Cardio Flashcards
Definition of MI
Myocardial necrosis due to an occlusion of a coronary artery
3 conditions of ACS
STEMI
NSTEMI
Unstable angina
Definition of angina
Sudden acceleration of anginal symptoms on minimal activity
Pathophysiology of a STEMI
Vessel entirely occluded by plaque rupture and subsequent thrombus formation
Differentials for ACS
PE
Acute pericarditis
Aortic dissection
Pneumonia
GORD
Oesophageal spasm
Cholecystitis
MSK
Pancreatitis
GU
What is needed on an ECG for a STEMI?
> 2mm in two contigous chest leads
1mm in two or more limbs
What is a new onset LBBB with a typical history considered to be?
STEMI until proven otherwise
Diagnostic criteria of LBBB on ECG
Heart rhythm must be supraventricular in origin
QRS >120
QS or rS complex in lead V1
notched (M shaped) R wave in lead 6
The T wave should be deflected opposite the terminal deflection of the QRS complex; a concordant T wave may suggest ischaemia or MI
Partial blocks of the LBB - left anterior fasicular block and left posterior fasciular block; this refers to bifrucation of the LBB
NSTEMI includes
ST depression
T wave inversion
Troponin rise
In unstable angina - there may be ECG changes but no what?
No troponin rise
Physiology of troponin
Released by damaged myocardial cells
The level of troponin is directly related to the amount of cardiac damage and is assosiated with the likelihood of later adverse outcomes
Absaloute contradindications to thrombolysis
Active internal bleeding
Uncontrontrolable external bleeding
Recent head trauma (<2 weeks)
Suspected aortic dissection
Intracranial neoplasms
History of proved haemorrhagic stroke or cerebral infarct < 2 months ago
Uncontrollable high BP
Relative contraindications to thrombolysis
Traumatic prolonged CPR
Bleeding disorders
Recent surgery
Probable intracardiac thrombus (e.g. AF with mitral stenosis)
Active diabetic haemorrhagic retinopathy
Anticoagulation or INR > 1.8
Pregnancy
Complications of anterior infarctions
Late VT/VF
Left ventricular aneurysm
Left ventricular thrombus and systemic embolism (usually 1-3 weeks post MI)
Complete heart block (rare)
Ischaemic mitral regurg
Congestive cardiac failure
Cardiac rupture
VSD with septal rupture
Pericarditis and pericardial effusion
Complications of inferior infarctions
Higher re infarction rate
Inferior aneurysm with mitral regurg (rare)
PE (rare)
Complete heart block and other degrees of heart block
Papillary muscle dysfunction and MR
What is indicated in an anterior MI complicated by heart block?
Temporary pacing
What has happened when you get heart block post MI?
The ischaemic damage has disrupted the myocardial innervation from the nerves leading to abnormal myocardial contraction
Occlusion of which artery can cause complete heart block and why?
Right coronary artery
It is the dominant vessel which supplies the AVN and SA nodes
Possible origins of aberrant conductions
Atrial
Ventricular
Junctional (AV node)
Definition of AF
Supraventricular tachycardia (atrial arrythmia)
Assosiated with irregular, disorganised electrical activity, ineffective contraction of the atria, chaotic firing of the AV node and resulting irregular contractions of the ventricles
Defintion of paroszymal AF
Recurrent episodes lasting longer than 30 seconds but less than 7 days
What is used for pharmacological conversion of AF if no structural heart disease?
Amiodarone
Flecanide
What is warfarin?
A vitamin K antagonist
Virchows triad of VTE
Hypercoagulable state
Endotherlial damage
Blood stasis
Pathophysiology of HFpEF
Diastolic heart failure
Impaired cardiac relaxation due to increased ventricular stiffness from a range of causes, resulting in poor cardiac filling and elevated diastolic pressures
This results in signs of fluid overload and peripheral oedema, typical of right sided or biventricular failure because the blood effectively backs up into the circulatory system
Defintition of HFrEF
Systolic heart failure
EF <35-40%
When is BNP secreted?
Secreted by cardiac myocytes and elevated levels are observed when they are overstretched
What is the first heart sound produced by (S1)?
Closing of mitral and tricuspid valves
Where is the mitral valve auscultated?
Left 5th IC space, mid clavicular line
Where is the tricuspid valve auscultated?
4th IC space, left sternal edge
Where is the mitral valve?
Between the left atria and ventricle
Where is the tricuspid valve?
Between the right atria and ventricle
What is the second heart sound produced by? (S2)
Closing of aortic and pulmonary valves
Where is the aortic valve auscultated?
2nd IC space, right sternal border
Where is the pulmonary valve auscultated?
2nd IC space, left sternal border
What is the third heart sound? (S3)
Caused by rapid ventricular filling
Who can S3 be a normal variant in?
Children
Adults up to 40 years old
Causes of the third heart sound
Ventricular dysfunction
- ischaemic heart disease with ventricular dysfunction
- cardiomyopathy
- myocarditis
- valve regurgitation
- cor pulmonale
Increased volume load on the ventricle
- Valve regurgitation
- high output states (e.g. pregnancy)
- left to right cardiac shunts
- volume overload
Two main types of implantable cardiac devices
Pacemakers
Defibrillator
In temporary pacing, what may be seen on ECG?
LBBB due to the nature of electrode placement
In heart failure, pacing is indicated when all of the following are present;
NYHA classification 3/4
QRS > 130
LV EF < 35% with dilated ventricle
Patient on optimal medical therapy
What is PHTN?
A progressive increase in resistance in the pulmonary circulation, eventually leading to right heart failure (cor pulmonale)
What is the most common cause of PHTN and why?
COPD
Airway rigidity leads to increased circulatory pressures to maintain blood flow
What systemic diseases are related to PHTN?
Collagen vascular disease (e.g. scleroderma)
HIV
SLE
Cirrhosis
What happens to the right ventricle secondary to PHTN?
Hypertrophy
Rules re INR (for patients on long term warfarin therapy) and procedures
As long as INR not >2, the procedure may take place in the standard way
Most common organism of IE
Strep Viridans
Murmur of MS
Long diastolic murmur
Apical thrill
Soft first heart sound
Murmur of MR
Prescence of S3
Pansystolic murmur
Displaced and hyperdynamic apex
Murmur of TS
S4
Late peaking of a long murmur
Which of the murmurs has a collapsing radial pulse and what is this called
Corrigans pulse
Aortic regurg
Other clinical signs of IE
Splinter haemorrhages
Oslers nodes (painful)
Janeway lesions (non-painful)
Clubbing (late)
Retinopathy (roths spots)
Hepatosplenomegaly
Causes of mid/late systolic murmur
Innocent murmur
Aortic stenosis or sclerosis
Coarctiation of the aorta
Pulmonary stenosis
Hypertrophic cardiomyopathy
Papillary muscle dysfunction
ASD
Mitral valve prolapse
Causes of mid-diastolic murmur
Mitral stenosis
Rheumatic fever
ASD, VSD, PDA, MR, TR
Atrial tumours
Causes of continous murmurs
PDA
Rupture of sinus of valsalvas aneurysm
ASD
Large AV fistula
Anomalous left coronary artery
Intercostal AV fistula
ASD with MS
Bronchial collaterals
What is the most common isolated congenital heart defect?
VSD
Two parts of the ventricular septum
- Superior membranous component - which contains the AV node
- Inferior muscle componentt
Symptoms of large VSD
Poor feeding
Reduced exercise tolerance
Complications of VSD
PHTN
Eisenmengers
Syndromes assosiated with VSD
Edwards
Pataus
Downs
Turners
Holt Oram
Foetal alcohol syndrome
Why are membranous VSDs more complicated?
AVN
Proximity to the aortic apparatus
What do large VSDs result in?
Left to right shunt
Causes elevated heart pressures and consequently PHTN
Murmur of VSD
Ejection systolic on LSE
Also parasternal heave
Differentials of VSD
PDA
Pulmonary stenosis
Findings of VSD on an ECG
LVH
Biventricular hypertrophy
PHTN
Management of VSD
Spontaneous closure
Digoxin (positive inotropic effect)
Heart failure
- diuretics
- ACEIs (reduce afterload)
In which VSDs are spontaneous closures most common?
Muscular defects`
Indications for surgical closure of VSD
Significant L > R shunt
Assosiated with other defect requiring cardiotomy
Elevated right heart pressure causing PHTN
Endocarditis
Membranous VSD causing
Murmur heard in LBBB
Soft first heart sound
Reversed splitting of the second heart sound
Which drug used to treat angina has no survival benefit post MI?
ISMN
What is a common complication following an anterior MI?
LBBB
Treatment of acute mitral regurg following MI
Emergency surgery
What does sudden death in family members and a long QT indicate
congenital long QT syndrome
WHat is congnital long QT syndrome assosiated with
torsades dde points VT
Examples of drugs that can prolong QT interval
erythromycin
ketoconazole
antihistamines
antiarrythmics
Feautres of aortic dissection
HTN
Tearing chest pain radiating to back
Audible diastolic murmur (from aortic regurg)
Unequal blood pressure readings
Widened mediastinum on CXR
Backward tear is capable of causing dissection to the right coronary artery, giving rise to inferior lead changes on ECG
Significantly raised D dimer
Possibly a raised troponin
How does the body during exercise deliver blood around the body
Dilation of the blood vessels - causes a fall in total peripheral resistance, resulting in a decrease of diastolic BP
Decrease in venous complicance (dilatation) caused by sympathetic stimulation, helping to maintain ventricualr filling during diastole
Pulmonary vessels undergo passive dilatation, as more blood flows into the pulmonary circulation, leading to decreased pulmonary vascular resistance
Increased venous return to the heart means an increased stroke volume
Systemic arterial pressure increases secondary to an increase in HR
S/es amiodarone
Corneal microdeposits
Pulmonary fibrosis
Hepatotoxicity
Hyper / hypo thyroidism
Lengthening of QT interval
Pancreatitis
WHat drugs have evidence that they prevent and allow the reversal of myocardial hypertrophy?
ACEIs and ARBs
WHat type of pacemaker is appropriate for someone with AF and pauses/periods of complete heart block
DDDR
first letter of pacemaker means what
Related to the chamber that needs to be paced
A = atrium
V = ventricle
D = both
Second letter of pacemaker means what
the chamber that is sensed
A, V or D
Third letter of pacemaker means what
the response to the sensed beat by the pacemaker
I = inhibits
T = triggers
D = both (inhibits and triggers)
What is a VOO pacemaker
Fixed output setting
The O as second and third symbol implies that the chamber is not sensed and therefore is no response to a sensed beat
e.g. pacing at 60bpm irrespective of intrinsic activity
What is the fourth letter of a pacemaker mean
Wether or not the pacemaker has rate adaptive properties
What are the main carriers of cholesrerol
LDL
there is a strong assosiation between LDL-C concentration and what
risk of coronary artery disease
What is seen in left ventricular hypertrophy and pressure overload
4th heart sound
What murmur is known to improve in pregnancy
AORTIC REGURG
Inheritance of HOCM
AD
(note has a high degree of penetrance)
Pathology of nitrate tolerance
Generation of reactive oxygen species
Causes of a reversed splitting of the 2nd heart sound
Aortic stenosis
HCM
Ischaemic heart disease with LBBB
S/Es amiodarone
Skin deposits
- photodermatitis
- greyish-blue discolouration
Tingling and numbness in hands and feet
Lethargy
SOB
Weight gain
Fatigue
Slowing of peripheral reflexes
Pulmonary toxicity
Hypo or hyper thyroidism
Pathology in gene for HOCM
Beta myosin heavy chain mutation
Defects in which ion channels are present in congenital long QT syndrome
Potassium
Commonoest cause of restrictive cardiomyopathy in the UK
Amyloidosis
Most common drugs used for cardioversion in AF
Flecanide
Amiodarone
Which drug should you use for cardioversion in a structurally normal heart?
Flecanide
Who should flecanide be avoided in ?
Previous ischaemic cardiac history
Cardiac assosiations of turners syndrome
Bicuspid aortic valve
Coarctation of the aorta
VSD
ASD
ECG diagnosis of VT
Rapid ventricular rhythm
Broad QRS
AV dissociation may result in visible P waves
Capture and fusion beats seen
Each QRS is identical (apart from capture / fusion beats)
Ventricular tachycardia is more likely than SVT with BBB when there is
Very broad QRS (>0.14)
AV dissociation
Bifid upright QRS with a taller first peak in V1
Deep S wave in V6
Concordant (same polarity) QRS direction in all chest leads
Most likely common causative organism of prosthetic valve IE
Staph epidermidis
AntiHTN of choice in <55s
ACEIs
AntiHTN of choice in > 55s / african or carribean descent
CCBs
What artery and ECG changes are affected in an anterior MI?
LAD occlusion
ST elevation V1-V4
What artery and ECG changes are affected in a lateral MI?
LAD occlusion
ST elevation in V5,6 and AVL
What artery and ECG changes are affected in an inferior MI
Right coronary artery
ST elevation in II, III, avF and reciprocal depression in aVL
What artery and ECG changes are affected in a posterior MI
RCA or LC occlusion
ST depression V1-V2
ST elevation in posterior leads if placed
What is the first heart sound in reference to on an ECG
R waves
What is kauslmauls sign and where is it seen?
Inspiratory increase in venous pressure
Steep y descent in the jugular pulse
Seen in constrictive pericarditis
causes of constrictive pericarditis
TB
incomplete drainage of purulent pericarditis
fungal and parasitic infections
chronic pericarditis
post viral pericarditis
post-op
post-MI
Assosiation with pulmonary asbestosis
Causes of reversible PEA
Hypovolaemia
Hypo/hyperkalaemia
Hypothermia
Hypoxia
Tension pneumothorax
Thrombus
Toxins
Tamponade
ECG change of mod - severe hypothermia
J waves
Slow AF
Death from ventricular arrythmias
Most common cardiac abnormality seen in downs syndrome
AVSDs
What blood test is elevated in 80% of patients with a cholesterol embolism?
Eosinophils
Murmur of HOCM
Ejection systolic murmur
Who usually has Mitral valve prolapse
Young females
Narrow AP chest diameter
Low body weight
Low/Normal BP
Increased incidence of MVP in
Autoimmune thyroid disease
Ehlers Danlos syndrome
Marfans syndrome
Pseudoxanthoma elasticum
Pectus excavum
MUrmur of MVP
Mid to late systolic click
Best heard at apex
Late systolic murmur
Values of PHTN
MAP > 25 at rest or > 30 with exercise
What is cardioinhibitory carotid sinus hypersensitivtiy
cardiac asystole > 3 seconds
What is usually required in carotid sinus hypersensitivity and why
Some form of ventricular pacing, with or without atrial pacing
As AV block can occur during the periods of hypersensitive carotid reflex
Absaloute contraindications to carotid sinus massage
MI
TIA last 3 months
CVA last 3 months
Carotid artery occlusion
Previous ventricular arrythmia
Definition of pure vasodepressor type of carotid sinus hypersensivity
systolic BP drop > 50 in the abscence of significant bradycardia
INR and routine DC cardioversion
Needs to be 2 or above on day of and 4 weeks prior to procedure
Causes of the reversed splitting of the second heart sound
AS
LBBB
HOCM
Physical signs of coarctation of the aorta
Radio-femoral pulse delay
Development of collateral vessels (may be heard as systolic murmur over precordium)
LVF
ESM
Cyanotic heart diseases
Teratology of fallot
Total anomalous pulmonary venous congestion
Hypoplastic left heart syndrome
Transposition of great arteries
Truncus arteriosus
Tricuspid atresia
Interrupted aortic arch
Pulmonary artresia
Critical pulmonary stenosis
When do you see tuberoeruptive xanthomas
Type III Hyperproteinlipidaemia
Murmurs seen in marfans
AR
MVP
What should patients with SVT be cardioverted with if they are asthmatic
Verapamil rather than adenosine
Why can you get constrictive pericarditis post heart surgery?
Fibrosis seen around surgery site / site of graft
Causes of constrictive pericarditis
Post heart surgery
Infective pericarditis
TB
Kidney disease
Physical signs of constrictive pericarditis and what is this called
Asucultation of heart sounds with inspiration is assosiated with a drop in BP > 10
Pulsus paradoxus
Classic feature of a automatic supraventircular tachycarrythmia
Show a warm up phenomenon
Rate accelerates after inititation
What should you avoid drinking if you are on warfarin
Cranberry juice
Interactions of cranberry juice
Warfarin
Amitriptyline
Diazepam
NSAIDs
Fluvastatin
Losaratan
Irbestran
What is used to prevent episodes of VT in patients with long QT syndrome
Beta blockers (atenolol)
Signs of HOCM
Double apex beat
Jerky pulse
Mid systolic murmur
What do recurrent palpitations with a short PR interval indicate
Prescence of an accessory pathway
- AVRT
- WPW
- LGL
What is the findings on an ECG classic for WPW
Delta wave (slurred upstroke)
Broadening of QRS
What sound on auscultation indicates more severe AS
Quiet S2
Examples of secondary harm of HTN
LVH
Raised creatinine
Who is pulsus alternans found in
Patients with acute left ventricular failure
Assosiatio nof pulsus alternans
Third heart sound
Only occurs in low output states
There are more chance of complete heart block in occlusion of which artery
Prioximal right coronary
Who does torsades de points occur in
Patients with a prolonged QT interval
1st line therapy of torsades de points
IV magnesium (even if its normal)
The epsilon potential is seen on ECG in what condition
Right ventricular dysplasia
Murmur of an atrial myoxoma
Patient in sinus rhythm
No opening snap on auscultation
Murmur changes character with posture
Which side are atrial myoxomas most common
left atrium
What are atrial myoxomas
Gelatinous friable tumours
Lead to transient signs of MS that occur only if the tumour approahes the valve orifice
Complications of atrial myoxomas
Since they are friable, small fragments can break off during movement and cause tia/stroke
What would be an indication for surgery in IE
Increase of PR interval (suggests extension of endocardiac infection into the myocardium and also raises the posibility of an infection)
MR or AR with heart failure
Septal perforation
Valvular obstruction
Large vegetations (>15mm) can be refered for surgical assessment however not immediate intervention
Mechanism of action of flecanide
Sodium channel blocker
Mechanism of action of amiodarone
Potassium channel blocker
Commonest cardiac abnormality seen in patients with marfans syndrome
Aortic root dilatation
What is strep bovis assosiated with
Colonic carcinoma
Infection of the biliary tree
What is systolic click murmur sydnrome
Features of MVP and recurrent non cardiac chest pains
What murmur do you get in systolic click murmur syndrome and what happens to it on standing
MIdsystolic click and late systolic murmur
During standing or the valvalva manouvre the ventricular volume gets smaller
the click and the murmur move earlier into systle
What is recognised as a cause of sudden death in patients on methadone
Long Qt sydnrome
Eye findings in malignant HTN
Bilateral retinal haemorrhages
Exduates
Cotton wool spots
Physical findings suggestive of rheumatic fever
History of previous pharyngitis
Fever
Polyarthritis
Carditis (including MR murmur)
Prescence of S/c extensor surface nodules
Blood findings of rheumatic fever
Positive anti-streptolysin O titre
Raised ESR
CRP
Leucocytosis
How to calculate the EF
(EDV - ESV) / EDV
What is the preferred drug in patients with a multifocal atrial tachycardia in patients with pulmonary artieral HTN
Verapramil
How does adenosine work
G protein coupled receptor agonist
What causes a wide fixed split of S2
ASD
RBBB with HF
ECGs in HOCM
LVH
Appearances of ischaemia despite normal coronary arteries
- deep T wave inversion
- anterir Q waves
Murmur in HOCM
Sytolic murmur
- worse on standing
- quieter on sqautting
Displaced and foreful apex
Loud S4
Treatment of early prosthetic valve IE
IV vanc, gent and oral rifampicin
What is J point depression on an ECG
Physiological response to an increase in HR
ECG findigns WPW
Short PR interval (<0,12s)
Slurring of QRS - delta wave
Paroxysms of tachycardia
What conditions shoud beta blockers not be used
asthma
myasthenia gravis
Mechanism of action of clopidogrel
Blocks ADP receptors
P2Y12 inhibitor
Indications for permanent pacing
Persistent symptomatic bradycardia
Trifascicular block
Mobitz type 2 AV block
Sinus pauses >3s
Selected patients with tachyarythmias
Symptomatic heart failure on max medical therapy that fulfil guideliens fr cardiac resynchronisatin therapy
What does the dicrotic notch refer to
Aortic valve closing
digoxin and QT interval
shortens it
Whcih murmur is heard loudest in the left lateral position
mitral stenosis
Infarction of which artery can cause complete heart block and why
Right cornary
- supplies the AV node
systolic function in restrictive cardiomyopathy
normal
Where is the commenst site for radiofrequency ablation in AF
Pulmonary veins
WHat can haemodynamically ASDs lead to over time?
Pulmonary HTN
Differential diagnosis of acute pulmonary oedema
Severe LVSD
Paroxysmal arrythmias
3 vessel or left mainsteam coronary artery disease
In context of HTN
- renal artery stenosis
- phaechromocytoma
WHat is the anti HTN of choice for a patient on lithium
Amlodipine
Triad of aortic stenosis
Angina
LVF
Syncope
Features of teratology of fallot
Large VSD
Overriding aorta
Right ventricular outflow obstruction
Right ventricular hypertrophy
What drugs should be used in caution with patients with AS
Beta blockers
JVP signs in a patient with increased atrial contraction pressure (i.e. secondary to e.g. TS or PS)
Dominant A waves
Murmur heard in severe pulmonary HTN
Narrow splitting of the second heart sound
What is the intervention of choice in patients with HOCM who have significant left ventricular outflow obstruction
Beta blockers
Where does the coronary sinus drain into
Right atrium
Triad of heyde syndrome
AS
Angiodysplasia
Acquired von willebrand disease
ECG findings of hypokalaemia
U waves
Small or absent T waves (occassionaly inversion)
Prolong PR interval
ST depression
Long QT
Two clinical findings of hypocalcaemia
Trousseaus sign
Chvosteks sign
Trosseaus sign
Carpal spasm if the brachial artery is occluded by inflating the BP cuff and maintaining the pressure above systolic
Wrist flexion and fingers drawn together
Chvosteks sign
Tapping over the parotid causes facial muscles to twitch
What does significant pulmonary HTN lead to (murmur wise)
Tricuspid regurg (due to significant back pressure)
What is the treatment of ventricular tachycardia secondary to tricyclic antidpressaant overdose where there is acidosis
Sodium bicarcbonate
Triad of cardiac tamponade
SOB
Tachycardia
Elevated JVP
Features of cardiac tamponade
SOB
Tachycardia
Elevated JVP
Pulsus paradoxus
Kussmauls sign (rise in JVP on inspiration)
Area of dullness to percussion with bronchial breathing below the angle of the left scapula (ewarts sign)
JVP findings of complete heart block
Cannon a waves
Features of ASD (never identified in infancy)
Large shunt later teenage years leading to hypoxia, pulmonary HTN and tricuspid regurg
Decreased exercise tolerance
Palpitations assosiated with AF
Pericarditis ECG assosiations
Widespread conCAVE or saddle shaped ST elevation
1st line interventions for pericarditis
NSAIDs
Colchicine
Pathology of long QT syndrome
Potassium channel alpha subunit
Treatment of HTN in marfan patient
ARBS (e.g. valsartan) or beta blockers
What is the glucose content in 1 litre of 5% glucose
50g
What would a patient with recurrent viral pericarditis iwth new signs of cardiac failure indicate
Development to constrictive pericarditis
Treatment of constrictive pericarditis
Anakira
Mechanism of action of ticagrelor
P2Y12 receptor inhibitor
Treatment of native valve endocarditis
Amoxicillin and gentamicin
Treatment of prosthetic valve endocarditis
Fluclox, gentamicin and rifampicin
Drug treatment of choice for medical cardioversion of VT post MI
aMIODARONE
ASD murmur
Fixed split second heart sound
Treatment of paroxysmal SVT where patients refuse an ablation procedure
Beta blockers e.g. metoprolol
Verampramil / diltiazem
Gene mutation in HOCM
MYH7
How does pregabalin work
Voltage gated calcium channel inhibitor
WHat is streptococcus gallolyticus assosiated with with IE
Underlying colon cancer
Cholangiocarcinoma
Most common cardiac defect in patients with noonsans syndrome
Pulmonary stenosis
What can reduce the level of clopidogrel
Omeprazole
