Cardio Flashcards
In what 2 situations would statins be provided without calculating QRISK?
1) CKD
2) T1DM for ≥10 years or ≥40 y/o
What investigations are required after starting statins?
Lipid profile & LFTs 3 months after
What are 4 serious adverse effects of statins?
1) Myopathy
2) Rhabdomyolysis
3) T2DM
4) Haemorrhagic stroke
What is used for 2ary prevention of CVD? (4)
1) Statins
2) ACEi
3) Beta blocker
4) Aspirin
In what 2 situations would clopidogrel be used instead of aspirin in 2ary prevention of CVD?
1) PAD
2) Ischaemic stroke
What is a key exam finding in familial hypercholesterolaemia?
Tendon xanthomata
What 3 investigations can be done in angina?
1) Stress testing
2) CT coronary angiography
3) Invasive coronary angiography
Medical mx of stable angina?
1) aspirin and a statin in the absence of any contraindication
2) GTN for acute attacks
3) beta blocker or CCB (note, if CCB is used as monotherapy, use verapamil or diltiazem)
Note - beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
In stable angina, if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker, addition of what drugs can be considered?
1) a long-acting nitrate e.g. isosorbide mononitrate
2) ivabradine
3) nicorandil
4) ranolazine
2 treatment options for stable angina?
1) PCI
2) CABG
What are 2 key ECG findings in NSTEMI?
1) T wave inversion
2) ST depression
What ECG leads are affected in MI affecting left coronary artery?
I, aVL, V3-V6
What ECG leads are affected in MI affecting left circumflex artery?
I, aVL, V5-V6
2 key ECG findings in pericarditis?
1) Saddle shaped ST elevation
2) PR depression
Mx of pericarditis? (2)
Acute –> NSAIDs
Reduce risk of recurrence –> colchicine
4 CXR findings in CHF?
1) Bilateral pleural effusions
2) Cardiomegaly
3) Fluid in septal lines (Kerley B lines)
4) Upper lobe venous diversion
What can be used to increase heart function in HF?
Inotropes e.g. dobutamine
At home BP readings for stage 1 vs stage 2 HTN?
Stage 1 –> 135/85
Stage 2 –> 150/95
What 2 findings indicate malignant HTN on fundoscopy?
1) Retinal haemorrhages
2) Papilloedema
What murmur is heard best with patient leaning forward and holding expiration?
Aortic regurg
What murmur is heard best with patient lying on left?
Mitral stenosis
What pulse abnormality can aortic stenosis cause?
Narrow pulse pressure
Murmur heard in mitral stenosis?
Mid diastolic, low pitched rumbling
Murmur heard in mitral regurg?
Pansystolic high pitched whistling
Murmur heard in tricuspid regurg?
Pansystolic & split S2
1st line therapy in HF with reduced EF?
ACEi + beta blocker
2nd line therapy in HF with reduced EF?
1) Aldosterone antagonist e.g. spironolactone
2) Increasing role for SGLT-2 inhibitors e.g. dapagliflozin
Mx of of warfarin in intracranail haemorrhage?
Stop warfarin, give IV vitamin K 5mg + PCC
1st line treatment of bradycardia + adverse features?
Atropine 500 micrograms
What type of heart valves tend to be given to younger patients?
Metallic valves –> last longer
What investigations can you do in aortic dissection?
1) CXR
2) CT angiography of the chest, abdomen and pelvis
3) Transoesophageal echocardiography (TOE)
What is the investigation of choice in aortic dissection?
CT angiography of the chest, abdomen and pelvis (but is only suitable for stable patients and for planning surgery).
What is the investigation of choice in unstable patients with aortic dissection?
Transoesophageal echocardiography (TOE)
Key finding on CXR in aortic dissection?
Widened mediastinum
Key finding on CT angiography of the chest, abdomen and pelvis in aortic dissection?
False lumen
What is Beck’s triad?
Indicates cardiac tamponade:
1) Persistent hypotension
2) Raised JVP
3) Muffled heart sounds
What are some causes of pericarditis?
1) viral infections (Coxsackie)
2) TB
3) uraemia
4) post-MI:
- early (1-3 days): fibrinous pericarditis
- late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)
5) radiotherapy
6) connective tissue disease:
- SLE
- RA
7) hypothyroidism
8) malignancy e.g. lung cancer, breast cancer
9) trauma
Regarding cardiac catheterisation results, what condition does a jump in O2 saturation from the RA to RV indicate?
Ventricular septal defect (indicating that oxygenated blood is travelling from the LV into the RV).
Regarding cardiac catheterisation results, what is the normal O2 saturation levels for all 4 chambers?
RA: 70%
RV: 70%
LA: 100%
LV: 100%
Regarding cardiac catheterisation results, what is the normal O2 saturation levels for all 4 chambers in an ASD?
RA: 85%
RV: 85%
LA: 100%
LV: 100%
The oxygenated blood in the LA mixes with the deoxygenated blood in the RA, resulting in intermediate levels of oxygenation from the RA onwards.
What are the 2 most common causes of a bisferiens pulse?
1) Mixed aortic valve disease (i.e. aortic regurgitation and stenosis)
2) HOCM
What is a bisferiens pulse?
A double pulse felt in systole
Mx of stage 1 HTN (ABPM/HBPM >= 135/85 mmHg)?
Treat if <80 years of age AND any of the following apply:
- target organ damage
- established CVD
- renal disease
- diabetes
- QRISK ≥10%
Mx of stage 2 HTN (ABPM/HBPM >= 150/95 mmHg)?
offer drug treatment regardless of age
Mx of HTN in patients <40?
consider specialist referral to exclude secondary causes
In general, how many days before surgery is warfarin stopped?
Normally 5 days before surgery.
Once the INR is <1.5, surgery can go ahead.
What is the complication if a patient develops acute heart failure around 5 days after an MI?
VSD
How does a VSD following an MI present?
Features of acute HF:
1) Severe SOB
2) Bibasal crackles
3) Raised JVP
4) New-onset pan-systolic murmur
What does rheumatic fever develop following?
Rheumatic fever develops following an immunological reaction to a recent (2-4 weeks ago) Strep. pyogenes (GAS) infection.
What is diagnosis of rheumatic fever based on?
Evidence of recent streptococcal infection accompanied by:
2 major criteria, or;
1 major with 2 minor criteria
What are the 5 major criteria for rheumatic fever?
1) erythema marginatum
2) Sydenham’s chorea: this is often a late feature
3) polyarthritis
4) carditis and valvulitis (eg, pancarditis)
5) subcutaneous nodules
What are the 4 minor criteria for rheumatic fever?
1) raised ESR or CRP
2) pyrexia
3) arthralgia (not if arthritis a major criteria)
4) prolonged PR interval
Mx of rheumatic fever?
1) Oral penicillin V
2) NSAIDs
3) Treatment of any complications that develop e.g. heart failure
What is a broad complex tachycardia following an MI almost always due?
Ventricular tachycardia
Mx of a witnessed cardiac arrest in a monitored patient (e.g. in a coronary care unit)?
Deliver up to 3 quick successive shocks.
(rather than 1 shock followed by CPR)
Infective endocarditis in IVDU most commonly affects which valve?
Tricuspid
In infective endocarditis, what is the most commonly affected valve?
Mitral valve
What is the strongest risk factor for developing infective endocarditis?
A previous episode of endocarditis
What is the most commonly affected valve in endocarditis in IVDU?
Tricuspid valve
What is the half life of adenosine?
8-10 seconds
What is the investigation of choice for suspected aortic dissection (in stable patients)?
CT angiograph
What is the treatment of Mobitz type II?
Pacemaker
What is an alternative to anticoagulation for 3 weeks prior to cardioversion in a patient who has been in AF for >48 hours?
Transoesophageal echo (TOE) to exclude a left atrial appendage thrombus
What investigation is indicated in clinically unstable patients with a suspected aortic dissection?
Transoesophageal echocardiography (TOE)
An opening snap is considered pathognomonic of which condition?
Mitral valve stenosis
An opening snap indicates the leaflets still have some mobility.
What is an opening snap?
This is a high pitched early diastolic sound (just after S2) due to the sudden contraction of the valve leaflets after their initial opening.
What are the 3 layers to the aorta?
1) intima
2) media
3) adentitia
What 2 systems can be used to classify aortic dissection?
1) Stanford system
2) DeBakey system
Describe the Stanford system of aortic dissection classification
Type A –> ascending aorta, typically affects brachiocephalic artery
Type B –> descending aorta, typically affects left subclavian
Which condition is giant cell arteritis often linked to?
Polymyalgia rheumatica
Where is the most commonplace for the initial tear to occur in aortic dissection?
Ascending aorta
What is the most common risk factor for aortic dissection?
Chronic HTN
Aortic dissection can be triggered by events that temporarily cause a dramatic increase in blood pressure.
What can cause this?
1) heavy weightlifting
2) cocaine use
3) emotional stress
Why are connective tissue disorders a risk factor for aortic dissection?
Due to inherent weakness in walls of aorta
What are 2 inflammatory conditions that can predispose to aortic dissection?
1) giant cell arteritis
2) Takayasu arteritis
What type of MI does aortic dissection typically cause?
Inferior MI - due to RCA involvement
How often should BP be measured in patients with T2DM?
Annually
What 2 eye signs may be seen in malignant HTN?
Papilloedema
Retinal haemorrhages
What LFT results would indicate that statins would need to be stopped?
Rise in ALT/AST >3x upper limit of normal
Atorvastatin 20mg is offered as 1ary prevention to which 3 groups of patients?
1) QRISK ≥10%
2) CKD (eGFR <60)
3) T1D for ≥10y or aged ≥40 y/o
What is the antiplatelet of choice in peripheral arterial disease and following an ischaemic stroke?
Clopidogrel
What medication can be used in cardiac stress testing?
Dobutamine
How many doses of GTN spray can patients take?
Up to 3, then call an ambulance.
Take them 5 minutes apart.
Why are statins contraindicated in pregnancy?
As cholesterol is essential for foetal development.
How is familial hypercholesterolaemia inherited?
Autosomal dominant
Which group of medications can lead to atherosclerosis?
Atypical antipsychotics
What investigation can be done following anaphylaxis to confirm?
Serum trypsin
What is the BP target for patients with CKD?
<130/80
What are 2 causes of a raised BNP?
1) HF
2) Renal dysfunction (eGFR <60)
Why can raised BNP be seen in CKD?
Due to reduced excretion
What are 3 factors that may affected eGFR result?
1) pregnancy
2) muscle mass (e.g. amputees, body-builders)
3) eating red meat 12 hours prior to the sample being taken –> can increase levels of creatinine
Next steps in BP ≥180/120:
a) + no worrying signs
b) + signs of retinal haemorrhage or papilloedema OR life-threatening symptoms e.g. new-onset confusion, chest pain, signs of HF or AKI
a) admit for specialist assessment
b) arrange urgent investigations for end-organ damage (e.g. bloods, urine ACR, ECG)
What OGTT results indicate impaired glucose tolerance?
7.8-11
What does a diagnosis of diabetes require? (2)
1) fasting plasma glucose level ≥7.0 mmol/l
or
2) an HbA1c ≥48 mmol/mol (6.5%)
What ECG leads will be affected in an MI affecting the lateral heart?
I, aVL, V5-V6
What ECG leads will be affected in an MI affecting the anterolateral heart?
I, aVL, V3-V6
Which antiplatelet carries a higher bleeding risk: clopidogrel or ticagrelor?
Ticagrelor
What does the GRACE score give?
6m risk of mortality following an NSTEMI
Management of Dressler’s syndrome?
NSAIDs
What does of ticagrelor is given in NSTEMI?
180mg
What can be seen on an echo in Dressler’s syndrome?
Pericardial effusion
What is a type 4 MI?
Associated with procedures e.g. PCI, CABG
What investigations are needed in the diagnosis of Dressler’s syndrome?
(3)
1) ECG
2) Echo
3) Inflammatory markers
2 key ECG features in Dresslers syndrome?
1) Global ST elevation
2) T wave inversion
What system is used to stratify risk post myocardial infarction?
Killip class
What is often the first ECG sign in an MI?
hyperacute T waves
What is a type 3 MI?
Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
Describe Killip class I-IV
Class I - no clinical signs of HF
Class II - lung crackles
Class III - frank pulmonary oedema
Class IV - cardiogenic shock
What is the most specific ECG marker for pericarditis?
PR depression
How does LV aneurysm following MI typically present?
Persistent ST elevation + LV failure
What mx is required for patients with LV aneurysm after MI?
Anticoagulation (as thrombus may form within the aneurysm increasing the risk of stroke).
When starting ACEi, renal function should be measured.
What are 2 key features that should be measured?
1) K+ –> increase up to 5.5 mmol/L is ok
2) Creatinine –> increase up to 30% from baseline is ok
What is a sinusoidal ECG pattern indicative of?
Severe hyperkalaemia (>9 mmol/L)
What can over rapid aspiration/drainage of a pneumothorax result in?
Re-expansion pulmonary oedema
What is the most common cause of mitral stenosis?
Rheumatic fever
With an irregularly irregular pulse, what does a regular heart rate during exercise suggest a diagnosis of ?
Ventricular ectopics
These disappear when HR gets above a certain threshold
What are the 2 main differentials for an irregularly irregular pulse?
1) AF
2) Ventricular ectopics
Cardioversion in AF can be electrical or pharmacological.
What are 2 options for pharmacological cardioversion?
1) Amiodarone
2) Flecainide
What is the drug of choice for pharmacological cardioversion in patients with structural heart disease?
Amiodarone
What can be considered before and after electrical cardioversion to prevent AF from recurring?
Amiodarone
What is reversal agent for apixaban and rivaroxaban?
Andexanet alfa
How long should the patient should be anticoagulated for before delayed cardioversion?
At least 3 weeks
What score is used or assessing the risk of major bleeding in patients with atrial fibrillation taking anticoagulation?
ORBIT score
O - older age (>75)
R - renal impairment (eGFR <60)
B - bleeding previously (history of GI or intracranial bleeding)
I - iron (low Hb or haematocrit)
T - taking antiplatelet
What is an option for patients with contraindications to anticoagulation and a high stroke risk in AF?
Left atrial appendage occlusion
What is the aim of left atrial appendage occlusion?
Aimed at closing off the appendage, reducing the ability of thrombus formation and risk of embolism.
If a CHA2DS2-VASc score suggests no need for anticoagulation, what investigation is important?
Echo –> to exclude valvular heart disease
AF + valvular heart disease –> absolute indication for anticoagulation (even if CHA2DS2-VASc score is low).
When should digoxin be considered in AF? (2)
1) Only considered if the person does no or very little physical exercise or other rate-limiting drug options are ruled out because of comorbidities.
2) May have a role if there is coexistent HF.
Which part of the QRS complex is used for synchronisation in DC cardioversion?
R wave
In what 2 situations is cardioversion used in AF?
1) electrical cardioversion as an emergency if the patient is haemodynamically unstable
2) electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred.
Adenosine and asthmatics?
Adenosine causes bronchospasm
At what EF is cardiac resynchronisation therapy considered in HF?
<35%
2 key actions of BNP?
1) Relaxes smooth muscle in blood vessels –> reduces systemic vascular resistance
2) Acts on kidneys as diuretic
What defines cardiomegaly on a CXR?
Cardiothoracic ratio >0.5
What drugs should be offered after an MI (i.e. 2ary prevention)?
1) High dose statin
2) Dual antiplatelet
3) ACEi
4) Beta blocker
What is torsades de pointes?
Torsades de pointes (‘twisting of the points’) is a form of polymorphic ventricular tachycardia associated with a long QT interval.
It may deteriorate into ventricular fibrillation and hence lead to sudden death.
What 3 ECG features are seen in Wolff-Parkinson White?
1) Short PR interval (<0.12s)
2) Wide QRS complex (>0.12s)
3) Upsloting delta waves
What condition is Wolff-Parkinson White associated with?
HOCM
Mechanism of furosemide?
inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
What is the investigation of choice in PE in renal impairment?
V/Q scan
Mx of patients on warfarin with INR 5.0-8.0 with no bleeding?
Withhold 1-2 doses, restart at a lower dose
In which type of heart defect is there Quincke’s sign (nailbed pulsation)?
Aortic regurgitation
In which type of heart defect is there De Musset’s sign (head bobbing)?
Aortic regurgitation
What can be given alongside furosemide in patients with acute heart failure with concomitant myocardial ischaemia or severe HTN?
GTN
What scale can be used to grade the intensity of murmurs?
Levine scale
Mx of patients on warfarin undergoing emergency surgery?
Give four-factor prothrombin complex concentrate
How does IV adenosine need to be infused?
via a large-calibre cannula (e.g. 16G) or central route
What is the most common cause of 2ary HTN?
1ary hyperaldosteronism
Which type of HTN medication can worsen glucose control?
Thiazide diuretics
What is the next step in mx if patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI?
CABG
Mx of intracranial haemorrhage on warfarin?
Give IV vitamin K 5mg + PCC and stop warfarin
Most common valvular defect associated with rheumatic fever?
Mitral stenosis
Most common cause of mitral stenosis?
Rheumatic fever
What is myocarditis in young people typically preceded by?
Viral illness
Triad of symptoms in aortic stenosis?
1) SOB
2) Chest pain
3) Syncope
1st line investigation in phaeochromocytoma?
Plasma & urinary metanephrines
Typical triad of symptoms in phaeochromocytoma?
1) sweating
2) headaches
3) palpitations
in association with severe HTN
Mx of phaeochromocytoma?
Surgery is the definitive management.
The patient must first however be stabilised with medical management:
1) alpha-blocker (e.g. phenoxybenzamine), given before a
2) beta-blocker (e.g. propranolol)
What protein are Abs targeted against with GAS infection?
M protein on Strep. pyogenes molecule
What is most common clinical feature of rheumatic fever?
Migratory polyarthritis
What is the most common cause of death in acute rheumatic fever?
Myocarditis - leads to HF
What is the name of the diagnostic criteria used in rheumatic fever?
Jones critiera
What is the 5 major diagnostic criteria for rheumatic fever?
Previous strep infection plus:
1) Polyarthritis
2) Carditis
3) SC nodules
4) Erythema marginatum
5) Sydenham chorea
How soon after strep infection do symptoms of rheumatic fever appear?
2-3 weeks after
What causes a raised ESR?
During inflammation, fibrinogen causes RBCs to stick together.
These clumped up RBCs fall to bottom of test-tube faster –> raised ESR
