Cardio 3 Flashcards

1
Q

anti-coags and their antidote

Dabigatran-

A

Dabigatran- Idarucizumab

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2
Q

post-MI what suggests a left ventricular aneurysm?

A

pulmonary oedema- bibasal crackles.
S3 heart sound suggests the left ventricle is larger than normal (as S3 represents the sloshing of blood into a large ventricle during diastole)
S4 heart sound suggest that the left ventricle is stiffer than normal (as S4 represents the forceful atrial push of blood against a hard ventricular wall)

left ventricular aneurysm will cause persistent ST elevation in V1-6 on an ECG. This is because the fibrosis and dead tissue is not able to properly move as expected.

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3
Q

Wellen’s syndrome ECG

A

shows deeply inverted T-waves in leads V2-V3 (which may extend to V1-V6) with no or minimal ST-elevation and preserved R wave progression.

biphasic or deep T wave inversion in V2-3
minimal ST elevation
no Q waves
high-grade stenosis in the left anterior descending coronary artery.

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4
Q

Kussmaul’s sign constrictive pericarditis

A

JVP will rise on inspiration;

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5
Q

NSTEMI (managed conservatively) antiplatelet choice

A

aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk

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6
Q

What does a pacemaker look like on ECG?

A
  • A long straight line vertical going over all the leads, it precedes the QRS complex
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7
Q

peri-arrest management bradycardia + haem unstable
1
2 can repeat step 1. up until…
3
4

A
  1. Atropine Atropine (500mcg IV)
  2. Can repeat up to a max of 3mg
  3. Trans-cutaneous pacing
  4. Isoprenalne/ adrenaline infusion titrated to response
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8
Q

Clinically how can you differentiate Rheumatic fever from IE?

Rhemuatic (4)

A

Rheumatic fever:
- Recent sore throat
- rash (annular macules)
- Arthritis
- Murmur
(usually strep! think sore throat!)

IE
- Obvs fever and new murmur but more likley to be IV drug user/ staph infection from skin
- Rashes are less common, Skin changes are more nail changes splinter haemorrhages, roth spots, osler nodes and janeway lesions

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9
Q

What do these meand and condition

Soft S1 (2 condition)

Absent S2 (1 condition)

Loud P2

S3 ( 1 condition but normal if…)

S4 (3 condition)

A

Soft S1- prolonged PR, severe mitral stenosis or mitral regurgitation

Absent S2- severe aortic stenosis

Loud P2- early sign of pulmonary hypertension (right sided HF)

S3 - Rapid ventricular filling- LV failure. Normal if < 30yo

S4- atrial contraction against a stiff ventricle- hypertrophic obstructive cardiomyopathy and hypertension, aortic stenosis

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10
Q

What should you do If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI (hours after)

A

urgent coronary artery bypass graft (CABG) is recommended

because PCI has failed

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11
Q

Post MI complications what is the STEM that gives it away

Pericarditis (3)

Dresslers (when, 4 key signs, treatment)

Left ventricle Aneurysm (ECG, risk of…, treatment)

Left ventricular free wall rupture (when, TRIAD! treatment)

VSD (when, 2 features, echo to differentiate between it and…, management)

Acute mitral regurg (what territory MI increased likelihood and why, 2 presentations, murmur, treatment 2)

A

Pericarditis-
- in first 48 hours is common
- pain worse on lying flat, better leaning forward
-may auscultate muffled heart sounds if effusion, echo to confirm

Dresslers (autoimmune ttack myocardium)
- 2-6 weeks after MI
- fever, pleuritic pain, pericardial effusion and increase ESR
- treat with NSAIDs

Left ventricle Aneurysm
- persistent ST elevation and left ventricular failure.
- Thrombus may form within the aneurysm increasing the risk of stroke
- Patients are therefore anticoagulated.

Left ventricular free wall rupture
- 1-2 weeks post-mi
- acute HF secondary to cardiac tamponde (muffled heart sounds, raised JVP, pulses paradoxicus- BP drop when breathing in)
- Urgent pericardiocentesis and thoracotomy

VSD
- first week
- heart failure associated with a pan-systolic murmur.
Acute mitral regurg
- Echo to rule out acute mitral regurg which presents similarly
- Urgent surgical correction is needed.

Acute mitral regurgitation
- More common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle
- Acute hypotension and pulmonary oedema
- early-to-mid systolic murmur
- treated with vasodilator therapy but often require emergency surgical repair.

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12
Q

What drug can cause cool peripheries?

A

Propranolol

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13
Q

Which betablocker can cause long QT syndrome?

A

Sotalol

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14
Q

Aortic stenosis common causes
< 65yo think-
> 65yo think -

A

younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification

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15
Q

What are the indications for treating stage 1 essential HTN?

(6)

A
  1. < 80yo (if 80+ dont bother!)
  2. Q-RISK > 10%
  3. Diabetes
  4. established coronary vascular disease
  5. Renal disease
  6. End organ failure damage
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16
Q

What do you look out for wolf-park white ECG?

(3)

A
  1. sloped QRS (delta wave)
  2. Short PR interval
  3. non-specific ST-T changes
17
Q

non-shockable rhythm management

1.
2.
3.
4.

dont give…

A
  1. Commence CPR 30;2
  2. IV access if no interosseous give adrenaline 1mg - repeat every 3-5 mins
  3. 2 mins chest compress
  4. Repeat adrenaline at 3-5 mins

don’t give amiodarone in non-shockable!

18
Q

name drugs which can lower INR in someone on warfarin
7!!

cytochrome p450 inducers!

drug metabolised quicker so has less effect

A
  1. carbemazapine, pheytoin
  2. barbiturates: phenobarbitone
  3. rifampicin
  4. St John’s Wort (depression mild herbal)
  5. chronic alcohol intake
  6. griseofulvin
  7. smoking (affects CYP1A2, reason why smokers require more aminophylline)
19
Q

when starting ACEi it can cause a lucid drop in renal function but if too low can highlight what pathology?

A

significant renal impairment may occur if the patient has undiagnosed bilateral renal artery stenosis

20
Q

management of cardiac tamponade

non-metastatic cause

metastatic cause (which is what cancer)

A

Non met = urgent pericardiocentesis

Met
= Percutaneous balloon pericardiotomy

Melanoma most common
others- lung, breast, haematological cancers

21
Q

Acute HF management
1. first things first

3.

3.5- may have a role in…
main CI…

If severe hypotension this is trickyyyy….

  1. med
  2. med if 1. doesn’t work
  3. mechanical
A
  1. sit patient up!
  2. IV high dose furosamide or bumetanide (repeat CXR to see if improve)
  3. O2! target 94-98%
  • 3.5- vaodilators not routinely used but nitrates may have a role if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease
    the major side-effect/contraindication is hypotension
  1. resp failure/ not improvement then CPAP

hypo

  1. inotropic agents
    e.g. dobutamine
    if - severe left ventricular dysfunction who have potentially reversible cardiogenic shock
  2. vasopressor agents
    e.g. norepinephrine
    - used if insufficient response to inotropes and evidence of end-organ hypoperfusion
  3. mechanical
    - intra-aortic balloon counterpulsation or ventricular assist devices
22
Q

ALS guidlines

Shockable rhythm =
1
2
3
4
5
6
7. If PE suspected

Non-Shock-able rhythm =
1
2
3

A

Shockable rhythm =
1. Start compressions 30;2 whilst waiting for defib
2. Shock once (stacked if witnessed in cardiac centre)
3. adrenaline 1mg after 3rd shock - repeat 1mg every 3-5mins
5. amioderone 300mg after 3rd shock (lidocaine as sub-situate)
6. repeat amioderone 150mg after 5th
7. PE suspected- give thrombolysis ad continue CPR for 60-90mins

Non-Shock-able rhythm =
1.Compressions 30:2
2. Give adrenaline 1mg asap
3. Re-check after 2 mins
4. Repeat adrenaline every 3-5 mins?

23
Q

Reversible causes for cardiac arrest 4H’s 4Ts

A

H- hypoxia
H- Hypothermia
H- Hyper K+, Hypo K+, Hypoglycaemia, acidaemia
H- Hypovolaemia

T- tension PTX
T- Thrombosis
T- Tamponade
T- Toxins

24
Q

Loop Diuretics Adverse Affects

A
  1. Hypo K+, Na+, Mg2+
  2. Ototoxicty
  3. HYPOCALCAEMIA
  4. Renal Immpair (stop in AKI)
  5. Gout
  6. Hypergycaemia
25
Drug induced Ototoxicity FAV Q&A ( + 2 more)
FAV. Q&A F-furosamide A- Aminoglycosides (gentamicin) V- Vancomycin Q- Quinolines A- Aspirin Also NSAIDs and cisplatin (chemo drugs)
26
CI (2) for statins 1 2- other meds Dosages - Primary prevention = increase the dose if... - Secondary prevention =
1. Preg 2. macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course Dosages - Primary prevention = 20mg increase the dose if... non-HDL >= 40% - Secondary prevention = 80mg
27
What is Pulses alternans whats it seen in? Kaussmauls sign whats it seen in? (2*/6)
Pulses alternans- drop in BP on inspiration - Cardiac tamponade Kaussmauls sign- Rasied JVP on inpiration - *Constrictive pericarditis - *right-sided heart failure - right-sided heart infarction - tricuspid stenosis and massive pulmonary embolism.
28
What do you see on ECG in hypothermia? *1. 2 3 4
*1. J waves (Osborne waves) - small hump at the end of the QRS complex 2. first degree heart block 3. long QT interval 4. atrial and ventricular arrhythmias
29
Hypothermia - Vasoconstriction occurs and 2 hormones are released Mild = mod or severe = Risk Factors (4/6)
- TSH - ACTH Mild = 32-35 mod or severe = < 32 1. Homeless 2. Elderly/ extremes of age 3. Hypothyroidism 4. impaired mental status 5. substance misuse 6. GA
30
Hypothermia Investigations Bedside - Obs- Temp (probe where?) - - Bloods - FBC (2) - Electrolyte - ABG - Imaging -
- rectal or thermistor probs - ECG: J waves, or acute ST elevation - BM- stress hormones are increased and the body czn have more peripheral resisitcne to insulin Bloods - FBC- Hb and haematocrit can increase - WCC and Plt low as sequested in spleen - K+ HYPO - Coagulation - ABG CXR
31
Hypothermia Management Conservative/ Initial: 1 2 3 4. If don't respond... * should be ready for... in severe cases - don't use....
Initial 1. remove from cold + wet/cold clothing 2. warm by blankets 3. secure airway 4. If don't respond to passive warming give warmed IV fluids or apply forced warm air * be ready for CPR IV drugs should be avoided as patient more likely to have drastic response to drugs
32
What Anti-hypertensive is CI in patients with renovascular disease? (bilateral renal artery stenosis)
ACE inhibitors causes the creatinine to increase dramatically as a result of angiotensin II constricting the efferent arteriole, subsequently leading to dilatation of the efferent arteriole and reduced filtration.
33
Patients on warfarin undergoing surgery: - Emergency = - can wait 6 -8 hours =
emergency = four-factor prothrombin complex concentrate 6-8 hours= give 5 mg vitamin K IV both occasions stop warfarin
34
ECG seen in severe cardiac tamponade
Electrical alternans- alternation of QRS complex amplitude between beats.
35
Differenciate these classic post MI complications Left ventricular free wall rupture - when? - presents with Ventricular septal defect - when? - presents with (2) - do.... Acute mitral regurg - when? - MI where? Presents (3) need...
Left ventricular free wall rupture - 1-2 weeks after - presents with Cardiac tamponade: Muffled heart sounds, pulsus paradoxicus, raised JVP Ventricular septal defect - first week - presents with pans-systolic mrumur and assoc. heart failure - DO ECH TO RULE OUT ACUTE MITRAL REGURG! Acute mitral regurg - first week presents with: - Inferio-posterior infarction- therefore PAPILLARY muscle rupture 1. Acute hypotension 2. Pul oedema 3. early-to-mid systolic murmur - need emergecny surgery
36
Amyloidosis seen in patient s wtih mulptiple myeloma have what cardiomyopathy?
restrictive cardiomyopathy- Protein deposition in the myocardium
37
Management of NSTEMI - already given Asprinin loading dose, GTN, O2 if needed, +/- morphone etc.. If haem unstable: If stable: 1. 2. - - 3. Further drugs for PCI - everyone gets... Antiplatelet: - not taking anticoag = - taking anti-coag = 3. Conservtive STEMI Further anti-platelet = anti-platelet =
If haem unstable: - Immediate coronary angio and PCI If stable: 1. Fondiparinux 2. GRACE score: - > 3% high risk next 6 month mortality = coronary angio < 72hrs - < 3% consider coronary angio 3. Further dru gs for PCI - everyone gets... unfractionated heparin Antiplatelet: - not taking anticoag = prasugrel or ticagrelor - taking anti-coag = clopidogrel 3. - Clopidogrel if high bleed risk Tecagralor if not high bleed risk
38
Common SE of thiazides 1. Electrolytes 2. 3 4 5 6 Rare SE of thiazides 1 2 3 4
Common - Hyper GLUC, Glucose, Urea, Lactate, Ca2+ - Hypo Na+, K+, Mg2+ - Gout - Impotence - Postural hypotension - Dehydration Rare 1- pancreatitis 2- agranulocytosis 3- photosensitive rash 4- thrombocytopaenia
39
In broad complex tachycardias, which classic cardio drug is CI and why?
verapamil can precipitate marked haemodynamic deterioration, ventricular fibrillation (VF), and cardiac arrest.