Cardio Flashcards
An MI in which area of the heart is most likely to cause an AV block?
Inferior MI
What are the common complications of an MI?
Cardiac arrest, cardiogenic shock, brady/tachycardias, pericarditis, dressler’s syndrome
In which leads would you see changes in an inferior MI?
II, III and aVF
What are the characteristic features of acute mitral regurgitation?
acute onset SOB, bibasal crackles, hypotension and a systolic murmur
What are the presenting features of a left ventricular wall aneurysm?
Acute-onset SOB, bilateral infiltrates, S3 heart sound, persistent ST elevation
What are the features of superior vena cava obstruction?
facial and upper limb swelling, with distended veins, breathlessness
What is P mitrale?
A bifid P wave, due to left atrial hypertrophy e.g. in mitral valve stenosis
What are the risk factors in the CHA2DS2VASc score acronym?
Congestive HF, Hypertension, Age >75 or age >65, diabetes, prior stroke/TIA/DVT, vascular disease, Sex (female)
What chadvasc score requires anticoagulation?
> 2
What are the signs of cardiac tamponade?
Beck’s triad: hypotension, elevated JVP, diminished heart sounds.
Pulsus paradoxus (drop in BP during inspiration)
Can be after trauma
What is the management of aortic dissection?
ascending aorta - IV labetalol and surgery
descending aorta - IV labetalol
When would you use unsynchronised cardioversion?
When the patient is in cardiac arrest or pulseless ventricular tachycardia
When would you use synchronised cardioversion?
For haemodynamically unstable tachyarrhythmias
What would classify as unstable signs?
hypotension <90 systolic, syncope, clammy etc, myocardial ischaemia, heart failure.
How can you tell the difference between aortic dissection in the ascending vs descending aorta?
Ascending - you get changes in heart sounds (diastolic murmur over the 2nd intercostal space, right sternal edge)
What are the X-Ray findings of aortic dissection?
widened mediastinum
What is the management of aortic dissection?
Ascending: surgical management, BP controlled
Descending: conservative management, IV labetalol
Why do you get a soft ejection systolic murmur in anaemia?
Anaemia makes blood thinner causing turbulent flow in the aorta which creates a murmur
Why do people with CKD get anaemia?
reduced EPO and reduced absorption of iron
What are the features of hypertrophic obstructive cardiomyopathy?
Autosomal dominant - FH. Often asymptomatic, can get exertional dyspnoea, angina, syncope,
What are the finding of hypoertrophic obstructive cardiomyopathy on echo?
MR SAM ASH. Mitral regurgitation, systolic anterior motion of anterior mitral valve, asymmetric hypertrophy
What is Wellen’s syndrome?
ECG pattern seen due to stenosis of LAD - biphasic or deep T-wave inversion in V2-3, minimal ST elevation
What is the first line management of heart failure?
ACE-I and beta-blocker
What is the second line management of heart failure
add an aldosterone antagonist (spironolactone, eplerenone)
or SGLT-2 inhibitors (dapaglifozin)
What vaccines should you offer those with heart failure?
annual flu vaccine, one of pneumococcal vaccine
What is the management of new onset AF?
anticoagulation and DC cardioversion (if within 48 hours of AF starting)
What investigation should you do before cardioversion in AF?
transoesophageal echo to exclude left auricular appendage thrombus
Which score should be used to assess whether patients with AF should be on anticoagulation?
ORBIT
What are the 5 parts of the ORBIT score?
- Haemoglobin <140 for men, <120 for females (2)
- Age > 74 (1)
- Bleeding history (2)
- Renal Impairment (1)
- Treatment with anti-platelets (1)
Which haemodynamic changes are seen in hypovolaemic shock?
- decreased cardiac output
- increased heart rate
- reduced left ventricular filling pressure
- reduced blood pressure
- increased systemic vascular resistance
What commonly causes neurogenic shock?
- decreased sympathetic tone or increased parasympathetic tone - marked decrease in peripheral vascular resistance due to vasodilation - decreases preload and CO causing reduced tissue perfusion and therefore shock
Which murmur is associated with a VSD?
pansystolic
What is the management of angina?
BB or CCB, if symptoms not controlled on one, start both
What investigations should be done in suspected pericarditis?
ECG, transthoracic echo, bloods (inflammatory markers, troponin)
What is the medical management of pericarditis?
NSAIDs and Colchicine until symptoms resolution
What does an opening snap sound indicate?
mitral valve leaflets are still mobile
what murmur is heard in mitral stenosis?
mid-late diastolic murmur (best heard in expiration)
What is takotsubo cardiomyopathy?
Paralysis at the apex of the heart, can cause transient reduction in CO, may present with chest pain or collapse in stressful situation
What are the common causes of dilated cardiomyopathy?
alcohol, coxsackie B, wet beri beri, doxorubicin
What are the common causes of restrictive cardiomyopathy?
amyloidosis, post-radiotherapy, endocarditis
What is the management of a patient with peripheral arterial disease?
Clopidogrel and atorvastatin
What ABPI value confirms peripheral arterial disease?
< 0.9
Which valvular disease is associated with quinke’s sign?
Aortic regurgitation
What is the murmur in aortic regurgitation?
Early diastolic
What is the management of hypertrophic obstructive cardiomyopathy?
A - amiodarone
B - beta blocker
C - cardioverter defibrillator
D - dual chamber pacemaker
E - endocarditis prophylaxis
What is the management of bradycardia with shock?
500ug Atropine and repeat
What is the next step if IV atropine does not help bradycardia?
- repeat
- transcutaneous pacing
- adrenaline infusion
- transvenous pacing
What is the management of angina?
- sublingual GTN spray
- CCB or BB first line
- Then both - but must give longer acting CCB or likely to get heart block
What is the management of a patient who presents with acute coronary syndrome?
MONA - morphine, oxygen, aspirin 300mg, nitrates
What is the management of a STEMI?
300mg aspirin,
if possible PCI within 120 mins
if not, fibrinolysis with ticagrelor
What is the management of an NSTEMI/unstable angina?
- aspirin 300mg
- Fondaparinux if no PCI
- if GRACE risk 3.1> give ticagrelor
- if GRACE risk >3.1 send to PCI centre, give ticagrelor and unfractionated heparin
What is the GRACE score for?
Assessing likelihood of cardiac mortality in next 6 months
What is the gold standard investigation for cardiac tamponade?
Echo
What is the first line management for chronic AF?
beta blockers
- then CCBs/ digoxin
rhythm control comes after: amiodarone
What is the management of acute limb ischaemia?
Analgesia, IV heparin and vascular review
What are the features of acute limb ischaemia?
Pale, pulseless, painful, paralysed, paraesthetic, cold
What are the ECG findings of a posterior MI?
Tall R waves in V1 and V2
Which organism causes endocarditis in IVDU?
Staphylococcus aureus
What medication do you give for anti-clotting in AF/venous clots?
Warfarin or apixaban/rivaroxaban - as this type of clotting is due to blood stasis and is therefore clotting-factor driven
Which medication do you give for arterial clots?
Low dose aspirin, clopidogrel, ticagrelor, dipyramidole. Mainly platelet driven due to damaged endothelium
What is the first line anti-platelet in coronary heart disease?
Aspirin 75mg
What is the first line antiplatelet in cerebrovascular disease?
Clopidogrel 75mg
Which calcium channel blockers are rate limiting?
Verapamil and diltiazem
Which antiplatelets do you give prior to PCI in a STEMI?
aspirin 300mg
prasugrel if not already taking oral anticoagulant
Clopidogrel if taking anticoagulant
Which anticoagulants are used in PCI?
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor
What are the ECG signs of a posterior MI?
St depression in leads V1-V3
Which murmurs are louder on inspiration and which on expiration?
RILE
Right sided loud on inspiration
Left sided loud on expiration
A pulmonary embolism shows what kind of picture on blood gases?
Respiratory alkalosis (causes hyperventilation, low CO2 - alkalosis)
What is the first line medication for reducing stroke risk in AF?
Rivaroxaban/apixaban
What is the management of a pulmonary embolism?
DOACs first line
if not LMWH followed by warfarin.
If circulatory failure: thrombolysis
What medications should be given in ALS after 3 shocks in VF/VT?
Adrenaline 1mg and amiodarone 300mg
What investigation do you do in suspected aortic dissection?
CT angio if stable
transoesophageal echo is unstable
Which drugs do you use for which tachycardia?
adenosine - narrow complex SVT
amiodarone - broad complex
magnesium sulphate - torsades de pointes
What do you give patients on warfarin needing emergency surgery?
Prothrombin complex
if surgery can wait 6-8hrs - vit K
What does an ASD murmur sound like?
ejection systolic mumur louder on inspiration
When does left ventricular free wall rupture occur following an MI?
1-2 weeks after, presents with acute heart failure secondary to cardiac tamponade
What are the features of a left ventricular aneurysm?
Persistent ST elevation and left ventricular failure
When does pericarditis and dressler’s syndrome occur following an MI?
pericarditis - within 48 hours, usually following transmural MI
Dressler’s syndrome - 2-6 weeks after MI - autoimmune pericarditis
Give an example of a long-acting nitrate
Ivabradine, nicorandil, ranolazine
A GRACE score of greater than what should indicate PCI in an NSTEMI?
3% - PCI within 72 hrs
What is the management of bradycardia with signs of shock?
500mcg atropine repeated up to 3mg. Atropine is anti-cholinergic - blocks parasympathetic activity
In acute coronary syndrome, when would MONA not be used?
No Morphine if not severe pain
No oxygen if SATS < 94%
No nitrates if hypotensive
What are fusion and capture beats on an ECG?
capture - when SAN happens to produce a normal QRS in the context of AV block
fusion - when sinus and ventricular beats coincides
Which arrythmias are broad complex?
Those that originate below the AV nodes - in the ventricles
Which drugs do you give in an NSTEMI?
Aspirin + fondaparinux if not having angio or not at high risk of bleeding
if having angio, give unfractionated heparin instead
Which CCB can you use in heart failure?
Amlodipine
Which thiazide-like diuretic do you use in heart failure?
Indapamide - less impact on glucose levels, reduces afterload, longer half-life
What medications are used for rate control in AF?
Beta-blockers +/or rate limiting CCBs (diltiazem)
2nd line: digoxin
Which medications are used for rhythm control in AF?
Amiodarone + Fleicanide
When are adrenaline and amiodarone given in VF/Pulseless VT?
After 3rd shock - if non-shockable give adrenaline straight away
Which valvular pathology causes an quinke’s and demussets signs?
Aortic regurgitation - early diastolic murmur
Which coronary artery supplies the inferior aspect of the heart?
The right coronary
Between which heart sounds are systolic and diastolic murmurs?
systolic - between 1-2
diastolic - between 2-1
What are the ECG findings in cardiac tamponade?
Electrical alternans - Beat-to-beat variation in QRS amplitude due to the swinging motion of the heart within the pericardial sac
Can people drive following a PCI?
If private vehicle - yes
If bus/lorry - wait 6 weeks then DVLA must reassess
What is the management of orthostatic hypotension?
fludrocortisone
How do you diagnose postural hypotension?
symptomatic fall in BP > 20 systolic or 10 diastolic
Which scoring system is used to risk-stratify which patients with a PE should be admitted?
PESI (pulmonary embolism severity index)
What is the acute management of heart failure?
IV loop diuretics (furosemide/bumetanide)
Oxygen. GTN if ischaemia/hypertension/valve disease
What are the steps for managing hypertension?
- ACE/ARB if <55 or diabetic. CCB if > 55 or AC
- Add either CCB/ACE/ARB or thiazide diuretic
- add a third drug or the preceding options
- if K+ < 4.5 add spironolactone, if K+ > 4.5 add alpha/beta blocker
Name some alpha blockers
Tamulosin, doxazosin
How long should patients be anticoagulated before they have cardioversion for AF?
At least 3 weeks
Which drugs are used for pharmacological cardioversion?
amiodarone if structural heart disease or mechanical heart valve
amiodarone/flecainide without structural heart disease
Why can aortic dissection cause horner’s syndrome?
the expanding aorta compresses the sympathetic trunk causing horners (ptosis, miosis and anhidrosis)
What is the timeline of ECG changes seen in an MI?
- hyperacute T waves (mins)
- ST-elevation (mins-hours)
- T wave inversion (hours-days), pathological Q waves if necrosis
What is the management of SVT?
valsalva. IV adenosine as rapid IV bolus 6mg, then 12, then 18, or electrical cardioversion
Which coronary artery supplies the AVN?
Right coronary
What causes a third heart sound?
Rapid filling of the ventricles, seen in LV failure, dilated cardiomyopathy, pericarditis, mitral regurg
What causes a fourth heart sound?
Forceful atrial contraction against a stiffened ventricle, such as in hypertrophic obstructive cardiomyopathy and aortic stenosis
Which anticoagulant is used in mechanical heart valves?
Warfarin
What ECG changes are seen in pericarditis?
Widespread saddle-shaped ST Elevation, PR depression
What are some common contraindications for statins?
Pregnancy and macrolides (erythromycin/clarithromycin)
What is the target INR?
2.5
How can you tell the difference between SVT and sinus tachycardia on ECG?
SVT: HR > 160bpm, narrow qrs
What are the steps for the management of angina?
- BB or CCB (diltiazem, verapamil)
- BB+CCB (amlodipine, nifedipine)
- add long acting nitrate, ivabradine, nicorandil
What is boerhaave syndrome?
vomiting, thoracic pain, subcutaneous emphysema. middle aged alcoholics
What are the features on exam of coarctation of the aorta?
Radio-femoral delay, LV heave, weak peripheral pulses, ejection systolic murmur
What is the best way to monitor treatment in heart failure?
Urine output - catheterisation
