Cardio 2 Flashcards
Management of aortic stenosis
Asymptomatic= observe unless valvular gradient >40mmHg or LVF dysfunction
Symptomatic= valve replacement
What are different types of valve replacement in AS
Transcatheter or surgical
Choice depends on patient risk
What is soft/absent S2 seen in
AS
If someone has HF, low BP and poor U&Es, what do
Increase furosemide dose to ensure their is sufficienct concentration of drug in kidneys
What treat cardiac tamponade with if neoplastic cause
Percutaneous balloon pericardiotomy
If not giving opiod for ACS, what use instead
Paracetamol
Avoid NSAIDs
What is a pedunculated heterogenous mass on echo attached to atrial septum
Atrial myxomaA
Atrial myxoma presentation
B symptoms
AF
Mid-diastolic murmur
Murmur in ASD
Fixed splitting of S2
ESM
If someone has had AF for over 48 hours but need to electrically anticoagulate, what can do beforehand
Echo to look for thrombus
First line anti-anginal if known HF
Bisoprolol
If using a standard release nitrate, how prevent tolerance
Asymmetric dosing where take 1 in evening and 1 in morning
How differentiate aortic sclerosis from aortic stenosis on examination
Aortic stenosis will radiate to carotids but sclerosis won’t
Cardiac causes of stroke
Aortic dissection
ASD
Infective endocarditis
Ventricular thrombus
How investigate if having recurrent episodes of syncope but a normal ECG
Holter monitoring
What causes radial pulse to disappear on inspiration
Pulsus paradoxus- cardiac tamponade
Side effects of amiodarone
thyroid dysfunction
corneal deposits
pulmonary fibrosis
liver fibrosis
peripheral neuropathy myopathy
photosensitivity
‘slate-grey’ appearance
thrombophlebitis
bradycardia
lengths QT interval
What investigations need to do before starting on amiodarone
TFT, LFT, U&E, CXR
What tests need to do while on amiodarone
LFT
TFT every 6 months
What does prolonged PR interval suggest in IE
Aortic abscess
When prioritise rhythm control over rate in acute AF
HF
First onset AF
Obvious reversible cause
What surgery is done for stanford A
Aortic root replacement
What do if someone post PCI starts reinfarcting or has haemodynamic instability
Urgent CABG
What cardiac drug can cause GI ulceration and sometimes perforation
Nicorandil
What drug is strictly CI in VT
Verapamil
Management of irregular broad complex tachycardia
Seek expert help
How differentiate between pericarditis from tamponade
Kussmauls sign positive in pericarditis where JVP does not fall on inspiration
What vessel use for venous cutdown
Long saphenous vein
What investigation do all pericarditis patients need
TTE
What drugs can be given for VT
Amiodarone
Lidocaine
Procainmide
What do if drug therapy fails for VT
Electrical cardioversion
What do if someone on dual antiplatelet therapy for CVD presents now requires DOAC for AF
If stable
- stop antiplatelets
Commence DOAC
What test is needed pre digoxin
Hypokalaemia needs to be excluded as predisposed to toxicity
How know when to treat HTN
Treat all stage 2 and 3
Only treat 1 if age <80 and 1 of
- renal disease
- DM
- CVD
- Q-RISK>10%
What is first line anti-hypertensive use guideline
Under 55 or T2DM
-ACEi or ARB
Over 55 or black
- CCB
What is second line anti hypertensive for a black person
ARB not ACEi
Second line management of HTN
If taking ACE i or ARB, add CCB or thiazide like diuretic
If taking CCB, add ACEi, ARB or thiazide like diuretic
(ARB if black)
Third line for HTN
Add whatever missing of ACEi/ARB, CCB or thiazide like diuretic
What do 4th line for HTN
Either seek expert help or add 4th line drug
- if potassium>4.5 then add beta blocker
- if potassium 4.5 and lower then add spironolactone
Metabolic side effects of thiazide diuretics
Hyperglycaemia
High lipids
High uric acid
Target BP for HTN
Clinic
- Under 80 BP<140/90
- Over 80 BP<145/85
ABPM
- Under 80 BP<135/85
- Over 80 BP<150/90
What cardiac drug would cause marked tongue and facial swelling after starting
ACEi from angioedema
Why are thiazide like diuretics preferred nowadays
Poor metabolic SEs
- high lipids, glucose and uric acid
How do ventricular premature beats appear on ECG
Wide QRS complexes between normal P wave- QRS
How differentiate between RBBB and LBBB
RBBB- MaRRoW= M in V1 and W in V6
LBBB- WiLLiaM- W in V1 and W in V6
Causes of RBBB
Normal variant- particularly common as become older
RVH
Cor pulmonale
PE
MI
Cardiomyopathy
What happens in Mobitz T1 HB
Progressive prolongation of PR before missing a beat
What happens in Mobitz T2 HB
PR interval constant but not always followed by a QRS
How describe a Mobitz T2 HB
Ratio of QRS to p waves
Which cardiac drugs can prolong the QT
Sotalol
Amiodarone
Which diuretic most likely to cause hypocalcaemia
Loop diuretics
On which cardiac drug do you see bright spots in vision
Ivabradine
Presentation of left ventricular aneurysm post MI
Persistent ST elevation in absence of chest pain
Left ventricular failure
What is wenkenbach phenomena
T1 HB
Progressive PR elongation before skipping a QRS
Which HB/’s can be normal
T1
Mobitz T1
What can consider 3rd line for black people with HF
After ACEi, beta blocker and spironolactone
Can consider hydralazine and nitrate
Patient presents with sudden onset chest pain worse on breathing in, with RBBB
PE
When starting an ACEi, how manage a rise in creatinine
If less than 30% acceptable, repeat bloods
Where calculate QT to and from
Start of Q to end of T
If has HF and has HTN, which drugs should avoid
CCB ideally as exacerbates oedema but can give amlodipine if thiazides CI like in goût and diabetes
What determines what length of time holter give
Depends on the frequency of palpitations
Eg- if get 2-3 x a week then want to have a 72 hour tape as opposed to 24 hour
What is seen in gallop rhythm
S3 from HF
In what lead it T wave inversion normal
aVR and III
What is in trifasicular block
RBBB with left axis deviation PLUS 1st degree HB
Presentation of stokes adams attacks
Get complete heart block and episodes of syncope
What wave is electrical cardioversion synchronised to
R wave
What is combined alpha and beta blocker
Labetalol
What rise in troponin is concerning from baseline
20
When can be confident not having an MI based off troponin
4 hours between first and final measurement
Loading clopidogrel dose
300mg
Loading ticagrelor dose
180mg
Daily ticagrelor and clopidogrel dose
Tic- 90
Clopi- 75
On top of meds, what is given part of managementfor MI
Cardio rehab
Who are silent MIs seen in
DM
Elderly females
CKD stage 5
Why is echo important in MI
To see if regional wall abnormalities- akinesia, dyskinesia
What need to check daily on furosemide
U&Es for hypokalaemia
How manage furosemide hypokalaemia
Options include adding spironolactone or SandoK
What valves shut in S1
Mitral and tricuspid
What valves shut in S2
Aortic and pulmonary
Causes of mitral regurg
Mitral vavle prolapse
IHD- regional wall abnormalities
Dilated cardiomyopathy
Marfans
IE and rheum fever
What worsens progression of valve disease
CKD as calcification
Hyperlipidaemia and DM
What is the most common cause of secondary htn
Primary hyperaldosteronism
What do if someone presents with new onset AF within last 48 hours
Cardiovert, options include
- DC cardioversion
- medical with flecainide or amiodarone if structural heart disease
What medication affects effectiveness of clopidogrel
Omeprazole
When see bisferiens pulse
Mixed aortic disease
Which CCB use for angina
If monotherapy use verapamil or diltiazem
If in combination with beta blocker use longer release
Lung crackles with normal CXR
PE
How manage DM after a MI
Dose adjusted insulin infusion with regular monitoring of glucose to ensure under 11
MOA of clopidogrel, prasugrel and ticagrelor
P2Y12 receptor antagonist
What do with results of BNP in GP
If over 2,000 then cardio referral in 2 weeks
400-2000 cardio referral in 6 weeks
Under 400- consider other diagnoses
Management of preserved EF HF
Loop diuretic
Manage rfx and supportive
Typically if echo not preferred what use
Cardiac MRI
Which valve replacement operation is preferred
Open as TAVI new and only do in people with lots of rfx
Severe aortic stenosis signs
Absent S2
Narrow pulse pressure
S4
Most common presenting aortic stenosis symptom
Exertional dyspnoea
What can be done for palliative patients with severe aortic stenosis
Percutaneous balloon valvulotomy
Long term complications of valve replacements
Endocarditis
Thrombus formation
Haemolysis
When operate on asymptomatic aortic valve disease (regurg and stenosis)
Reduced LVF
Investigations for IE
3 blood cultures
TTE often first line but if available to TOE as more sensitive
What is most common presenting symptom of right sided endocarditis
Pulmonary septic emboli
Where get septic emboli from IE
Lungs
Brain
Eyes
Spleen
Kidney
Complications of IE
HF
Aortic abscess
Septic emboli- stroke, PE, kidneys
Osteomyelitis
Discitis
Psoas abscess
Valvular dysunction
Post prosthetic valve replacement what is most common cause of IE
Within 2 months= s epidermis
After= s aureus
How tell if axis deviation
Look at leads 1 and AVF
- if both positive then normal
- if both away from eachother then LAD
- if towards then RAD
- if both negative then extreme deviation
Where does PR interval run from
Start of p wave to start of q wave
Where is ST segment between
End of S to start of T
What equation use for corrected QT
Bazzett- which estimates using HR of 60BPM
QT/RR^-2
