Cardio Flashcards
1
Q
Why is hyperkalaemia so dangerous
A
VF + cardiac arrest
2
Q
What are the signs and symptoms of hyperkalaemia
A
- fast irregular pulse
- chest pain
- weakness
- palpitations
- light headedness
3
Q
Give three hallmark signs of hyperkalaemia
A
1) small p wave
2) wide qrs
3) tall tented t waves
4) slurred ST segment
4
Q
What ecg appearance is present in patients with severe hyperkalaemia
A
Sine wave pattern
5
Q
List some possible causes of hyperkalaemia being an artefact finding
A
- haemolysis e.g. Rapid blood transfusion
- contamination with edta (hence do FBC after u+e)
- thrombocythaemia
- delayed analysis
6
Q
List the 4 steps of management for hyperkalaemia, with doses
A
1) ecg
2) 10ml 10% calcium gluconate
3) insulin e.g. 10 U rapidly acting insulin + glucose e.g. 50ml
4) nebulised salbutamol 2.5mg
7
Q
What do you do if you’ve tried everything and hyperkalaemia >7mmol/L persists
A
Consider dialysis
8
Q
What are the steps you take to manage a patient with stemi
A
1) 12 lead ecg
2) high flow O2
3) 300mg Aspirin
4) 5-10mg morphine + 10mg metroclopramide
5) GTN - 2 puffs or 1 tablet
9
Q
What is the definitive treatment for stemi
A
Primary PCI within 120mins from when you can give thrombolysis and within 12hours of symptom onset
Otherwise fibrinolysis with streptokinase
10
Q
How do you manage an nstemi
A
1) ECG
2) high flow O2
3) 300mg Aspirin +/- 300mg clopidogrel
4) 5-10mg morphine + 10mg metroclopramide
5) heparin e.g. Dalteparin 120U/Kg/12hours sc
6) iv nitrate if pain continues
11
Q
What is the definitive treatment for nstemi
A
Urgent angio,
If high risk: infusion of gpiib/iiia inhibitors e.g. Tirofiban
If low risk and no further pain: discharge if 12hr troponin is negative
12
Q
What is stage1 in the New York classification of hf
A
heart disease present but no undue dyspnoea from ordinary activity
13
Q
What is stage2 of the New York classification of hf
A
Comfortable at rest, but symptoms on ordinary activities
14
Q
What is stage 3 New York classification of hf
A
Less than ordinary activities cause dyspnoea, which is limiting
15
Q
What is stage 4 of the New York classification of hf
A
Dyspnoea at rest, all activity causes discomfort
16
Q
How do you manage broad complex tachycardia with no pulse
A
ARREST CALL
17
Q
How do you manage a patient with broad complex tachycardia, with adverse signs present
A
1) sedate
2) synchronised do of 200>300>360J monophasic
3) AMIODARONE 300mg iv over 20-60 mins
4) correct K+ and Mg2+
18
Q
What other drugs or management would you consider if normal cardio version techniques don’t work
A
- lidocaine
- flecainide
- procainamide
- overdrive pacing
19
Q
If a patient is in broad complex tachycardia, with no adverse signs and regular rhythm, how would you manage them
A
AMIODARONE 300mg iv over 20-60mins or 50mg LIDOCAINE over 2 min
20
Q
If a patient with broad complex tachycardia, with no adverse signs and irregular rhythm present to you, how would you manage them?
A
Refer, Synchronised do shock 200>300>360J monophasic
21
Q
What is the first sign you check for in a patient with broad complex tachycardia
A
Pulse
22
Q
What are the two non shockable rhythms
A
1) asystole
2) pulse less electrical activity
23
Q
What are the 2 shockable rhythms
A
1) VF
2) pulseless VT
24
Q
How do you treat narrow complex tachycardia with an irregular rhythm
A
As AF
25
What are the first steps in managing narrow complex tachycardia
Continuous ecg and Vaal manoeuvres
26
How do you treat regular rhythm narrow complex tachycardia even before you assess adverse signs
ADENOSINE 6mg bolus injection
27
How do you treat narrow complex tachycardia with regular rhythm and adverse signs present
1) sedate
2) give synchronised cardioversion 100>200>300J
3) AMIODARONE 300mg iv over 20-60mins
28
If a patient has narrow complex tachycardia, with regular rhythm and no adverse signs, how do you treat them
```
Try any of
Esmolol
Digoxin
Amiodarone
Verapamil
Overdrive pacing if not AF
```
29
What is the level of k+ which makes hyperkalaemia and emergency
Over 6.5 mmol/L
30
Which condition often causes radio-radio delay
Aortic dissection
31
Which condition often causes radio femoral delay
Coarctation of the aorta
32
What does the first heart sound correspond with
Closure of the atrioventricular valves (mitral and tricuspid valves)
33
What does the second heart sound correspond with
Closure of the aortic and pulmonary valves
34
Between which heart sounds is systole
Between s1 and s2
35
Between which heart sounds is diastole
Between s2 and s1
36
Give some causes of a bounding pulse
Volume overload, co2 retention (e.g. COPD), pregnancy
37
Give a cause of regularly irregular rhythms
Atrial or ventricular ectopics
38
Give cause of irregularly irregular heart beat
AF
39
How should you investigate possible AF on auscultation during examination of the patient
Listen to apex with Steth while feeling pulse
40
Which pulse should you feel for while listening to the first heart sound
Carotids
41
What quick systems review questions would you ask for in a patient you are taking a cardiovascular history from
Bowels ok?
| Any problems with waterworks
42
What is the pahtophysiological cause of third heart sounds
Stiff or dilated ventricle suddenly reaches its elastic limit and decelerates the incoming rush of blood during diastole, hence causes an extra heart sound
43
What ages is it normal to have a third heart sound
Under 30
44
List the causes of third heart sounds
1) heart failure
2) mi
3) cardiomyopathy
4) hypertension (pressure overload)
45
When do you hear a systolic and when do you hear a diastolic murmur
```
Systolic = between first and second heart sound
Diastolic = between second and next first heart sound
```
46
What is the pathophysiology of fourth heart sounds
Atrial contraction into a non compliant of hypertrophied ventricle causes fourth heart sound as the atria is struggling to puch blood into the ventricle
47
Give some causes of fourth heart sound
```
Ventricular hypertrophy
Hypertension
Mi
Heart failure
Hypertension
(Always abnormal)
```
48
What causes a heave on palpating over the murmur
LV hypertrophy
49
What is a thrill
A palpable murmur
50
Which murmurs are heard best on inspiration and which are heard best on expiration
On Inspiration - rIght sided
| On Expiration - lEft sided
51
What are grades 1, 2, and 3 of intensity of heart murmurs
1- very faint
2- soft
3- heard easily
52
What are grades 4, 5, and 6 of intensity of heart murmurs
4- loud with palpable thrill
5- very loud, with thrill, may be heard with Steth partly off chest
6- very loud, with thrill, may be heard with Steth entirely off chest
53
What are the causes of mitral stenosis
Rheumatic fever
| Old age and calcification
54
What are the consequences of mitral stenosis that lead to right heart failure
High LA pressure > pulmonary venous hypertension
> pulmonary arterial hypertension > RV hyper trophy
> tricuspid regurgitation > RHF
55
Which valve abnormality may result as a consequence of mitral stenosis
Tricuspid regurg
56
What are some of the signs which may be associated with mitral stenosis
AF on pulse
Malar flush
Tapping apex beat due to palpable 1st heart sounds
57
What may be heard on auscultation of a patient with mitral stenosis
Loud s1
Opening snap
Rumbling mid diastolic murmur
58
What is the best way to hear mitral stenosis
With bell of the stethoscope held lightly at apex with patient lying on their left side
59
What are some of the CXR signs in mitral stenosis
Normal sized heart with enlarged left atrium
| The signs of pulmonary oedema
60
What are some of the ecg changes of a patient with mitral stenosis
1) AF
2) bifid p waves if sr
3) rvh causes right axis deviation and tall r waves in leads v1 and v2
61
What are the causes of mitral regurgitation
1) prolapsing mitral valve
2) rheumatic mitral regurg
3) papillary muscle rupture
4) cardiomyopathy of any sort
5) connective tissue disorders e.g. Marfans
62
List some of the connective tissue disorders that may lead to mitral regurg
Marfans syndrome
Ehlers Danlos
Osteogenesis imperfecta
63
What are some of the signs that may be found in a patient with mitral regurg
Malar flush
Displaced apex beat
Palpable thrill
64
What may be heard on auscultation of a patient with mitral regurg
Pansystolic murmur radiating to axilla
65
What may a CXR of a patient with mitral regurg show
Left atrial and left ventricular enlargement - cardiomegaly
66
Which chamber is likely to be affected by disease in a patient with bifid p waves on ecg
LA
67
What may be seen on ecg of a patient with mitral regurgitation
Bifid p wave
| Left ventricular hypertrophy
68
What are some of the causes of aortic stenosis
Bicuspid aortic valve
Age related calcification
Rheumatic fever
69
What are some of the symptoms of aortic stenosis
Exercise induced syncope - Angina and dyspnoea develop
70
What is found on the pulse of patients with aortic stenosis
Slow rising
Low volume
Narrow pulse pressure
71
What is felt on palpation of the apex region with aortic stenosis
Forceful apex beat
72
What is heard on auscultation of a patient with aortic stenosis
Ejection systolic murmur radiating to the carotids
73
Where else should you listen with the diaphragm of the Steth in a patient with aortic stenosis
The carotids
74
What do you listen for with the bell of the Steth in the carotid area
Bruits
75
What may be seen on the CXR of a patient with aortic stenosis
Relatively small heart with a prominent, dilated ascending aorta
76
Why do you get a dilated ascending aorta in patients with aortic stenosis
Post stenosis dilatation
77
What may be seen on ECG of a patient with aortic stenosis
LVH
| LV strain pattern - depressed St segments and t wave inversion I leads directed towards left ventricle
78
How is aortic regurgitation best heard on auscultation
Sit the patient forward with their breath held in expiration
| Listen at left eternal edge in the fourth intercostal space
79
What is the typical murmur of a patient with aortic regurgitation
High pitched early diastolic murmur
80
What are the causes of aortic regurg
```
Rheumatic fever
Bicuspid valve
Infective endocarditis
Marfans
Tertiary syphillis
```
81
Give two infective causes of aortic regurgitation
Syphillis
| Infective endocarditis
82
What is the typical pulse sign in patients with aortic regurg
Collapsing
| Wide pulse pressure
83
What is the difference in pulse pressure between aortic regurg and aortic stenosis
Aortic stenosis has a narrow pulse pressure
| Aortic regurg has a wide pulse pressure
84
What is quincke's sign in aortic regurg?
Capillary pulsation in nail beds
85
What is de mussels sign in aortic regurg
Head nodding with each heart beat
86
What aid the pistol shot femorals sign in aortic regurg
Sharp bang heard on auscultation over femoral arteries in time with each heartbeat
87
What may be seen on an ecg of a patient with aortic regurg
LVH
88
What is p. mitrale on an ecg, and what is it an indication of
Bifid p wave
| LA abnormality e.g. Dilatation, hypertrophy
89
What is p. pulmonale on ECG and what is it an indication of
Peaked p waves >2.5mm
| An indication of Right atrium enlargement
90
What is the pathophysiological cause of fourth heart sounds
Atrial contraction into a non compliant or hypertrophied ventricle
91
Why are right heart murmurs heard best on inspiration
Inspiration increases venous blood return to the right side of the heart
92
When are left sided murmurs heard loudest
On expiration
93
What is a grade 1 and 2 murmur
1) very faint
| 2) soft
94
What is grade 3 and 4 murmur
3) heard easily
| 4) loud, with palpable thrill
95
What is grade 5 and 6 murmur
5) very loud, with thrill, may be heard with Steth partly off chest
6) very loud, with thrill, may be heard with Steth entirely off chest
96
On an ecg, what is he normal PR interval
3-5 small sq (0.12-0.2 secs)
97
What is the normal QRS interval length
2-3 small sq
98
What is the normal ST segment length
2-3 small sq (0.08-0.12s)
99
How do you calculate heart rate from a regular rhythm strip
300 divided by number of big squares between R-R interval
100
How do you calculate heart rate in a ecg rhythm strip which is irregular rhythm
Count number of qrs complexes in a 19 second rhythm strip and multiply by 6
101
What defines sindus rhythm
Each qrs preceded by p wave, with normal rhythm
102
What does atrial flutter look like on ecg
Sawtooth p waves
103
At what rate do atria and ventricles contract in atrial flutter
Atria contact at 300 bpm but eb tricked do not conduct that many atrial ap's so the ventricular date is often around 150 bpm
104
How do you calculate the rate of block in atrial flutter, considering the atrial rate is usually 300 bpm and the ventricles don't contract at the same rate
Ventricular rate 150 = 2:1 conduction
Rate 100 = 3:1 conduction
Rate 75 = 4:1 conduction
105
What does ventricular tachycardia look like on ecg
Fast 120-180 bpm, broad complexes
106
What is the cardiac axis
The direction of spread of depolarisation through the ventricles
107
How do you work out the heart axis looking at an ecg
Find the isoelectric lead (or most isoelectric lead). The axis is perpendicular to that
Compare the leads to lead II, III, AVL and AVR in terms of which ones show negative and positive deflections
108
What angles does the normal axis lie between
-30 to +90
109
At which angles does left axis deviation lie
Less than -30 deg
110
At which angles does right axis deviation lie
At over +90 deg
111
Is the lead I is greatly positive and lead II and AVF are negative, what axis deviation is it likely to be
Left axis deviation
112
If lead AVF/III is greatly positive and lead I is negative, what axis derivation is it likely to be
Right axis deviation
113
What does left atrium enlargement show in ecg
P mitrale - bifid p waves
114
What does right atrial enlargement show on ECG
Tall p waves (p pulmonale)
115
Over how many squares is considered a prolonged p wave
>3 small squares
116
How many square's height is considered tall p waves
Over 3 small squares height
117
List the degrees of heart block
- first deg
- second deg - mob its I (wenkebach) and Mobitz 2
- third deg
118
What is first degree heart block
PR interval prolonged by constant amount
119
What is Mobitz type 1 (wenckebach) heart block
Progressive lengthening of PR interval until one qrs complex is dropped
120
What is mobitz type II second degree heart block
Intermittent failure of AVN to conduct atrial depolarisation to the ventricles
May be fixed 2:1 , 3:1 etc
121
What is third degree heart block
No relationship between the p waves and qrs complexes
122
What is the usual HR in patients with third degree heart block
30-50bpm
123
What is consistently firing off in third degree heart block
P waves
124
What does increased qrs height indicate
Left or right ventricular hypertrophy
125
What does increased qrs width indicate
Left or tight bundle branch block
126
What ecg features indicate left ventricle hypertrophy
S wave in V1+ R wave in V5 or V6 together over 35mm (3.5 large ecg squares)
127
What are the ecg features of right ventricular hypertrophy
R wave tall in right ventricular leads (>5mm) + RAD
128
How do you determine right bbb from left bbb
Compare lead V1 with V6
Lbbb: W in V1 and M in V6
Rbbb: M in V1 and W in V6
129
List some causes of St segment elevation
Acute mi
| Pericarditis (widespread)
130
How do you define St depression
> 1 mm in 2 consecutive limb leads OR
| > 2 mm in 2 consecutive chest leads
131
What are the ecg changes seen over time with stemi
- within hours : St elevation
- within days : St elevation and t wave inversion, pathological q waves
- within weeks : St flattening, t wave inversion and pathological q waves persist
- months : pathological q waves persist
132
Which leads are affected in septal infarct
v1 and v2
133
Which leads are affected in anterior infarct
V3 and 4
134
Which leads are affected in lateral infarct
V5 and 6
135
Which leads are affected in high lateral infarct
I, AVL
136
Which leads are affected by inferior infarct
II, III, AVF
137
What ECG changes are seen in PE
S1, Q3, T3
Large S wave in lead 1
Q wave inversion in lead 3
T wave inversion in lead 3
138
List some other precipitates of angina expect for exercise
Emotion, cold weather, heavy meals
139
Which special investigations may be tried in patients with angina pectoris
- exercise stress ecg
- coronary angiography
- cardiac ct
- stress echo
140
Which angina patients should be considered for referral
- diagnostic uncertainty
- new angina of sudden onset
- recurrent angina e.g. Past mi/cabg
- angina uncontrolled by drugs
- unstable
141
What is Percutaneous Transluminal Coronary Angioplasty
balloon dilatation of stenotic vessels
142
List the steps for management of angina pectoris
- modify lifestyle risk factors
- aspirin
- Beta blockers
- nitrates
- long acting calcium antagonists
- potassium channel activator
143
What is the mechanism of action of nicorandil
Potassium channel activator - promotes K+ efflux
144
When is cabg performed
```
Left mainstem disease
Multi vessel disease
Multiple severe stenosis
Those unsuitable for angioplasty or failed angioplasty
Refractory angina
```
145
How is the procedure of cabg performed
Angiography
Heart stopped and blood pumped artificially by a machine outside the body
Patients own saphenous vein / internal mammary artery used as graft
146
What is aortic dissection
Blood splits the aortic media
147
How does aortic dissection present
Sudden tearing chest pain +/- radiation to the back
148
What is the typical sign of aortic dissection found on examination
Radio radial delay
149
As a result of aortic dissection, branches of the aorta may occlude, what can then result
- Hemiplegia (carotid)
- unequal arm pulses or bp
- paraplegia (anterior spinal artery)
- Anuria (renal arteries)
150
What is the difference between type a and b aortic dissection
A - ascending aorta involved
| B - ascending aorta not involved
151
Which type of aortic dissection requires urgent surgical review more than the other - a or b
A (involves aortic arch)
152
What is the definition for heart failure
CO is inadequate for body's requirements
153
List the main causes of heart failure
Ischaemic heart failure
Non ischaemic dilated cardiomyopathy
Hypertension
154
List the congenital heart diseases that can lead to heart failure
Asd, vsd
155
List some pericardial diseases that can lead to heart failure
Constrictive pericarditis, pericardial effusion
156
List some causes of RHF
Pulmonary hypertension, PE, RV infarct
157
List the pathophysiological changes in heart failure
Ventricular dilatation, myocyte hypertrophy
158
What are the systemic blood pressure changes in the pathophysiology of heart failure
- sympathetic stimulation
- peripheral vasoconstriction
- salt and water retention
Leads to increased ANP secretion
159
What is starlings law
The greater the volume of blood entering the heart during diastole, the greater the volume of blood ejected from the LV during systolic contraction (stroke volume)
160
What is the ejection fraction
Fraction of blood pumped out of the ventricles with each heart beat
161
How is ejection fraction measured
ECHO
162
What is the difference between systolic and diastolic heart failure
Systolic - inability of ventricle to contract therefore reduced ejection fraction
Diastolic - inability of ventricle to relax and fill normally
163
List some chases of systolic heart failure
IHD, cardiomyopathy
164
List some causes of diastolic heart failure
Constrictive pericarditis, tamponade
165
What are the early compensatory mechanisms for marinating cardiac output in heart failure
Venous pressure increased, preload increased, therefore end diastolic volume increased
Coupled with sinus tachycardia
Reduced ejection fraction
166
What are the late compensatory mechanisms for marinating co in mod-severe heart failure
Co can only be maintained by massive increases in venous pressure, which leads to dyspnoea, hepatomegaly, ascites, dependent oedema
167
Can CO be maintained in severe heart failure
No, it is decreased even at rest despite increased venous pressure and sinus tachy
168
What are the main causes of left heart failure
- IHD
- non ischaemic dilated cardiomyopathy
- hypertension
- mitral/aortic valve disease
169
List the main symptoms of left heart failure
Fatigue, exertional dyspnoea, orthopnoea, PND, pink frothy sputum, poor exercise tolerance
170
What are the physical signs on doing a cardiovascular examination of left heart failure
Displaced apex beat, gallop rhythm on auscultation (3rd heart sound), mitral regurgitation, crackles at lung bases, dependent pitting oedema
171
How do ANP and BNP act on the kidneys
Increase GFR, and decrease renal sodium absorption
172
What investigations should be carried out, except for blood tests, in heart failure
CXR, echocardiogram
| ECG may indicate cause
173
Which molecule should be tested for in blood tests of patients with heart failure
B type natriuretic peptide
174
What is class 1 and 2 NYHA heart fissure classification
1 - no limitation to physical activity
| 2 - slight limitation to physical activity
175
What is stage 3 and 4 of NYHA classification of HF
3- marked limitation on physical activity
| 4- symptoms at rest
176
List the causes of right heart failure
- chronic lung disease (cor pulmonale)
- PE or pulmonary hypertension
- tricuspid/pulmonary valve disease
177
What how can asd/vsd cause right heart failure
Left to right shunts, putting more pressure on the right side of the heart which is not adapted to such high pressures
178
List some of the symptoms of RHF
Fatigue, dyspnoea, anorexia, nausea
179
List some of the physical signs on examination of a patient with right heart failure
- increased jugular venous pressure
- cardiomegaly
- hepatic enlargement
- ascites
- dependent pitting oedema
180
List some of the general management steps in heart failure
Low level exercise, low salt diet, stop smoking, education, vaccination
As well as treating the cause
181
List the steps of a management in heart failure
1) diuretics
2) ace inhibitor
3) beta blockers
4) spironolactone (aldosterone antagonist)
5) inotropic agents e,g, digoxin
6) nitrates
7) anticoagulation
182
What are the first, second and third line diuretics used in heart failure
Step 1- furosemide
Step 2- change to bumetanide
Step 3- add a thiazide
183
List a thiazide diuretic that is commonly used in heart failure
Metolazone
184
If a patient on ace inhibitors for heart failure gets a dry cough side effect, which drug class can be sued instead
Angiotensin receptor blockers
185
How does dobutamide work
It is an inotrope - acts as a beta 1 agonist, acting as a sympatheticomimetic
186
When is digoxin considered in the treatment of hf
Patients who have severe hf in spite of therapy with vasodilators, beta blokes and diuretics
187
How do nitrates work positively to help with hf
Reduce preload and after load
188
List the nitrate drugs that may be given in heart failure
Glyceryl trinitrate, isosorbide momonitrate
189
What are the other non pharmacological treatments for hf
Revascularisation, biventricular pacemaker, defibrillator, cardiac transplant
190
What is the difference between low input and high output heart failure
Low output - co reduced and fails to increase normally with exertion
High output - this is rare. Output is increased with increased needs, however with high output filature inability to increase CO in response is of faster onset than in the normal heart
191
What are the Framingham criteria for
Diagnosis of CCF
192
How many minor and major criteria are required in Framingham CCF criteria
2 major or
| 1 major and 2 minor
193
List the major Framingham criteria
1) PND
2) crepts
3) s3 gallop
4) cardiomegaly
5) increased Central venous pressure
6) weight reduction in response to treatment
7) neck vein distension
194
What are the minor criteria for framinghams CCF diagnostic criteria
1) bilateral ankle oedema
2) dyspnoea on exertion
3) tachy >120
4) reduction in vital capacity
5) nocturnal cough
6) hepatomegaly
7) pleural effusion
195
List the CXR signs of hf
1) dilated prominent upper lobe vessels
2) alveolar oedema - bats wings sign
3) cardiomegaly
4) kerley b lines
5) pleural effusion
196
Why does pleural a effusion occur with CCF
Increased pulmonary capillary pressure
197
What is the pathophysiology of bats wings and kerley b lines in CCF chest Xray
Alveolar oedema - bats wings sign
| Interstitial oedema - kerley b lines
198
List the pathophysiological steps of atherosclerosis
- triggered by injury
- lipoproteins oxidised
- taken up by macrophages and creates foam cells
- release of cytokines
- accumulation of fat and smooth muscle proliferation
- plaque formation
199
List the steps where atherosclerotic plaques becomes myocardial ischaemia
- rupture of coronary artery plaque
- platelet aggregation and adhesion
- localised thrombus, vasoconstriction
- myocardial ischaemia results
200
What are the ECG criteria for diagnosing a stemi at j point
- 0.2 mV or more increased in leads V1-V3
| - 0.1 mV or more increased in any of the other leads
201
How do you manage a stemi, after a-e assessment, iv access, and 12 lead ecg has been sorted
- assess for risk factors e.g. Pulse, bp, jvp, murmurs
- aspirin 300mg
- morphine 5-10mg IV + metoclopramide 10mg
- GTN sublingual 2 puffs
- assess for PCI
202
Within how many minutes should a PCI be performed in stemi
120 minutes of when thrombolysis could have been given and within 12 hours of symptom onset
203
What is given to a patient who cannot have a PCI within 120 minutes with a stemi
Thrombolysis, e.g. Streptokinase, or more commonly reteplase
204
How is an n-stemi treated?
- admit to CCU
- O2 - 2-4litres aiming for sats over 95%
- morphine - 5-10mg plus metoclopramide 10mg
- aspirin - 300mg +/- clopidogrel 300 mg
- oral beta blocker
- heparin
- IV nitrate if pain continues
205
If a patient with n-stemi is managed adequately and is low risk, with no further pain, and negative Troponin, how are they managed next
Discharge, if repeat troponin is negative over 12 hours. Treat medically and arrange further investigation.
206
If a patient with n-stemi is treated adequately but is still high risk, has recurrent ischaemia, ST depression, or troponin is raised, how do you manage them next
Urgent angiogram, tirofiban plus clopidogrel. Optimise health with beta blocker, CCB, ACI, Nitrates, statins
207
If there is still no improvement with n-stemi patients who are high risk, and have been treated adequately, what is the final step in their management
Angiography +/- PCI/CABG
208
Which enzymes do you test for in the blood of a patient suspected with MI
CK, troponin I
209
Which leads does ST elevation occur in in anteroceptal MIs
V1-4
210
Which leads show ST elevation in a lateral stemi
V5-6
211
Which leads show ST elevation in a high lateral STEMI
Lead I, AVL
212
Which leads show ST elevation in an inferior STEMI
Leads II, III, AVF
213
Which coronary artery is usually the cause of an inferior STEMI
RCA
214
Which coronary artery is responsible for a STEMI in the anteroceptal region
LAD
215
The circumflex artery becoming blocked can lead to which two areas becoming ischaemic hence causing a STEMI
Lateral and high lateral MI
216
List the indications for thrombolysis in a STEMI
Less than 12 hours onset of pain plus any of the following:
217
List the complications of STEMI
- heart failure/ pericarditis
- rupture of papillary muscles or septum
- embolism
- aneurysm/arrhythmias
- Dressler's syndrome
- sudden death
218
List the symptoms of Dressler's syndrome
Low grade fever, pleuritic chest pain, pericarditis, pericardial effusion
219
Which drugs are given to patient with STEMI after discharge
```
Aspirin, clopidorgel
Acei
B blockers
Statin
Address modifiable risk factors/comorbidities
```
220
How many months off work do you have to take after suffering a STEMI
1 month
221
Who long do you have to abstain from driving after an STEMI
4 weeks
222
How do you distinguish between NSTEMI and unstable angina
Troponin I - negative troponin in unstable angina
223
What is flash pulmonary oedema
Rapid onset pulmonary oedema, most often precipitated by acute mi or mitral regurgitation, heart failure.
224
How does acute LV failure present
Acute pulmonary oedema
| With symptoms of breathlessness, frothy pink sputum, orthopnoea, collapse, arrest, cardiogenic shock
225
List the signs of acute LV failure
- distressed, pale and sweaty
- tachycardia
- fine crepts bilaterally
- gallop rhythm 3rd heart sound
226
What are the commonest causes of LVF
Myocardial ischaemia, hypertension, aortic stenosis, aortic incompetence, mitral incompetence
227
How do you treat acute LVF, after a to e assessment
```
100% O2 via non rebreathe mask
Morphine 5 mg iv + metoclopramide 10mg
Nitrate if high systolic bp
Furosemide 40-80 mg iv
CPAP
```
228
List the narrow complex tachycardias
AF, atrial flutter, re entrant tachycardia, others e.g. Atrial tachycardia
229
Lost the main crowd complex tachycardias
VT
| SVT with BBB
230
List the three main mechanisms of tachy arrhythmia production
1) accelerated automaticity
2) triggered activity e.g, myocardial damage
3) re entry
231
How is regular SVT managed
-A-E, O2 and iv access
- Vagal manoeuvres
- Adenosine
Seek help
- Antiarrhythmiac
- DC cardioversion if haemodynamically unstable
232
How are narrow complex SVTs which are irregular managed
As per AF
- b blocker iv or digoxin iv
- AMIODARONE 300 mg iv
233
How is narrow complex SVT with regular rhythm managed
Vagal manoeuvres
Adenosine 6mg iv, then further doses as per guidelines
Monitor ecg continuously
234
List the causes of ventricular tachycardia
- torsades de pointes
- SVT with bbb
- pre excited tachycardia
235
What is pre excitement
When ventricles become depolarised too early, which leads to their partial premature contraction. Abnormal pathway leads to lack of normal AVN delay
236
How are broad complex tachycardias managed if they show no adverse signs
Amiodarone/lidocaine
K+/Mg2+ if needed
Sedation and DC cardioversion
237
How are broad complex tachycardias treated if they show adverse signs
Sedation, DC cardioversion, amiodarone/lidocaine
238
Which diuretic classes cause hypokalaemia and which cause hyperkalaemia
Loop and thiazide diuretics - hypokalaemia
| k+ sparing diuretics - hyperkalaemia
239
What type of drug is metolazone
Thiazide like diuretic
240
Which particular part of the LoH do loop diuretics affect
TAL
241
What are the side effects of loop diuretics
Hypokalaemia, deafness (ototoxicity), hypovolaemia , and hypotension
242
List some side effects of thiazide diruetics
Hypokalaemia, hyponatraemia, hyperuricaemia, hyperglycaemia
243
List some contraindications to thiazide diuretics
Refractory hypokalaemia, hyponatraemia, hypercalcaemia, Addison's disease,
244
What is the mechanism of action of spironolactone
Aldosterone antagonist
245
What is the mechanism of a iron of amiloride
Inhibits ENaC channels
246
Which drugs are potassium sparing diuretics co used with
K+ losing diuretics e,g, furosemide
247
What are the side effects of potassium sparing diuretics (spironolactone, amiloride)
Impotence, gynaecomastia, menstruated problems,
| Hyperkalaemia, hyponatraemia
248
Why can spironolactone cause menstruated problems, gynaecomastia etc.
Blocks mineralcocorticoid receptors, but also has effects on androgens
249
What are the three main lipid lowering drug classes
- statins
- Fibrates
- ezetimibe
250
What are the two principal mechanism of action of statins
1) inhibit HMG-coA reductase, hence inhibiting liver cholesterol synthesis
2) increased absorption of Ldls from the bloodstream into the liver, dour to upregulation of ldl receptors
251
List the side effects of statins
Myositis, rhabdomyolysis, altered LFTs, paraesthesia, GI effects
252
What are the contraindications of statins
Acute liver disease, pregnancy, breast feeding
253
Which particular lipids do Fibrates act to lower
Triglycerides MORE than LDL
254
How does Ezetimibe work
Lowers cholesterol absorption in the intestine
255
What would you suspect in a patient with freer and a new murmur
Endocarditis until proven otherwise
256
What is infective endocarditis
Microbial infection of normal or prosthetic heart valves, the endothelial surface of the heart, or a congenital defect such as PDA
257
What is the main causative organism for infective endocarditis
Streptococcus viridans
258
Which patients are at risk of infective endocarditis caused by staphylococcus aureus
Those with Skin infections, abscesses, central lines, iv drug abusers
259
List the steps in the pathophysiology of infective endocarditis
1) endothelial damage/damaged valve
2) platelets and fibrin deposited
3) bacteria is delivers bacteria to surface of heart
4) adherence and colonisation of bacteria
5) fibrin aggregates protect bacteria vegetation from host defence mechanisms
260
List the consequences of infective endocarditis
- disruption of valve cusps, commonly leading to mitral or aortic regurgitation
- vegetations embolise
- deposition of immune complexes
261
Where can infective endocarditis vegetations embolise in the body
Cerebral, pulmonary, coronary, renal
| Can cause abscesses/haematuria
262
What are the immune vasculitis presentations of infective endocarditis
- Roth spots
- oslers nodes and janeway lesions
- clubbing
- splinter haemorrhages
- glomerulonephritis
263
What are the two major criteria in diagnosing infective endocarditis
- positive blood culture for IE (2 separate +ve cultures, or persistently positive cultures)
- evidence of endocardial involvement (+ve Echo, or new vascular regurg)
264
What is TOE in cardiology
Trans oesophageal echo
265
List the five minor criteria in diagnosing infective endocarditis
1) predisposition
2) fever >38 deg
3) vascular/immunological signs
4) positive blood culture not meeting major criteria
4) positive echo not meeting major criteria
266
What combinations of major and minor criteria lead to a diagnosis of infective endocarditis
- 2 major
- 1 major + 3 minor
- 5 minor
267
How many cultures do you take in suspected infective endocarditis, and where from
3 different cultures form different places, at oeak temperature
268
How is infective endocarditis managed
A to E
Refer to cardio and micro
Drugs depends on organism
Empirical treatment of benzylpenicillin and gentamicin, at least 4 weeks
269
What is the empirical treatment. For infective endocarditis
Benzylpenicillin and gentamicin
270
When should surgery be considered in infective endocarditis
Heart figure, valvular obstruction,mrepreatrd emboli, fungal endocarditis, abscess, unstable infective prosthetic valve
271
Why is antibiotc prophylaxis no longer given to patients at risk of infective endocarditis who are undergoing procedures
It has shown little evidence of benefit in practice and must be weighed up with the negatives of adverse effects a DM antibiotic resistance
272
Wha it's the visceral layer of the pericardium made of
Mesothelial cells
273
Where does pericardial fluid drain
Via the thoracic duct and right lymphatic duct into the right pleural space
274
What are the signs and symptoms of acute pericarditis
Chest pain, pericardial friction rub, serial ecg changes
275
What is the pathophysiology of pericarditis
Inflammation of pericardium;
| Infiltration of polmorphonuclear leucocytes and pericardial vascularisation
276
What are the possible consequences of pericarditis
- constrictive pericarditis
| - pericardial effusion
277
Why can constrictive pericarditis occur in pericarditis
Exudates and adhesions encase the heart
278
What may pericardial effusion lead to as it develops from pericarditis
Accumulation of pressure can lead to cardiac tamponade
279
What is the most common cause of pericarditis
Virus - particularly Coxsackie virus
280
Expect for viral causes, what are the other causes of pericarditis
- TB
- bacterial
- cardiovascular disease e.g, mi, Dressler's syndrome
- neoplasm
- renal failure
- inflammatory/autoimmune
281
How is bacterial pericarditis treated
Antibiotics for at least 4 weeks and drainage of pericardial fluid
282
List some inflammatory conditions associated with pericarditis
- rheumatoid arthritis
- sarcoidosis
- SLE
283
List the main symptoms of pericarditis
- pleurisy: sharp pain worse on inspiration
- central chest pain, radiating to left shoulder
- eased sitting forward
284
What may be found on examination of a patient with pericarditis
- tachycardia
- tachypnoea
- fever
- pericardial friction rub
- shins of RHF / high pitched loud s3
285
Apart form the usual bloods, which other serology investigations should you do on a patient with suspected pericarditis
- virology screen
- blood cultures
- antistreptolysin culture
- rheumatoid factor
- antinuclear antibodies
- anti DNA antibodies
- tuberculin testing and sputum test for acid fast bacilli
286
What are the serial ecg changes in pericarditis
1) saddle shaped ST elevation
2) ST segment returns to normal a couple of days later
3) T wave inversion
4) ECG returns to pre pericarditis baseline weeks to months after onset
287
How is pericarditis imaged
Echocardiography
| Ct/mri
288
What is the treatment of pericarditis
- high dose PO aspirin and bed rest
- corticosteroids sometimes used if disease does not subside rapidly
- pericardial window/pericardiectomy
289
What is the calculation for the ejection fraction
Stroke volume/end diastolic volume
290
Define a pericardial effusion
Abnormal accumulation of fluid in the pericardial cavity
291
Define cardiac tamponade
Pericardial effusion causing haemodynamically significant cardiac compression
292
How does pericardial effusion affct venous return
Inhibits it
293
How does cardiac tamponade affect blod flow int he heart and body
Reduces cardiac output hence results in hypotension and shock
294
What are some of the acute causes of oericardial effusion
- trauma
- iatrogenic
- aortic dissection
- spontaneous bleed
- cardiac rupture post mi
295
What are the subacute causes of pericarditis
- malignancy
- idiopathic pericarditis
- uraemia
- infection
- radiation
296
What is Becks triad of signs in pericardial effusion
- increased jvp
- decreased blood pressure
- muffled heart sounds
297
The presentation of pericardial effusion depends on the speed at which fluids collects. Give some of the different presentations of the condition
- cardiac arrest
- hypotension
- confusion
- shock
- sob, dysphagia, cough, hiccups if slowly developing
298
What is kussmauls sign
Jvp is increased with inspiration
299
What is pulsus paradoxus
Massive decrease in bp on inspiration
300
What is pulsus paradoxus a sign of
Pericardial effusion
301
How is pericardial effusion/tamponade managed
Emergency
- a to e
- iv access and fluids
- ecg
- bloods
- senior help
- pericardiocentesis +/- drain
302
How is pericardiocentesis performed
Needle inserted in xiphisternum, USS guided. Ai, for tip of left scapula and aspirate continuously
303
What do you do with pericardial fluid aspirated from pericardial effusion
- send for micro and cytology
304
List two af risk factor scores
- CHADVASC
| - HASBLED
305
What is chadvasc used to predict
The risk of stroke in patients with AF, taking a variety of factors such as age, gender. And conditions such as DM into account
306
What is HASBLED used as a predictor of
Assess 1 year risk of major bleeding in patients with AF, taking into account factors such as stroke, labeled inrs, abnormal liver and renal function etc.
307
List a type 1A Antiarrhythmiac
Quinidine
308
List a type 1B antidysrrhythmic
Lidocaine
309
List a type 1C antidysrrhythmic
Flecainide
310
List a class 2 antidysrrhythmic
B blocker e,g, bisoprolol
311
List a class 3 antidysrrhythmic
K+ channel blocker e.g. amiodarone
312
List a type 4 antidysrrhythmic
CCBs e.g. Diltiazem
313
What are the effects of b blockers on the heart
Negatively chronological and inotropic
314
List the side effects of beta blockers
Bradycardia, hypotension, cold peripheries. Bronchospasm,
315
How does adenosine work
Causes transient heart block by inhibiting A1 therefore inhibiting Ca2+ influx and hence contraction
316
Which antidysrrhythmic class can exacerbate Raynaud's phenomenon
Class 2 - beta blockers
317
What are the contraindications to beta blockers
Asthma, marked bradycardia, heart block
318
List the two main types of CCBs
- non dihydropyridines: verapamil, Diltiazem
| - dihydropyridines: amlodipine, nifedipine
319
How do CCBs work
Dilates peripheral arteries, reduces after load of heart, dilates coronary vessels (acts on coronary apvessels more than myocardium)
320
List some of the side effects of verapamil and Diltiazem
COSNTIPATION, flushing, headache
321
List some side effects of amlodipine
Palpitations, flushing. Headache, dizziness
322
When are verapamil and Diltiazem contraindicated
Hf, 2nd and 3rd deg heart block, cardiogenic shock
323
When are dihydropyridines such as amlodipines contraindicated
Unstable angina, significant AS
324
What are dihydropyridines used to treat
HTN, prevention of angina
325
What is verapamil used for
Fast AF, SVT, HTN
326
What are the id citations for nitrates
Stable angina, unstable angina, acute hf, chronic hf
327
What are the contraindications to nitrates
Hypotension conditions, hypovolaemia, cardiac tamponade, constrictive pericarditis
328
What are some of the side effects of nitrates
Postural hypotension, throbbing headache, dizziness, tachy
329
What positive benefits do ace inhibitors have for conditions of the heart
- reversal of LV hypertrophy
| - reversals of endothelial dysfunction
330
What are some of the side effects of ace inhibitors
Renal impairment m chronic cough. Angio oedema, pancreatitis
331
List some of the constrain cations to ace inhibitors
Hypersensitivity to ace I, renal artery stenosis, pregnancy
332
What cod it one is digoxin used in
AF and atrial flutter with rapid ventricular response
333
How does digoxin work
Slows down the conduction in the AVN, I crashing its refractory period, hence reducing the ventricular rate
334
What arrhythmia is magnesium used to treat and how does it work
Torsades de pointes - shortens the QT interval
335
What is prinzmetals angina
Angina at rest occurring due to vasospams of the coronary arteries
336
Hey is prinzmetals angina treated
CCBs and nitrates. NOT b blockers
337
List the different types of anti platelets
Aspirin, clopidogrel, dipyridamole, glycoprotein IIA/IIIB antagonists
338
What is the mechanism of action of aspirin
Suppresses production of prostaglandins and thromboxane by irreversible inhibiting COX enzyme
339
What does cox enzyme act to do
Convert arachidonic acid to prostaglandin
340
What is the mechanism of action clopidogrel
Inhibits ADP-induced aggregation of platelets
341
How does dipyridamole work
Phosphodiesterase inhibitor to block platelet aggregation In conjunction with aspirin
342
List a glycoprotein IIA/IIIB inhibitor
Abciximab, tirofiban
343
Is LMWH fully reversible with protamine
No
344
Which factors does warfarin hip hint the production of
Vit k dependent - II, VII, IX, X
345
How is warfarin overdose treated if INR is
Decrease/omit warfarin
346
How is warfarin overdose treated if INR is 6-8
Stop warfarin and restart when INR is less than 5
347
How is warfarin overdose treated if INR is > 8
If no bleeding stop warfarin and give 9.5-2.5 mg vitamin K if at risk of bleeding
348
If a patient experiences a major bleed with warfarin od, how do you manage it
```
Stop warfarin
Prove prothrombin complex concentrate (beriplex) which contains factors 2, 7, 9 and 10
Or FFP
Give 5mg vit k
Get help/refer!!
```
349
What is the difference in the mechanism of action of UFH and LMWH
Both affect factor Xa and activate ATIII but LMWH does NOT affect thrombin
350
Give some contraindications of heparin
Uncontrolled bleeding, risk o fbleeding, peptic ulcer, recent de renal haemorrhage, endocarditis
351
What are the ecg changes in posterior MI
Dominant R wave v1-v3, with ST depression and upright t waves
352
Which other murmur is often associated with mitral stenosis and why
Tricuspid regurg - increased LA pressure caused by mitral stenosis leads to pulmonary venous, hence pulmonary arterial HTN. This causes RV hypertrophy and leads therefore to tricuspid regurg.
353
What are the Sokolow-Lyon ecg criteria for LVH
S wave in v1 + r wave in v5 or v6 (whichever largest) >35mm (7 large squares) - there is LVH
354
What are the ecg changes in posterior MI
v1-v3 show ST depression + tall (broad) QRS complexes
355
Which murmur can be heard with ventricular septal defect on auscultation
Harsh Pansystolic murmur at left eternal edge
356
Which type of deviation is seen on ecg of a patient with congenital septal a defects
Left axis deviation
357
What are the 4 features of tetralogy of fallot
1) overriding aorta
2) vsd
3) rv hypertrophy
4) pulmonary stenosis
358
What is grade 1 hypertensive retinopathy
Tortuous Arteries with thick shiny walls
359
What is Grade 2 hypertensive retinopathy
Av nipping (narrowing where arteries cross veins)
360
What is grade 3 hypertensive retinopathy
Flame haemorrhages and cotton wool spots
361
What is grade 4 hypertensive retinopathy
Papilloedema
362
What is the treatment for malignant hypertension
Iv nitroprusside
363
What is the defintion of malignant hypertension
BP >220/120 mmHg
| + bilateral retinal haemorrhage + exudates +/- papilloedema
364
What is the triad of symptoms you get in cardiac tamponade
- reduced bp
- raised jvp
- muffled heart sounds
365
What is kussmauls sung in cardiac tamponade
Raised jvp on inspiration
366
Raised levels of which electrolyte can cause cardiac tamponade
Urea
367
What are the major criteria for rheumatic fever
- carditis
- erythema marginatum
- arthritis
- subcut nodules
- Sydenham's chorea
368
List some viruses which can cause acute pericarditis
- Coxsackie
- EBV
- flu
- HIV
- varicella
- mumps
369
Give an example of iib/iiia antagonist
Tirofiban
370
Which class of drug do you stop in patients post mi
CCB
371
What are the four adverse signs looked for in patients with broad complex tachycardia
1) bp less than 90 mmHg
2) HR over 150 bpm
3) hf
4) chest pain
372
List the steps folded in the sinoatrial node action potential
First there is slow Na+ influx, followed by rapid Ca2+ influx causing depol. There is then outfit of K+ causing hyperpolarisation
373
Lost the steps in the cardiac action potential
```
Phase 0 - NA+ in
Phase 1 - K+ out, Cl- out
Phase 2 - Ca2+ in, K+ out
Phase 3 - Ca2+ channels close and K+ out
Phase 4 - K+ in
```
374
Go through how digoxin works on the heart
1) inhibits Na+ - K+ - ATPase which means more Na+ accumulates within cell of myocardium
2) increased Na+ levels means there is reversal of Na+ - Ca2+ exchanger, hence less Na+ will come into the cell and less Ca2+ will leave the cell
3) this causes increased Ca2+ levels in the myocardial cell, hence increased amounts available for contraction of myofibrils (actin and myosin) causing prolongation of the cardiac action potential
375
Which condition are you thinking about when asking a young patient with suspected heart problems about family history of sudden death
Hypertrophic cardiomyopathy
376
What are stokes Adams attacks
Transient arrhythmias causing reduced cardiac output and loss of consciousness
377
What features are suggestive of epilepsy rather than a faint
Aura, attacks when lying down, identifiable trigger e.,g tv, altered breathing, urinary incontinence, tongue biting, post ictal drowsiness prolonged, confusion, amnesia
378
What is carotid sinus syncope
Hypersensitive baroreceptors causing excessive reflex bradycardia with minimal stimulation e.g. Tight collar, or shaving
379
Which category of bacteria cause rheumatic fever
Lance field group A, beta haemolytic streptococci
380
List the major criteria for rheumatic fever
1) carditis
2) arthritis
3) subcut nodules
4) eryhtema marginatum
5) Sydenham's chorea
381
What is the definitive treatment for rheumatic fever
Benzylpenicillin/penicillin/erythromycin
382
List the common secondary causes for hypertension
- glomerular disease
- renal artery stenosis
- cocp
- pregnancy
- diabetes
- cushings
- phaeochromocytoma
- Conns syndorme
383
What are the broad categories of causes for pericarditis
1) infection
2) drugs
3) MI, Dressler's
4) autoimmune
384
What is the typical ecg chnage shown in acute pericarditis
Saddle shaped ST elevation
385
How is acute pericarditis managed
Analgesia, treat cause, steroids/immunosuppressants if relapsing
386
How is pericardial effusion managed
```
Treat cause (all causes of acute pericarditis can cause pericardial effusion)
Pericardiocentesis
```
387
What do you do with the fluid you aspirate from pericardiocentesis in a patient with pericardial effusion
Culture, cytology, ZN stain, TB culture
388
List two signs of pericarditis on auscultation
1) muffled heart sounds
| 2) pericardial rub
389
What is constrictive pericarditis
Heart encased in rigid pericardium, with unknown cause, but e,sew here in the world it is TB, or pericarditis of any cause
390
What are the CXR changes seen in constrictive pericarditis
Small heart, pericardial calcification
391
How is constrictive pericarditis managed
Surgical excision
392
What is cardiac tamponade
Accumulation of pericardial fluid raises intra pericardial pressure, causing poor ventricular filling and reduced cardiac output
393
List some causes of cardiac tamponade
1) any pericarditis
2) aortic dissection
3) haemodialysis
4) warfarin
394
What is the typical triad of cardiac tamponade
Pulsus paradoxus, increased jvp and muffled heart sounds
395
What is pulsus paradoxus
Abnormally large decreased in pulse rate during inspiration
396
In which conditions is electrical alternans seen
Cardiac tamponade, severe pericardial effusion
397
What is electrical alternans
Changing qrs complex amplitude between beats
398
What should you suspect in fever + new onset murmur
Infective endocarditis
399
What is the chief cause of infective endocarditis
Strep viridans
400
Which conditions predispose to infective endocarditis of acute course
Dermatitis, iv injections, renal failure, DM
401
What are the two types of clinical course for infective endocarditis
Acute (normal valves) and subacute (abnormal valves)
402
What are the risk factors for subacute course of infective endocarditis ( ii of abnormal valves)
Valve disease, iv drug use, congenital defects of the heart e,,g vsd, coarctation, patent ductus arteriosus, prosthetic valves
403
What is the empirical treatment for infective endocarditis
Benzylpenicillin + gentamicin
404
List some of the causes of acute myocarditis
- viral infection e.g, flu, mumps, rubella, HIV, Coxsackie, polio
- bacterial TB, meningococcus,clostridium
- spirochete e.g. Syphillis, Lyme
- Protozoa e.g. Chagas
- drugs
- toxins
- vasculitis
405
What would you hear on auscultation of a patient with acute myositis
S4 gallop
406
What are the changes in bloods in acute myocarditis
Troponin I and T positive
407
What other things is dilated cardiomyopathy associated with
Alcohol, HTN, haemocromatosis, viral infection
408
How may dilated cardiomyopathy present
Symptoms of rvf or arrhythmias
409
What is heard on auscultation of a patient with dilated cardiomyopathy
S3 gallop
410
Which blood test in particular would you do in a patient with dilated cardiomyopathy
Bnp
411
What is the management for dilated cardiomyopathy
As per hf - diuretics, digoxin, acei, anticoag, biventricular pacing, implantable cardiverter defibrillation
412
What is hypertrophic cardiomyopathy
Inherited condition where there is LV obstruction from septal hypertrophy
413
What ecg changes may be found in patients with hypertrophic cardiomyopathy
LVH, arrhythmias associated
414
What is the management for hypertrophic cardiomyopathy
B blockers, verapamil, AMIODARONE for associated arrhythmias
415
List some cusses of restrictive cardiomyopathy
Sarcoidosis, amylodosis, scleroderma, endomyocardial fibrosis
416
What is cardiac myxoma
A rare cardiac benign tumour
417
What are the features of restrictive cardiomyopathy
Like those of constrictive pericarditis
418
List the three types of AF
- paroxysmal
- persistent
- permanent
419
What is paroxysmal AF
AF that terminates SPONTANEOUSLY, usually within 48 hours
420
What is persistent AF
AF that terminates with cardioversion (electrical or chemical) but does NOT resolve spontaneously
421
What is permanent AF
AF that will not terminate spontaneously and is refractory to cardioversion
422
Which beta blocker is used for rate control in AF
Metoprolol
423
How is acute AF treated
```
Emergency cardioversion (chemical or electrical depending on signs)
Then give vp rate control drugs e.g. CCBs and b blockers, digoxin, amiodarone
```
424
Which drugs are given for rate control first line in AF
CCBs - verapamil, Diltiazem
B blocker - metoprolol
(NOT both CCB and b blocker at same time)
Then LMWH
425
Which drugs are given for chemical cardioversion of AF
Amiodarone or flecainide (WITH CAUTION)
426
What is chronic AF management
Rate (or rhythm) control, anticoag
| Rate control - first line
427
What are the first line drugs for chronic AF rate control
First line - b blocker (metoprolol) or CCB (verapamil, Diltiazem)
428
What are the second line drugs for rate control in patients with AF
Digoxin or amiodarone
429
Which combination of drugs do you NOT give in AF, unless advised by an EXPERT
CCBs and b blocker
430
What is the management for patients with paroxysmal AF
"pill in pocket" - sorta lol or flecainide
| + anticoagulation
431
What is the anticoagulation in acute AF
Heparinise; use warfarin if high risk of emboli
432
What are the anticoagulation options for chronic AF
Warfarin
Dabigatran
Apixaban, rivaroxiban
NOT aspirin
433
What is the CHADVASC score a measure of
Risk of stroke per year - increases as score increases
434
What are the components of the CHADSVASC score
```
CCF (1)
HTN (1)
Age >75 (2)
DM (1)
Stroke/Tia (2)
Vascular disease (1)
Age 65-74 (1)
Sex (F) (1)
```
435
What is the CHADSVASC score out of and what score is needed to put. As patient on anticoagulation
Out of 9 max
| Score of 2 or higher needed to treat with warfarin etc
436
What does the HASBLED score assess risk of
1 year risk of major bleed in patients with AF
437
What are the parts that make up the HASBLED score
```
HTN (1)
Abnormal liver/kidney function (2x1)
Stroke (1)
Bleeding (1)
Labile INRs (1)
Elderly (>65 yo) (1)
Drugs/alcohol (2x1)
```
438
What is the HASBLED score out of, and what score is concerning
Out of 9
| Score of 3 or more requires regular review as they are high risk of bleeding
439
Ecg arrhythmia may wpw underlie
AF
440
Which drugs should be avoided in wow sydnrome
Verapamil, Diltiazem and digoxin (as these affect the AVN)
441
Which drug may be used in wpw syndrome
Flecainide
442
Which drug may be given in patients with u resolving bradycardia
Atropine
443
Which two places should you palmate if a patient has AF
Feel apex beat and radial pulse at same time
444
What is the typical ecg appearance of atrial flutter
Sawtooth baseline +/- 2:1 av block depending on ventricular and atrial rates
445
Which two things can you do to try and find the underlying rhythm in a patient with atrial flutter
Vagal manoeuvre e.g. Carotid sinus massage
| Iv adenosine
446
What is the treatment for asymptomatic bradycardia with rate over 40
No treatment
447
What is treatment for bradycardia with rate under 40bpm or patient who is symptomatic
Atropine
448
What wells score makes pe likely
4 or more, if below 4 do D dimer
449
Which 2 factors would score 3 points on wells score
- clinically suspected PE
| - alternative diagnosis to PE less likely
450
Which 3 factors would score 1.5 points in a wells score
- bpm over 150
- immobilisation
- prev PE/DVT
451
Which two factors would score 1 on a wells score
- haemoptysis
| - malignancy
452
Symptoms of which emergency can b blockers mask
Hypoglycaemia
