cardio Flashcards
clopidogrel
- mechanism of action
- which drug makes it less effective?
- antagonist of the P2Y12 adenosine diphosphate (ADP) receptor, inhibiting the activation of platelets
- omeprazole (and other PPIs)
statin & dose for cardiac:
- primary prevention
- secondary prevention
- atorvastatin 20mg
- atorvastatin 80mg
in T1DM without CVD offer primary prevention statin (20mg atorvastatin) if:
(4)
> 40y
have had T1DM >10yrs
have nephropathy
have other CVD RF
adverse effects of statins (2):
- myopathy
- liver impairment (thus LFTs at baseline, 3 months and 12 months)
contra-indication to statins (2):
- macrolide therapy
- pregnancy
who should receive a statin?
all people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
following the 2014 update, NICE recommend anyone with a 10-year cardiovascular risk >= 10%
patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins
patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
MI secondary prevention drugs (5):
- dual antiplatelet (aspirin + another)
- ACEI
- B blocker
- statin
beta blocker side effects (5):
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
normal ECG variants in the SPORTY: (4)
- sinus bradycardia
- junctional rhythm
- first degree heart block
- Mobitz type 1 (Wenkebach)
beta blocker contra-indications (4):
- uncontrolled heart failure
- asthma
- sick sinus syndrome
- concurrent verapamil use (may precipitate severe bradycardia)
adenosine
- what’s it used to treat?
- who should it be avoided in?
- adverse effects (4)
- SVT
- asthmatics
- chest pain
bronchospasm
transient flushing
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
loop diuretics (e.g. furosemide)
adverse effects:
HYPO:
hypotension
hyponatraemia
hypokalaemia, hypomagnesaemia
hypochloraemic alkalosis
hypocalcaemia
ototoxicity
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout
angina medical mgt:
all pts:
- aspirin
- statin
- GTN
- BB or CCB (rate limiting e.g. verapamil/ diltiazem*)
- if CCB + BB use longer acting CCB e.g. amlodipine/ MR nifedipine
- add CCB/ BB
if on monotherapy and cannot tolerate addition of CCB/ BB consider one of:
- long acting nitrate
- nicorandil
- ranolazine
which drug offers no PROGNOSTIC benefit in chronic heart failure?
furosemide
which drug is beneficial to LT survival in heart failure
ramipril
chronic heart failure mgt: -
for all:
- annual influenza vaccine
- once-off pneumococcal vaccine
- ACE (have no effect on mortality in heart failure with preserved ejection fraction) &BB
- aldosterone antagonist (e.g. spironolactone, eplerenone)
?SGLT-2 inhibitors (if reduced ejection fraction) _GLIFOCIN
- ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
thiazide diuretics SE: (7)
postural hypotension
HYPOkalaemia (increased sodium delivery to distal convuluted tubule–>: increased sodium absorption in exchange for potassium and hydrogen ions)
HYPOnatraemia
HYPERcalcaemia
gout
impaired glucose tolerance
impotence
cardiac tamponade presentation
Beck’s triad
1. hypotension
2. raised JVP
3. muffled heart sounds
dyspnoea
tachycardia
an absent Y descent on the JVP - this is due to the limited right ventricular filling
pulsus paradoxus - an abnormally large drop in BP during inspiration
Kussmaul’s sign - much debate about this
ECG: electrical alternans (variability in amplitude of QRS)
1st degree heart block definition:
PR prolongation (PR>0.2s)
2nd degree heart block definition:
type 1 (Mobitz I/ Wenckebach)
- PR prolongation until dropped beat occurs
type 2 (Mobitz II)
- constant PR but p wave often not followed by QRS
3rd degree heart block definition:
no association between p waves and QRS complex
complete heart block following MI
–> which coronary artery is most likely to be affected?
Right coronary artery
(as this supplies AV node)
HOCM sx:
(asx)
exertional SOB
angina
syncope (typically post exercise)
jerky pulse
HOCM murmurs: (2)
ESM - ventricular outflow tract obstruction
increased by valsalva
decreased by squatting
pansystolic murmur - mitral regurg
HOCM associations: (2)
Friedrich’s ataxia
WPW
HOCM echo findings:
MR SAM ASH
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH)
HOCM ECG features: (5)
LVH
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
AF (sometimes)
HOCM mgt
ABCDE
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
drug classes to avoid in HOCM (3)
nitrates
ACEi
inotropes
new AF mgt (<48hrs of onset of sx) : -
anticoagulate lifelong if RF for ischaemic stroke
cardioversion, either:
- electrical (DC)
- pharmacological - amiodarone (if structural heart disease)
(or flecainide if no evidence of structural heart disease)
new AF (onset >48hrs)
- anticoagulate for at least 3 weeks prior to cardioversion
OR TOE to exclude left atrial appendage (LAA) thrombus.
if -ve can heparinise and cardiovert immediately.
electrical cardioversion
If high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion
then anticoagulate for at least 4 weeks
amioderone monitoring:
TFT, LFT, U&E, CXR prior to rx
TFT, LFT every 6 months
amioderone adverse effects:
- thyroid dysfunction (hypo&hyperthyroid)
- corneal deposits
- pulmonary fibrosis/pneumonitis
- liver fibrosis/hepatitis
- peripheral neuropathy, myopathy
- photosensitivity
‘- slate-grey’ appearance - thrombophlebitis and injection site reactions
- bradycardia
- lengths QT interval
valve most commonly affected in infective endocarditis:
i. generally
ii. IVDU
i. mitral valve
ii. tricuspid valve
NSTEMI antiplatelets:
aspirin:
+ ticagrelor if not high risk of bleeding
+ clopidogrel if high risk of bleeding
should be based on 6 month mortality risk:
if >1.5% clopidogrel for 12 months
if >3% angio within 96hrs
CHA2DS2VS
C - CCF (1)
H - HTN (or treated HTN (1)
A- age >75 (2)
65-75 (1)
D - diabetes (1)
S - stroke/ TIA/ VTE (2)
V - vascular disease (IHD/ PAD) (1)
S - sex (1 if female)
CHA2DS2VS
when to offer anticoagulation
in males consider if 1+
2+ offer anticoagulation
hypercalcaemia ECG changes
short QT
GTN SE: (4)
hypotension
tachycardia
headache
flushing
cx post MI:
cardiac arrest (VF)
cardiogenic shock
chronic heart failure
arrhythmias
pericarditis (Dresslers’ syndrome)
left ventricular aneurysm
LV free wall rupture
VSD
acute mitral regurg
Dresslers’ syndrome
i. what is it?
ii. presentation
iii. rx
= pericarditis 2-6 weeks post MI
(thought to be autoimmune reaction to recovering myocardium)
ii. fever
pleuritic pain
pericardial effusion
raised ESR
iii. NSAIDs
LV aneurysm post MI
i. ECG changes
i. persistent ST elevation
LV free wall rupture post MI
i. how long after MI
ii. presentation
iii. mgt
i. 1-2 weeks
ii. raised JVP, pulsus paradoxus, diminished heart sounds
i.e. acute heart failure secondary to cardiac tamponade
iii. pericardiocentesis
VSD post MI:
i. how long after MI
ii. presentation
iii. ddx (1)
i. 1-2 weeks
ii. acute heart failure + PANSYSTOLIC MURMUR
iii. acute mitral regurgitation
acute mitral regurgitation post MI
i. following which type of MI is it most common
ii. type of murmur
i. infero-posterior
ii. early/mid SYSTOLIC murmur
ACEi SE (4)
cough
angioedema
hyperkalaemia
1st dose hypotension
ACEi inhibitor rx
–> what change of renal function acceptable?
creatinine increase by 30% from baseline
WPW ECG changes: (4)
short PR
wide QRS with slurred upstroke - delta wave
left axis deviation in R sided accessory pathway
right axis deviation in L sided accessory pathway
WPW mgt:
definitive = radiofrequency ablation of accessory pathway
sotalol (avoid in co-existant AF)
amioderone
flecainide
aortic stenosis presentation
SAD
Syncope
Angina
Dyspnoea
ESM
radiation to carotids
decreased following Valsalva
features of severe aortic stenosis (8)
narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure
aortic stenosis causes (5)
calcification (most common in >65)
bicuspid valve (most common in <65)
William’s syndrome
rheumatic
HOCM
aortic regurgitation presentation: (7)
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
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
mitral stenosis features:
dyspnoea
↑ left atrial pressure → pulmonary venous hypertension
haemoptysis
mid-late diastolic murmur (best heard in expiration)
loud S1
opening snap
low volume pulse
malar flush
atrial fibrillation (secondary to ↑ left atrial pressure → left atrial enlargement)
mitral stenosis causes
rheumatic fever
bradycardia + signs of shock mgt
atropine 500mcg (up to 3mg)
then transcutaneous pacing +/- isoprenaline/ adrenaline infusion
then transvenous pacing + specialist help
nicorandil
i. adverse effects (3)
ii. CI
i. headache
flushing
skin/ mucosal/ eye ulceration (including anal ulceration)
ii. severe hypotension
HTN mgt
SVT
i. mgt
ii. prevention
i.
1. Vagal manoeuvres
2. iv adenosine 6mg–> 12mg–> 18mg (CI in asthma, give verapamil instead)
3. cardioversion
ii. BBs
radio-frequency ablation
ECG territories
PE –> findings on blood gas
respiratory alkalosis
