CARDIO Flashcards
pharmacological options for treatment of orthostatic hypotension
Fludrocortisone and midodrine
If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI
urgent coronary artery bypass graft (CABG) is recommended
causes of raised troponin
Cardio: MI, Aortic dissection, HF, inflammation,
Resp: PE, ARDS
Infectious: SEPSIS
GI: severe GI bleed
Nervous: stroke
Adenosine half life
8-10 seconds
causes of orthostatic hypotension
primary autonomic failure: Parkinson’s disease, Lewy body dementia
secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
drug-induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhage, diarrhoea
postural hypotension that does not cause an increase in HR VS exaggerated increase in HR
no increase in HR: autonomic dysfunction e.g. DM,
exaggerated increase in HR: anaemia, hypovolemia
mixed aortic valve disease
Bisferiens pulse -
Takayasu’s arteritis symptoms
absent peripheral pulses
uneven blood pressure and pulses between arms
claudication
AR murmur
Takayasu’s arteritis Ix
MR angiogram or CT angiogram
Takayasu’s arteritis associated with
renal artery stenosis
‘non-shockable’ rhythms:
asystole
pulseless-electrical activity
‘shockable’ rhythms:
ventricular fibrillation
pulseless ventricular tachycardia
acute HF management
IV loop diuretics
Nitrates (GTN) if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease
‘Global’ T wave inversion
non-cardiac cause e.g. head injury
aortic dissection Ix stable vs unstable
stable- CT angiography
unstable- TOE
Acute heart failure with hypotension
- inotropes be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
elevated JVP, persistent hypotension and tachycardia despite fluid resuscitation in a patient with chest wall trauma
cardiac tamponade
how should adenosine be given in SVT
rapid bolus
loop diuretics electrolyte abnormalities
hyponatraemia
hypokalaemia, hypomagnesaemia
hypocalcaemia
thiazide diuretics electrolyte abnormalities
hypokalaemia
hyponatraemia
hypercalcaemia
blood pressure target for type 2 diabetics:
< 140/90 mmHg
In AF, if a CHA2DS2-VASc score suggests no need for anticoagulation
do an echo to exclude valvular heart disease
S3 causes
heard in left ventricular failure (e.g. dilated cardiomyopathy),
constrictive pericarditis (called a pericardial knock)
mitral regurgitation
Use rhythm control to treat AF if
there is coexistent heart failure, first onset AF or an obvious reversible cause
Moderate-severe aortic stenosis is a contraindication to
ACE-i
irregular broad complex tachycardia in a stable patient
Atrial fibrillation with bundle branch block
raised JVP that doesn’t fall with inspiration
Kussmauls sign
constrictive pericarditis
HF drug which reduced glycemic awareness
beta blocker
intervention of choice for severe mitral stenosis
Percutaneous mitral commissurotomy
digoxin ECG features
down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia
Concurrent use of clopidogrel and what drug can make clopidogrel less effective
PPI
polycystic kidney disease associated with what valvular abnormality
mitral valve prolapse
3rd line HF therapy:
ivabradine
sinus rhythm > 75/min and a left ventricular fraction < 35%
3rd line HF therapy:
sacubitril-valsartan
left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period
3rd line HF therapy:
Digoxin
coexistent atrial fibrillation
3rd line HF therapy:
hydralazine in combination with nitrate
Afro-Caribbean
3rd line HF therapy:
cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
For a person < 80, with stage 1 hypertension ( 135/90 - 149/99) only treat medically if:
diabetic,
renal disease,
QRISK2 >10%,
established coronary vascular disease
end organ damage
contraindications to thrombolysis
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
severe hypertension
causes of raised BNP other than HF
age over 70 years,
left ventricular hypertrophy, ischaemia,
tachycardia,
right ventricular overload, hypoxaemia (ie pulmonary embolism),
renal dysfunction (eGFR less than 60 ml/minute/1.73 m2),
sepsis,
chronic obstructive pulmonary disease,
diabetes,
or cirrhosis of the liver
arrhythmogenic right ventricular dysplasia ECG
T-wave inversion in leads V1-3 and a terminal notch in the QRS complex (epsilon wave)
Torsade de pointes Tx
IV magnesium sulphate
trifasicular block
RBBB +left anterior or posterior hemiblock + complete heart block
young patient with exertion dyspnoea
HOCM
(AS if older)
statin mechanism of action
Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis
Wolff Parkinson white ECG
short PR interval (<120ms),
wide QRS complex (>120ms),
upsloping delta wave
ostium secundum atrial septal defect
passage of an embolus from the right-sided circulation to the left causing a stroke
ejection systolic murmurs
aortic stenosis (expiration)
pulmonary stenosis (inspiration)
infective endocarditis acute Ix
3x blood cultures first
TTE >TOE
pulsus paradoxus
BP falls during inspiration
cardiac tamponade
NSTEMI management: unstable patients
immediate coronary angiography
young people with new onset chest pain with a recent history of viral illness
myocarditis
statin + clarithromycin/erythromycin
rhabdomyolysis- elevated CK
Acute heart failure: Ix in new-onset heart failure, cardiogenic shock, suspected valvular or post-MI problems
echocardiography
Prosthetic heart valves - antithrombotic therapy:
bioprosthetic: aspirin
mechanical: warfarin + aspirin
Eisenmenger’s syndrome ECG
RVH
Electrical alternans is suggestive of
cardiac tamponade
Infective endocarditis - indications for surgery:
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
ACS poor prognostic factors
age
development (or history) of heart failure
peripheral vascular disease
reduced systolic blood pressure
Killip class*
initial serum creatinine concentration
elevated initial cardiac markers
cardiac arrest on admission
ST segment deviation
IV adenosine needs to be infused via
a large-calibre vein or central route
Symptomatic aortic stenosis:
surgical AVR for low/medium operative risk patients
transcatheter AVR for high operative risk patients
first line investigation for stable chest pain
Contrast-enhanced CT coronary angiogram
verapamil and beta blocker
risk of complete heart block
Fondaparinux Mechanism of action
Activates antithrombin III.
Beck’s triad
muffled heart sounds, hypotension and raised jugular venous pressure
hypokalaemia ECG
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
mitral stenosis features
dyspnoea
malar flush
haemoptysis
AF
deeply inverted T-waves in leads V2-V3
wellen syndrome
critical stenosis of LAD
left ventricular aneurysm
typically occurs 2 weeks after MI symptoms mimicking heart failure (presenting with shortness of breath, cough, and crackles on auscultation) alongside persistent ST elevation (as the ECGs are not changing).
right heart failure triad
raised JVP, hepatomegaly and ankle oedema
SAH ECG
torsade de pointe
widened QRS complexes and a notched morphology of the QRS complexes in the lateral leads suggests
a left bundle branch block
bifasicular block
right bundle branch block and left axis deviation
inferior myocardial infarction and AR murmur
ascending aorta dissection
definitive treatment of Wolff-Parkinson White syndrome
radiofrequency ablation of the accessory pathway
Rupture of the papillary muscle due to a myocardial infarction
→ acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema
left ventricular aneurysm post MI
persistent ST elevation and left ventricular failure.
left ventricular free wall rupture
acute heart failure secondary to cardiac tamponade
atrial septal defect murmur
ejection systolic murmur louder on inspiration
asymptomatic mitral stenosis Tx
monitored with regular echocardiograms
Subclavian steal syndrome presentation
posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm
left ventricular hypertrophy ECG
sum of S wave depth in V1 and R wave in V5 or V6 exceeds 40mm
left atrial enlargement
left axis deviation
ST elevation in V1-V3
prominent U waves
causes of LVH
HTN
aortic stenosis/regurgitation
mitral regurgitation
coarctation of aorta
hypertrophic cardiomyopathy
large saddle embolus in pulmonary trunk
new LBBB
new STEMI
alternative to atropine in management of bradycardia
adrenaline/isoprenaline infusion
following a TIA AF management
anticoagulation started immediately once imaging excluded haemorrhage
lifelong apixaban
younger patient- which type of heart valve
prosthetic- last longer
stable angina treatment
1st line= beta blocker or calcium channel blocker (verapamil or dilitazem) one or both
if used in combination- a longer-acting dihydropyridine calcium channel blocker can be used (amlodipine or nifedipine)
2nd line= isosorbide mononitrate, ivabradine, nicorandil, ranolazine
mechanical valves target INR
aortic: 3.0
mitral: 3.5
AF target INR
2.5
severe anaemia can cause
high output cardiac failure
QT interval
start of Q and end of T wave
normal= less than 430 ms in males and 450 ms in females.
posterior MI
reciprocal changes in leads V1-V3:
ST depression
Tall, broad R-waves
Upright T-waves
Patients on warfarin undergoing emergency surgery -
give four-factor prothrombin complex concentrate
If fibrinolysis is given for an ACS,
an ECG should be repeated after 60-90 minutes and transfer for urgent PCI if ST elevation not resolved
P Mitrale represents
left atrial hypertrophy/strain e.g. in mitral stenosis
severe hypertension and bilateral retinal hemorrhages and exudates
malignant hypertension
NSTEMI management: patients with a GRACE score > 3%
should have coronary angiography within 72 hours of admission
Aortic stenosis management:
AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started when
two weeks after the event
Brugada syndrome ECG findings
convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
partial right bundle branch block
the ECG changes may be more apparent following the administration of flecainide or ajmaline
Brugada syndorme Tx
implantable cardioverter-defibrillator
Heart failure patients on maximum triple therapy with widened QRS complex –>
cardiac resynchronisation therapy
Beta-blockers should only be stopped in acute heart failure if
the patient has heart rate < 50/min,
second or third degree AV block,
or shock
If new BP >= 180/120 mmHg + no worrying signs then the first step is
urgent investigations for end-organ damage
e.g. urine dipstick for haematuria
fundoscopy
urinary ACR
ECG
most common cause of Infective endocarditis prosthetic valve
<2 months post valve surgery= staph epidermis
>2 months = staph aureus
broad complex QRS=
> 0.12 seconds
hypercalcaemia on ECG
shortened QT interval
