PCI with aspirin + prasugrel/clopidogrel prior and unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) during (if <12 hours and can be delivered in <120 mins)
- Fibrinolysis with fondaparinux
What encompasses the GRACE score
age
heart rate, blood pressure
cardiac (Killip class) and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?
immediate: patient who are clinically unstable (e.g. hypotensive)
within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
what pain relief instead of morphine is used in ACS
paracetamol: NSAIDs may precipitate bleeding after antiplatelet drugs are given
drug therapy for medically managed STEMI
Aspirin + ticagrelor
Right heart failure vs Left heart failure signs
Right (body)
- Raised JVP
- Hepatomegaly
- Anorexia
- Peripheral oedema
Left (Lungs)
- Dyspnoea
- fine bibasal crackles
- orthopnoea
what arrhythmia is associated with HOCM
WPW
PR <120ms and wide QRS
Complete heart block following a MI?
right coronary artery as it supplies the AVN node
hypokalaemia ECG
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
when should statins be taken
last thing in the evening
prosthetic valves antithrombotic therapy
bioprosthetic: aspirin
mechanical: warfarin + aspirin
posterior infarct ECG
ST elevation and Q waves in posterior leads (V7-9)
ST depression
Tall, broad R-waves
Upright T-waves
VF/pulseless VT treatment
not witnessed: 1 shock + 2 mins CPR
witnessed: up to 3 shocks
Heart sounds
S1: mitral + tricuspid closing
S2: aortic and pulmonary closing
S3: rapid filling of ventricles (normal in young patients)
S4: stiff/hypertrophic ventricle
Valve areas
Pulmonary: 2nd intercostal space left sternal border
Aortic: 2nd intercostal right sternal border
Tricuspid: 5th intercostal space left sternal border
Mitral: 5th intercostal space mid clavicular line (apex)
What maneuver helps hear mitral stenosis better?
make patient lay on their left side
what maneuver helps hear aortic regurg better
lean forward and exhale
mitral stenosis murmur features
- dyspnoea
↑ left atrial pressure → pulmonary venous - haemoptysis
- mid-late rumbling diastolic murmur (best heard in expiration)
- loud S1
- low volume pulse
- malar flush
- atrial fibrillation
secondary to ↑ left atrial pressure → left atrial enlargement
mitral regurg features
pansystolic murmur heard best at apex and radiates to axilla
reduced ejection fraction heart failure (S3)
aortic stenosis features
- high pitched ejection systolic murmur (crescendo decrescendo)
- narrow pulse pressure
- slow rising pulse
- left ventricular hypertrophy or failure
- radiates to carotids
aortic regurg features
- early diastolic murmur
- collapsing pulse
- wide pulse pressure
- Quincke’s sign (nailbed pulsation)
- De Musset’s sign (head bobbing)
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
symptomatic aortic stenosis treatment
surgical AVR for low/medium operative risk patients
transcatheter AVR for high operative risk patients
what murmur is associated with ADPKD
Mitral valve prolapse
loud s2 sound
pulmonary hypertension
in mitral stenosis, what implies that the valve leaflets are still mobile
loud opening snap
heart failure x ray
A: Alveolar oedema
B: Kerley B lines
C: Cardiomegaly
D: dilated upper lobe vessels
E: pleural effusion
how to differentiate cardiac tamponade and constrictive pericarditis
CP has a positive kussmaul sign (JVP that doesnt fall with inspiration)
patient with severe HF and hypotension
inotropes such as dobutamine
hypertension stages
Stage 1
Clinic: 140/90
Home: 135/85
Stage 2
clinic: 160/100
home: 150/90
management of aortic dissection
type a: surgery (aortic root replacement) and iv labetalol
type b: iv labetalol
investigation for aortic dissection
Stable: CT angiography of the chest, abdomen and pelvis
Unstable: TOE
IE antibiotic duration
4 weeks native valve
6 weeks prosthetic valve
infective endocarditis indications for surgery
severe valvular incompetence
aortic abscess
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
Dukes criteria
Major criteria
- Persistently positive blood cultures (typical bacteria on multiple cultures)
- Specific imaging findings (e.g., a vegetation seen on the echocardiogram)
Minor criteria are:
- Predisposition (e.g., IV drug use or heart valve pathology)
- Fever above 38°C
- Vascular phenomena (e.g., splenic infarction, intracranial haemorrhage and Janeway lesions)
- Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis)
- Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)
what can cocaine trigger
coronary artery vasospasm
what CCB is used as monotherapy in stable angina
diltiazam or verapamil
virchows triad
stasis, endothelial injury and hypercoagubility
rare complication of ace inhibitors
angioedema
when do you DC cardiovert with AF
HISS –> DC cardioversion
(HF, Myocardial infarction, Shock, Syncope)
which hypertensive is avoided in high hba1c
thiazide like diuretics
what arrhythmia can tension pneumothorax cause?
PEA
WPW ecg and treatment
W - delta Wave
P - short PR interval
W - Wide QRS complexes
Accessory pathway ablation
reversible causes of arrest
4 Ts
thrombus
tamponade
tension pneumothorax
toxins
what medication is stopped with macrolides
statins (pregnancy also a contraindication)
ecg findings in cardiac tamponade
electrical alterens
what drug is contraindicated in aortic stenosis
ramipril
causes of torsades de pointes
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage
what MI can cause RBBB
anterior
What is the most common cause of death in patients following a myocardial infarction?
v fib
PAD medication
statin 80mg and clopidogrel 75mg
TIA/stroke + AF
TIA due to AF: DOAC immediately and continue for life
TIA not due to AF: Aspirin 300mg immediately for 2 weeks and then clopidogrel lifelong
Stroke due to AF: Aspirin 300mg for 2 weeks and then DOAC lifelong
Stroke not due to AF: Aspirin 300mg for 2 weeks and then clopidogrel lifelong
normal QRS
3-5 little squares
all patients with tia should have a…
carotid doppler
normal PR interval
3-5 little squares (0.12-.0.20)
ALS adrenaline dose
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
first line imaging for stable angina
ct coronary angiography
what should be measured 3 months after starting statin
A lipid profile and liver function tests should be performed 3 months after starting a statin
what can make clopidogrel less effective
omeprazole
