Cardio Flashcards
Which cause of cardiac pain improves on leaning forwards?
Pericarditis
What conditions may cause angina?
Coronary artery disease
Aortic stenosis
Hypertrophic cardiomyopathy
Paroxysmal supraventricular tachycardia
Examination finds shock with raised JVP. Diagnosis?
Cardiac tamponade
Simple bedside test to look for aortic dissection?
unequal BP in both arms
On ECGs which features make a Q wave ‘pathological’ ?
What do they indicate?
Deeper than 2mm
Especially in R-sided leads V1-V3
Prior or current MI
What is the different pattern expected in ST depression caused by ischaemia Vs digoxin?
Digoxin = downward sloping Ischaemic = horizontal
Which ECG leads reflect the inferior aspect of the heart?
II, III, aVF
Which aspect of the heart do the following ECG leads indicate: V1-V4?
Anteroseptal
Which are the anterolateral leads of the heart?
V5-V6, I, aVL
Which leads are affected in a posterior MI?
Tall R and ST depression in V1-V2
MI in anteroseptal leads suggests which artery is affected?
Left anterior descending
Which artery of the heart is likely to be implicated in inferior MIs?
Right coronary
Which artery of the heart is likely to be implicated in posterior MIs?
Circumflex
Or right coronary
What adjuncts are available to help patients stop smoking?
Nicotine gum
Nicotine patches
Varenicline- selective nicotine R partial agonist
Bupropion- acts on noradrenaline and dopamine and nicotine systems
On the ECG there are tall tented T waves and absent P waves. What is the likely cause?
Hyperkalaemia-
T waves are from repolarisation, if the extracellular levels of K+ are high then the inside of cardiac cells is relatively more negative, so a greater change in charge occurs (resting potential is more negative + cells are less excitable)
What change on the ECG is seen in hypercalcaemia?
Short QT interval
High levels of Ca increase the speed of the plateau phase of the action potential (many channels are voltage gated so the faster a voltage is reached the quicker the cycle)
Causes of right bundle branch block?
Due to R-ventricular strain, slowing the QRS complex
Normal variant Pulmonary embolism Cor pulmonale (R-ventricular strain secondary to pulmonary hypertension)
Rx for acute heart failure with systolic dysfunction (echo shows reduced left ventricular ejection fraction)?
What additional medication can be given if systolic BP is below 100mmHg?
Pulmonary oedema:
Oxygen/CPAP
Furosemide
Vasodilator (nitrates etc)
± Inotrope if systolic BP is below 100mmHg
Rx for chronic heart failure- with left ventricular systolic dysfunction?
FAB DA
1st: Furosemide, ACEi, b-blocker
2nd: Digoxin, Aldosterone antagonist
Which b-blockers are licensed for heart failure?
Which one isn’t?
Bisoprolol
Carvedilol
Nebivolol
NOT Atenolol
A 70 year old gentleman who has had a previous MI gets a clinic BP reading of 145/91.
How should his BP be managed?
Calcium channel blocker (ie amlodipine, as over 55)
Give antihypertensive to anyone with Stage 1 HTN (>140/90) with: CVS disease Diabetes Renal disease Organ damage who is under 80
Which patients should be offered a calcium channel blocker as 1st line treatment for their hypertension?
Those over 55 or black patients
What are the different stages of hypertension?
Stage 1: 140/90mmHg in clinic
Stage 2: 160/100mmHg
Stage 3: 180mmHg systolic
110mmHg diastolic
What are the different BP targets for those Under 80 over 80 diabetic diabetic + end organ damage diabetic + renal disease
Under 80 160/100 or CVS issue etc)
Over 80
Patient is on Amlodipine, Atenolol + Indapamide
It is noticed that their Potaassium is 4.2mmol/L
What should be done?
For HTN: B-blocker + CCB + thiazide + low K+
Spironolactone + expert advice
What defines postural hypotension?
A drop by 20mmHg in BP on standing compared to sitting/lying
How does heart failure lead to pitting oedema?
Reduced perfusion of the kidneys leads to salt and water retention and activation of the renin-angiotensin system, which increases water retention further
What pressure in the pulmonary system is indicative of pulmonary hypertension?
15-20mmHg
At 21-30mmHg interstitial oedema occurs
What’s the difference between defibrillation and cardioversion?
Defibrillation is non-synchronised shock (as ventricular fibrillation is not a regular pattern)
Cardioversion is synchronised shock, an unsynchronised one could lead to ventricular fibrillation (for AF, flutter, junctional tachycardia…)
Which cardiac abnormality requires dual pacing?
AV block
How long a PR interval is considered prolonged?
> 0.20 seconds (or 200ms)
5 little squares
What is the difference between Mobitz I and II and which is riskier?
Mobitz I- PR increases until dropped beat
Mobitz II- every 2/3rd beat is dropped, PR interval is constant
Mobitz II is more likely to progress to Mobitz III
ECG shows LBBB and left axis deviation. Which bundle (anterior or posterior) is affected?
Knock out of anterior bundle causes L ventricle to be depolarised from inferior to superior causing a Left Axis deviation
Patient has ECG with a HR of 130bpm and narrow QRS complexes. They are stable but having palpitations.
Management?
Supraventricular tachycardia
Valsalva manoeuvre, Carotid sinus massage…
2nd: IV adenosine
Why are vasodilators not as good in heart failure from diastolic dysfunction?
In diastolic dysfunction, the heart does not fill well in diastole as the heart may not relax in a normal manner.
High pressures are needed therefore to fill the heart, vasodilators lower pressure.
Symptomatic Rx of angina?
NB: not preventative
Glyceryl Trinitrate SL
B-blocker- slows heart
Ca channel antagonist- relaxes coronary arteries
Long acting nitrate isosorbide dinitrate
What occurs in acute coronary syndromes to cause the pain?
Rupture of a fibrous cap on the atheromatous plaque causes thrombus/emboli.
Platelets release Seratonin and thromboxane causing localised vasoconstriction, worsening ischaemia
What test can be done for those who come into hospital with MI-symptoms but on balance of Tropinin and ECG, FHx, PMH etc are deemed low risk, to determine prognosis?
Exercise test:
If negative = good prognosis
How do the different anti-platelet drugs work?
Aspirin- prevents thromboxane A2 formation needed to aggregation of platelets
Clopidogrel inhibits ADP activation of platelets
Abciximab + Eptifibatide - glycoprotein IIb/IIIa inhibitor (found on platelet surface)
Tirofiban- reversible glycoprotein IIb/IIIa inhibitor
How does Rivaroxiban and LMWH and unfractionated heparin work?
Novel anticoags- Rivaroxiban inhibits Xa directly
LMWH activates antithrombin- targets Xa
Unfractionated heparin- activates antithrombin- targets Xa and thrombin
X > Xa enables Prothrombin > Thrombin
What are the contraindications to b-blockers?
Asthma
AV block (as self-generating rhythm will be slowed further)
Acute pulmonary oedema
If fibrinolytic is given, how do you know whether it has failed to reperfuse and now needs re-thrombolysis or coronary angioplasty?
Less than 50% decrease in ST elevation after 90 minutes
Rx for ventricular tachycardia?
Amiodarone 300mg IV over 20 mins
Amiodarone 900mg over 24 hours
Long term management post MI?
AABC’S
Aspirin ACEi B-blocker Clopidogrel Statin
What causes most mitral stenosis?
Rheumatic heart disease
Valves thicken, cusps fuse, calcium is deposited
Cause of a raised JVP with a normal waveform?
Fluid overload
Right heart failure
-unable to eject the venous return
Cause of raised JVP with absent pulse?
Superior vena cava obstruction
Backlog of blood from obstruction but is unrelated to heart contractions (not due to HF)
JVP has a large A wave, cause?
Pulmonary hypertension
Pulmonary stenosis
A wave is backflow of blood during atrial systole.
If ventricles are fuller, less blood goes from atria to ventricles, more backflow.
JVP with a cannon A wave
More severe than a large A wave:
Heart block
Atria contracts against a closed tricuspid valve
Cause of a JVP with an absent A wave?
Atrial fibrillation
No synchronised atrial systole
JVP with a large V wave?
Tricuspid regurgitation
V wave is ventricular systole, so atrial filling against a closed tricuspid valve. If tricuspid valve is leaky it allows more backflow as the atria fills from two directions.
Systolic murmurs louder on inspiration?
Tricuspid regurgitation
Pulmonary stenosis
L side during systolic
Freidrich’s ataxia is associated with which type of cardiac defect?
Hypertrophic (obstructive) cardiomyopathy
What signs are associated with HOCM?
S4 sound- as atria contracts against a stiff L ventricle
Jerky pulse
Double impulse at apex beat, as atria contracts and ventricle contracts as so hypertrophed
What kind of inheritance is hypertrophic cardiomyopathy associated with?
Autosomal dominant
Sarcomeric heavy chain or troponin gene mutation
Papillary muscle failure in the heart leads to prolapse of which valve?
Mitral valve
Of the systolic murmurs louder on expiration, which is louder with the valsalva manoeuvre and which is quieter?
L-sided systolic murmur (RILE)
Aortic stenosis is quieter- Valsalva increases pressure to expel blood out ventricle so less blood going past aortic valve
Mitral regurg is louder- more resistance to aortic outflow so more blood goes into atria
Which systolic murmur radiates to carotids?
Aortic stenosis (ejection systolic)
What signs of aortic stenosis indicate severity?
Presence of:
Slow rising pulse (limited flow)
Soft S2 sound (calcified valves are unable to slam shut)
What type of apex beat and pulse types are associated with aortic stenosis?
Heaving apex beat (due to hypertrophy)
Pulsus alternans- not all the blood gets evacuated
Slow-rising pulse- limited outflow
What heart sounds can be indicative of aortic stenosis?
Soft S2- calcified valves unable to slam shut
S4- hypertrophic ventricles vibrate as atria contracts
Split S2- slow outflow of L ventricle means P2 before A2
What is the difference cause of a thrUsting or Heaving apex beat?
Heaving in Hypertrophy- aortic stenosis, systemic hypertension
ThrUsting in flUid overload- aortic incompetence, mitral incompetence
Which treatments for heart failure help with symptoms but not mortality?
Furosemide and Digoxin
Patient has chronic heart failure, they are taking Ramipril, Carvedilol, Spironolactone and Digoxin, Furosemide PO and still they have breathlessness and swollen ankles.
What other options are there?
Salt and fluid restrict
bumetanide 1mg instead of furosemide (loop diuretic)
+ metolazone (thiazide)
IV furosemide
What treatments improve prognosis in angina?
And which one if someone has had a previous MI?
Aspirin
Simvastatin
Previous MI: b-blocker/CCB
Which treatments for angina improve symptoms but not prognosis?
GTN SL
If no previous MI:
B-blocker + CCB
if previous MI helps prognosis + symptoms
What are the different treatment approaches for permanent Af (lasting longer than 48 hours)
Rate control: b-blocker/ calcium channel blocker
Anticoagulate: Warfarin
Rhythm control: flecainide (normal heart), amiodarone (structural heart disease)
What ‘pill in the pocket’ is useful for paroxysmal AF?
Sotolol
Or
Flecainide
Someone has had palpitatios for the last four hours, and ECG shows AF, what anticoagulation would you use and why?
LMWH Dalteparin 5000 units
Warfarin will take too long to get up to a therapeutic dose whilst the patient is in acute AF (under 48 hours)
Want to cardiovert someone with acute AF, they have ischaemic heart disease. What drug should be used for medical cardioversion?
Amiodarone
If no IHD/WPW syndrome/normal heart
Flecainide
What are the stages of Fontaine’s peripheral arterial disease?
Stage 1: asymptomatic
Stage 2: intermittent claudication
Stage 3: ischaemic rest pain
Stage 4: ulceration/gangrene
CHAaDSsVasS Score?
Cardiac failure
Hypertension >140/90
Age- 65 (1 point)
75 (2 points)
Stroke (2 points)
TIA (1 point)
Vascular disease- PAD, MI, aortic plauque
Sex- female (1 point)Name for when JVP rises on inspiration (not normal)
And condition that causes it?
Kussmaul’s sign:
Inspiration reduces intrathoracic pressure increasing flow to the right side of the heart, unable to fit all the blood in restricted heart (due to constrictive pericarditis) so blood backlogs
Cause of a bounding pulse?
CO2 retention, liver failure and sepsis
Conditions causing low peripheral vascular resistance
(CO2 ret- autoregulation, liver failure- splanchnic circulation dilates)
Lead to low diastolic pressure and compensatory increased stroke volume so pulse is forceful and wide pulse pressure
Causes of a collapsing pulse?
Aortic regurgitation
AV malformation
Patent ductus arteriosus
Ventricle is more full than normal = strong upshoot
Rapidly falling away as blood whooshes back in via defective valve
Cause of bisferiens pulse?
Aortic stenosis with regurgitation:
Little blood coming out via ventricle, backflow of blood regurgitating back through valve allows for a second outflow pulse during systole.
Difference between bisferiens pulse and pulsus alternans?
Bisferiens pulse is two pulses of blood outflow during systole, pulsus alternans = one strong then weak heart beat
Bisferiens: aortic stenosis + aortic regurgitation
Alternans: aortic stenosis, LV failure, cardiomyopathy
What is the physiology behind pulsus paradoxus- systolic BP drops by 10mmHg on inspiration?
Inspiration- lowers thoracic pressure= increased blood flow to the R side of the heart + pulmonary vasculature expands leading to pooling of blood in the lungs and less L-sided output.
= reduced systolic BP
In cardiac tamponade, the R ventricle pressure may lead to septum being pushed into L ventricle reducing outflow,
82 year old with chest pain and feeling unwell. Pale and nauseous.
What are the crucial tests to exclude serious things?
BP- asymmetric pulses in aortic dissection
ECG- ACS
Troponin- ACS
CXR: Widened mediastinum in aortic dissection
Clear in PE
Gas in the mediastinum for oesophageal tear
How does management of AF differ if it has onset in the last 48 hours or longer ago than that?
In last 48 hours = acute
Give IV heparin and cardiovert (DC or pharmacologically)
Starting more than 48 hours ago
Anticoagulate for 4 weeks then DC cardiovert
What features make cardioversion of AF more likely (rather than rate control)?
(Demographics, AF, HPC)
Under 65
Symptomatic
First presentation of lone AF
Haemodynamically compromised
Congestive cardiac failure
What features make you more likely to rate control AF rather than try to cardiovert?
Over 65
Coronary artery disease
No congestive cardiac failure
What are the causes of cardiomegaly?
Where the cardiac:thoracic ratio is greater than 50%
D: Neonates, infants and athletes
PC: cardiac dilation (HF etc), pericardial effusion
PMH: Skeletal abnormalities
On an CXR how would cardiac effusion and heart failure look different?
Both would have cardiomegaly but in cardiac effusion the heart looks globular and there would not be associated change in vasculature, unlike heart failure
Which part of the aorta becomes calcified in syphilitic aortitis compared to atherosclerosis?
Syphilis- ascending aorta
Atherosclerosis- descending aorta
What causes pulmonary hypertension?
Lung: PE or chronic lung disease
Heart: mitral valve stenosis, LV failure, septal shunt from left to right
Test for vagovagal syncope?
What counts as a positive result?
Upright tilt table test- bradycardia or hypotension following tilting and isoprenaline/GTN infusion
What is the treatment for those with recurrent attacks of vagovagal syncope with proven reflex syncope?
Pacing (Not b-blockers)
Physical counter-pressure maneuvers - squatting, arm-tensing, leg crossing, when feel faint coming on
When might an apex beat be non-palpable?
Obesity
Hyper-expanded chest (COPD)
Dextrocardia
If someone is haemodynamically unstable and the heart rate is very slow, what drug can be given to speed it up?
Atropine (anticholinergic to counter parasympathetics)
0.5mg every 3-5 mins
What is a prolapsing mitral valve associated with?
Hear an ejection click and mitral regurgitation
Marfan’s and other connective tissue disorders (Ehlers-Danlos)
Thyrotoxicosis
Rheumatic fever (group A strep), endocarditis
A gentleman comes in, you notice he has long arms and long spidery fingers and a pectus deformity.
What is he at danger of and what are other features of this condition?
Marfan’s- poor elastic fibres
Aortic dissection/dilatation- can use b-blockers to slow dilatation
Mitral valve prolapse
Head: Lens dislocation, high-arched palate,
Shoulders: Scoliosis, Dural ectasia (ballooning of dural sac around spinal cord)
Knees: joint hypermobility
Toes: pes planus
Gentleman with Marfan’s syndrome has been identified as having growing aortic dilatation. What medication can be offered to slow progress?
beta-blockers
What organisms commonly cause infectious endocarditis in people with native valves?
Staph aureus
Strep viridans (not S. Pneumo)
Enterococcus
Which risk factor is particularly associated with R-sided valve endocarditis in native valves?
IV-drug users as venous access seeds to the valve.
What is the pathogenesis for the sequalae of infective endocarditis (splinter haemorrhages, Roth spots etc)?
Where immune complexes (Ig + antigen) get deposited, it causes vasculitis and small haemorrhages:
Osler’s nodes (ow- fingers), Janeway lesions (“WAY?!” High five- on palms, flat from high 5ing)
A gentleman has a fever and a recent onset heart murmur that has not been noted before. What needs to be considered and how can it be investigated?
Infective endocarditis
Blood cultures, echo (look for vegetations)
ECG: emboli can cause MI, conduction defects may arise
2 major criteria that have to be fulfilled to diagnose definite infective endocarditis can be:
Positive blood culture
Typical organism in 2 separate cultures
Persistently +ve blood cultures, ie 3/3, 12 hours apart
Endocardium involved
Positive echo- vegetation, abscess
New valvular regurgitation- not just a change in murmur
3 minor criteria + 1 major criteria (blood cultures, echo, valve regurgitation) enable a diagnosis of infective endocarditis according to Duke’s criteria. What are the minor criteria?
Predisposition- heart condition, IV drug use
PC: Fever >38 degrees
Vascular sequelae- septic PE, janeway lesions, mycotic aneurysm
Immunologic sequalae- Osler’s node, Roth spots, glomerulonephritis
IHx: +ve blood culture (not major enough)
+ve echo (not major enough)
Rx for native valve infectious endocarditis (organism unknown)
Amoxicillin ± Gentamycin
Rx for prosthetic valve infectious endocarditis where organism is not known
Vancomycin + Gentamycin + Rifampicin
Suspect a pulmonary embolism? Gold standard investigation?
Who can’t have this?
CT-PA
CT pulmonary angiogram
Uses contrast so not appropriate for impaired kidney function patients
You identify a massive PE on CT-PA. The patient says the breathlessness onset 2 hours ago.
BP: 90/50
How can it be managed?
Massive PE + evidence of acute heart strain (low BP):
Thrombolysis: Streptokinase/Alteplase
If less acute/urgent- anticoagulation: LMWH instead
Which score determines the likelihood of a PE?
Well’s score
Above 6 = high likelihood
What causes myocarditis?
Commonly viral- Coxsackie virus
Diptheria
Rheumatic fever- Strep A
Radiation injury
Patient has fever and biventricular failure (oedema of ankles and pulmonary oedema)
ECG shows nonspecific ST changes
CXR- cardiac enlargement
What could be going on?
Myocarditis
Only viral
Management: bed rest + treat heart failure
What would you find on an echo that would suggest a patient is getting heart failure because of dilated cardiomyopathy rather than it being due to ischaemia?
Dilated cardiomyopathy- global hypokinesis
Ischaemia- focal/regional impaired contraction
What are the stages of the New York functional classification of heart failure?
I- No limitation of physical activity, no fatigue, SOB, palpitation
II Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea.
III Less than ordinary activity causes fatigue, palpitation, or dyspnea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest.
When going up stairs a patient complains of shortness of breath and palpitations. What stage of New York Functional classification of heart failure is this?
Stage II:
I No limitation of physical activity, no fatigue, SOB, palpitation
II Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea.
III Less than ordinary activity causes fatigue, palpitation, or dyspnea.
IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest.
Leading cause of dilated cardiomyopathy in South America?
Clue: infectious
What anatomical defect is pathognomonic?
Chagas disease:
Trypansoma cruzi- a protozoa
Left ventricular apical aneurysm
(Get acute myocarditis, cardiac enlargement, tachycardia etc)
What anatomical/functional features define dilated cardiomyopathy?
Left ventricular chamber enlargement
Systolic dysfunction (heart failure)
Normal left ventricular wall thickness
Echo: global hypocontractility
Typically what is the difference in cardiac dysfunction observed in dilated cardiomyopathy compared to hypertrophic cardiomyopathy?
In dilated CM the lack of contractility leads to systolic failure.
In hypertrophic CM the enlarged interventricular septum leads to impaired filling and therefore a diastolic dysfunction
What is the pathophysiology of hypertrophic cardiomyopathy?
What happens anatomically?
Gene mutations in sarcomeric proteins (actin, myosin heavy chain etc)
Abnormal myofibril arrangement and fibrosis of the heart tissue, leading to hypertrophy (diastolic dysfunction, LV outflow obstruction, mitral regurgitation)
Often with narrowed coronary arteries due to thickening of the intima (may cause ischaemia)
Inheritance pattern of familial hypertrophic cardiomyopathy?
Autosomal dominant
HYPERTROPH IS DOMINANT
What can be the cause of a different blood pressure in each arm?
coarctation of aorta, subclavian steal aortic dissection
peripheral vascular disease
unilateral neuromuscular abnormalities
What gene, if mutated will cause familial aortic stenosis?
Elastin gene
In exercise ECG testing what comprises a positive result?
A horizontal or down-sloping ST depression.
An upsloping ST depression doesn’t count
A patient is undergoing a diagnostic cardiac catheterisation when an assistant notices the loss of the peripheral pulse, what could be the cause?
Dissection, thrombosis or arterial spasm
Mechanism of Aspirin?
Irreversibly inhibits cyclo-oxygenase enzymes in platelets, preventing thromboxane A2 production and platelet aggregation.
(TxA2 triggers expression of GpIIb/IIIa needed for platelet conformation changes for aggregation)
What are the different roles of B1 and B2 adrenergic receptors?
B1 = inotropic + chronotropic (bisoprolol is selective)
B2 = peripheral vasocontriction + bronchoconstriction
Which different transporters do loop, thiazide and potassium sparing diuretics act on?
Loop = Na/2Cl/K co-transporter
Thiazide = Na/Cl co-transporter
K+ sparing = ENaC distally, H/Na exchanger proximally
Metabolic SEs of different types of diuretic?
Loop- low K, low Ca
Thiazide- low K, high Ca, low Mg, high urate
K is low because more Na in the cortical collecting duct allows for exchange via ENaC
What are the two different types of Ca channel blockers and which drug is CI with one type?
Dihydropyridines: nifedipine, amlodipine =peripheral vasodilators
Non- dihydropyridines: verapamil, diltiazem =slow AV + SA node conduction
Don’t give verapamil with b-blockers (profound bradycardia/HF)
What’s the mechanism of Digoxin?
Na/K/ATPase pump takes K in and Na out.
Na/Ca exchanger takes Na in and Ca out.
Without lots of Na outside, can’t swap it for Ca so more Ca in heart muscle, stronger contraction
How do statins work?
Inhibit HMG-CoA reductase which recycles cholesterol so it all has to be made from scratch in the liver.
The lower levels of cholesterol trigger more LDL receptor expression in hepatocytes increasing LDL uptake and reducing blood levels
What kind of ACEi is best suited to the elderly?
Long acting ones like Lisinopril
1st dose can cause hypotension, best taken at night
What kind of change in BP as an ACE inhibitor is starter would make you worry about renal artery stenosis?
> 20% rise in creatinine
>15% decrease in GFR
How is the management different for those with Prinzmetal angina compared to normal angina?
Printzmetal angina is caused by coronary artery spasm rather than coronary artery disease
Rx: CCB ± long acting nitrates
Avoid aspirin (aggravates ischaemia) And b-blockers (increase vasospasm)
What conditions are included in acute coronary syndrome?
Unstable angina and evolving MI
Both due to plaque rupture, thrombosis and inflammation
Can also be due to emboli/coronary spasm of normal arteries or vasculitis
How do silent MI’s present in the elderly or diabetic?
Nausea, sweatiness, palpitations Dyspnoea Syncope, acute confusion Pulmonary oedema Epigastric pain/vomiting etc
Why does creatinine kinase-MM become raised?
From skeletal muscle Falls, seizures, prolonged exercise Myositis Hypothyroidism Afro-caribbean
Suspect MI from history, immediate management?
Rx not IHx
Morphine (+ metoclopramide)
O2
Nitrates
Aspirin 300mg to chew
For patients that have acute coronary syndrome without ST elevation, but are high risk (recurrent iscahemia, ST depression, diabetes, high troponin) what medication should you give them, and within how many hours should they receive angiography?
A GPIIb/IIIa antagonist and angiography within 96 hours (4 hours)
If someone develops 1st degree AV block following an inferior MI what medication may need to be stopped if things deteriorate further?
If second degree heart block develops, CCB and b-blockers will need to be stopped
Patient has an MI and then develops sustained VT for 2 minutes, how should they be managed?
If compromised DC cardiovert, if stable amiodarone
Amiodarone reduces Ca inflow to prolong repolarisation and slow the heart. It acts like a b-blocker on SAnode further slowing pace.
Rx for pericarditis following an MI?
NSAIDs
A patient takes amiodarone daily for his ventricular tachycardia, what monitoring IHx does he need to check up on the common side effects?
LFTs- hepatits
TFT- raises T4, lowers T3
Corneal deposits, photosensitivity
Lung fibrosis
How is Rx different for acute and chronic heart failure?
Acute: SYMPTOMATIC
Furosemide, morphine, GTN
Chronic: B-blocker, ACEi
(Then spironolactone or ARB. Then digoxin or cardiac resynchrony)
What is the Rx hierarchy for hypertension
ACEi (young + white) or CCB/thiazide (>55 or black)
A+C or D
A+C+D
A+C+D +b-blocker/a-blocker/diuretic
Rx for someone who has had palpitations for the last 30 hours, BP 80mmHg found to have AF, never had it before?
Unstable acute AF
Cardiovert: Flecainide (normal heart)
Amiodarone (IHD or structural abnormality)
Rate control: b-blocker or CCB
LMWH
What Rx should be offered for CHAADSSVasS scores (calculated for those with AF)?
Score 0 = no therapy
Score 1 = warfarin or NOACs
What does HASBLED stand for?
Hypertension (>160/uncontrolled) Abnormal renal (1) or liver (1) function Age >65 Stroke Bleeding disorder Labile INR Extra drugs- antiplatelets/NSAIDs Drugs/alcohol use
Score>3 warrants more regular review
Which part of the heart do Digoxin, b-blockers and ca channel blockers exert their effects on to slow the heartbeat?
Reduce AV nodal conduction
In those with AF who have wolff parkison white, which standard Rx can you not give?
Flecainide to cardiovert
B-blockers/CCBs to rate control as causes bradycardia
Supraventricular tachycardia is not responding to adenosine, what is next line Rx?
Beta blocker or Ca channel blocker (not both)
What is the different uses and mechanism of adenosine, atropine and amiodarone?
Adenosine terminates AV node re-entrant tachycardias (binds to AV node to transiently block it)
Atropine is used in bradycardias (anticholinergic to block vagal input)
Amiodarone prolongs action potential (reduces calcium permeability, slows AVnode conduction) used to cardiovert
What metabolic abnormalities can cause ventricular tachycardia?
Low K+, low Mg2+
What heart rhythms are shockable or non-shockable during ALS?
Shockable: ventricular fibrillation, pulseless VT
Non-shockable: pulseless electrical activity, asystole
During ALS what drug should you give and how often?
Adrenaline every 3-5 minutes
What are the reversible causes of cardiac arrest?
4 H’s, 4 T’s
Hypothermia
Hypovolaemia
Hypoxia
Hypo/Hyperkalaemia
Tamponade
Tension pneumothorax
Thrombosis
Toxins
What are the indications for a CABG that prolong survival?
Triple vessel disease
Left main stem (L coronary artery) disease
Patient keeps getting episodes of SVT and then bradycardia. What is the cause and potential management?
Tachy-brady syndrome occurs in sick sinus syndrome (sinus node dysfunction)
Requires pacing if symptomatic
How does sinus tachycardia and SVT look different on ECG?
Sinus tachy- p waves normal
SVT- p waves absent or inverted (due to the pace being set from the AVN and conducting through the atria retrograde)
Morphology of P waves looks different (at least 3 distinct appearances) and P-P intervals are irregular. HR is 140.
What is the name of this and what disease is it associated with?
Multifocial atrial tachycardia
COPD- Rx hypoxia and hypercapnia
What findings on an ECG suggest a broad complex tachycardia may be ventricular tachycardia?
Positive QRS concordance in chest leads (all up/all down)
Left axis deviation
AV dissociation
Fusion beat (normal beat fuses with VT complex)
Capture beat (normal beat between VT complexes)
Rx for torsades de pointes (polymorphic VT)
Magnesium sulphate over 5mins
+ DV cardiovert
What are the indications for a permenant pacemaker?
Type 3 or Mobitz type 2 AV block (regularly missing beats) Symptomatic bradycardias Heart failure (can have biventricular to resynchronise) Drug-resistant tachyarrhythmias (can have a defibrillator in it)
What causes diastolic heart failure?
If the ventricles can’t relax sufficiently to allow filling:
Ejection fraction may be normal
Constrictive pericarditis, tamponade
Restrictive cardiomyopathy
Hypertension
What investigations are suggestive or definitive of heart failure?
Suggestive: ECG abnormality, BNP (actually most accurate)
Definitive: echocardiography
CXR signs of heart failure?
Alveolar oedema (bat wing shadowing) Kerley B lines (interstitial oedema) Cardiomegaly Dilated upper lobe vessels Pleural Effusion
How does the presence of symptoms stratify heart failure severity In the New York Heart Association grading?
1- no symptoms on ordinary activity
2- symptoms of ordinary activity
3- symptoms with less than ordinary activity
4- symptoms at rest
Causes of secondary hypertension?
Renal interstitial: glomerulonephritis, PAN, systemic sclerosis, polycystic kidneys, chronic pyelonephritis
Renal vascular: atheroma, fibromuscular dysplasia
Endo: Conn’s (aldoesterone), Cushing’s (cortisol), phaeochromocytoma (adrenaline), acromegaly (GH), high PTH
Drugs: steroids, the pill
Coarctation, pregnancy
Tests for secondary causes of hypertension?
U+E: low K (Conn’s) or high Ca (PTH)
BM: acromegaly
Urine dip: glomerulonephritis
Renal USS: renal a stenosis
MR: coarctation aorta
Urinary metanephrines (phaeo), free cortisol (Cushings)
Renin, aldoesterone (Conn’s)
Which cardiovascular drugs increase the risk of gout?
Thiazide diuretics
Jones criteria of rheumatic fever:
(Recent strep infection and:
2 major
Or 1 major and 2 minor)
Group A b-haemolytic Strep infection:
+ve throat culture, strep antigen test +ve, rising strep antibody titre, recent scarlet fever
Major: (CASES)
Carditis, arthritis, subcutaneous nodules, erythema marginatum (truncal red raised rash), syndenhams chorea
Minor:
Fever, raised ESR, arthralgia, long PR, PMH rheumatic fever
Features of salicylate toxicity (ie aspirin)
Tinnitis
Metabolic acidosis
Hyperventilation
Which valve is most commonly affected in rheumatic heart disease?
Mitral
Signs of mitral stenosis
Diastolic murmur
Loud S1 (atria still getting blood out when valve shuts)
Tapping apex beat (L atria large and moves LV closer to hand to make apex beat more palpable)
What is a graham steell murmur?
Pulmonary regurgitation secondary to pulmonary hypertension secondary to mitral stenosis
What are the heart sounds of mitral regurgitation and why?
Pansystolic murmur radiating to axilla
Soft S1, mitral leaflets don’t meet
Split S2, LV emptying happens quicker as blood can exit from aorta and atria
Loud S3, atria overfilled, rapid ventricular filling
ThrUsting apex beat- mitral regUrgitation
How does aortic stenosis present?
Angina
Syncope
Exertional dyspnoea/HF
Dizziness/faints…
What are the eponymous signs of aortic regurgitation?
Corrigan’s- carotid pulsation
De Musset’s- head nodding with heart beat
Quincke’s- capillary pulsations in nail bed
Traube’s- pistol shot sound over femoral artery
Austin Flint murmur (low rumbling mid diastolic murmur=severe, the normal AR murmur is early diastolic, high pitched)
Intrinsic and extrinsic causes of acne?
Intrinsic
Hormonal: PCOS, virilising tumours, congenital adrenal hyperplasia, Cushing’s, acromegaly
Medical: steroids (increase keratinisation of ducts), combined pill (raise testosterone), phenytoin, lithium
Isoniazid, ciclosporin
Extrinsic: oils, coal, tar, weed killer
Name of the bacteria in acne?
Propionibacterium acnes
Pregnant woman with moderate acne, what can be given, what should be avoided?
CI: Tetracycline antibiotic
Erythromycin, trimethoprim = fine
CI: Oral retinoids, isotretinoin
Rx of mild comedonal acne?
Topical retinoids (adapalene, tretinoin, isotretinoin)
Salicylic acid
Azelaic acid
Rx of mild inflammatory (papulo-pustular) acne?
Topical retinoid (adapalene, tretinoin, isotretinoin) Topical Abx (doxycycline, tetracycline, minocycline) Benzoyl peroxide
Rx of moderate inflammatory (papulo-pustular acne)
Topical retinoid (adapalene, tretinoin, isotretinoin) Oral antibiotics (tetracycline, minocycline)
Rx of severe nodulocystic acne (cysts, abscesses, scarring)
Oral retinoid (isotretinoin)
Or contraceptive co-cyprindiol pill (high oestrogen, low testosterone)
Why does ST depression on an ECG stress test suggest coronary artery disease?
Ischaemia not affecting the whole wall, the injured cells are closer to the inner part of the heart (sub-endocardium). They do not depolarise as much as healthy cells, so the current flows from +ve charged depolarised cells to the inner part of the heart, during ST segment.
Anterior chest leads detect current flowing away from them (therefore ST depression)
RV cardiomyopathy + curly wool hair + palmoplantar keratosis on feet, is known as which disease?
Naxos disease- inherited in those of Mediterranean descent, autosomal recessive
PC: SOB, blackouts, poor exercise tolerance
Type of cardiomyopathy that may follow pre-eclampsia?
Dilated cardiomyopathy
Autoimmune associated cardiac disease where biopsy shows bands of necrosis surrounded by inflammatory infiltrate?
Giant cell myocarditis- rare
How does the site of a dissecting aorta determine your management approach?
Type A (2/3rds) in the ascending aorta require surgical management with blood pressure control (due to potential to affect carotid perfusion)
Type B (1/3rd) in the descending aorta may be conservatively managed with bed rest and reducing blood pressure with IV labetalol
