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Medicine > Cardio > Flashcards

Cardio Flashcards

1
Q

JVP: Location & features

A 
Location:
-  JVP is assessed by looking at the  
   internal jugular vein.
-  IJV is located deep to the sternomastoid 
   muscle.
Features/Differences from carotid pulse:
-  Complex wave form: beats twice in one 
   cardiac cycle.
-  Visible but not palpable
-  Occludable and fills from above.
-  Decreases with deep inspiration.
-  Changes with head position.
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2
Q

JVP Wave form

A 
A wave
-  Atrial contraction, coincides with first 
   heart sound.
-  Large/canon A waves = Tricuspid 
   stenosis, pulmonary stenosis, complete 
    heart block
C Wave
-  Tricuspid valve closure
-  Not visible.
X decent
-  Atrial relaxation
-  Absent = AF
-  Exaggerated = tamponade, constrictive  
  pericarditis.
V wave
-  Atrial filling
-  Large = tricuspid regurgitation
Y Descent
-  Rapid ventricular filling
-  Sharp = TR
-  Slow = TS
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3
Q

Inferior MI

A

Leads II, III, aVF

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4
Q

Anteroseptal MI

A

Leads V1-4

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5
Q

Anterolateral MI

A

Leads V4-6, I, aVL

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6
Q

Posterior MI

A

Tall R waves

ST depression in V1-2

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7
Q

ECG findings in pulmonary embolism

A 
Sinus tachycardia
RAD
RBBB
Right ventricular strain pattern = dominant R waves, T wave inversion/ST depression in V1 and V2
Classic pattern (rare) = S1Q3T3
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8
Q

Definition of ACS

A

Includes: unstable angina, STEMI, NSTEMI

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9
Q

Management of ACS with ST elevation

A
  • ABC’s
  • Quick history and physical exam
  • 12 lead ECG
  • Bloods: U&E, troponin, glucose,
    cholesterol, FBC, CXR.
  • Aspirin 300mg PO; consider clopidogrel
    300mg.
  • Morphine 5-10mg IV + Metoclopramide
    10mg IV.
  • GTN 1-2 tabs SL or spray.
  • BB Atenolol 5mg IV
  • O2 mask or nasal prongs.
  • Restore coronary perfusion: PCI
    (< 30min from admission,
    within 24hrs of onset of chest pain)..
  • Consider DVT prophylaxis.
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10
Q

Treatment of hypertension

A

Monotheray:

  1. If > 55 yrs or black of any age - CCB or thiazide.
  2. If < 55 yrs - ACEI is first choice; ARB if ACE CI,
  3. BB: not first line but consider in patient who can’t take ARB/ACEI, younger patients, women of child bearing potential.

Combination therapy:
1. ACEI + CCB
2. ACEI + diuretic
3. ACEI + CCB + diuretic
If still uncontrolled consider 4th drug = spironolactone, higher dose of thiazide, BB.
4. If patient only on BB and not well controlled - add CCB not thiazide to decrease risk of diabetes.

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11
Q

Doses of anti-hypertensive drugs

A

Thiazide: Chlortalidone 25-50mg
CCB: Nifedipine 30-60mg/24hrs
ACEI: Lisinopril 5-20mg/24 hr (max 40mg)
BB: Bisoprolol 2.5-5mg/24hrs

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12
Q

ECG Leads: Anteroseptal infarct

A

LAD

V1+V2

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13
Q

ECG Leads: Anterior infarct

A

LAD

V3+V4

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14
Q

ECG Leads: Anteriolateral

A

LAD artery involved

I, aVL, V3-V6

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15
Q

ECG Leads: Inferior infarct

A

RCA involved

II, III, aVF

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16
Q

Right ventricle

A

RCA involved

V3R, V4R (right sided chest leads)

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17
Q

ECG Leads: Posterior MI

A

RCA involved

V1, V2, prominent R waves

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18
Q

ECG Leads: Lateral MI

A

Circumflex artery

I, aVL, V5-V6

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19
Q

ECG changes: HyperK+

A

Mild hyperK+ (5-7mmol/L): tall peaked T waves

Severe hyperK+: P wave flattening, QRS widens.

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20
Q

ECG changes: HypoK+

A

ST segment depression
Prolonged QT interval
Prominent U waves

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21
Q

ECG changes: HyperCa++

A

Shortened QT interval

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22
Q

ECG changes: HypoCa++

A

Prolonged QT interval

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23
Q

Digitalis: Side effects

A 
Palpitations
Fatigue
Vision changes - yellow vision
Decreased appetite
Hallucinations
Confusion
Depression
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24
Q

Digitalis: ECG changes

A 
Therapeutic levels: Dig effect
ST downsloping/scooping = reversed tick
T wave depression/inversion
QT shortening
First degree heart block
Toxic levels:
Paroxysmal atrial tachycardia with conduction block
Complete heart block
Bradycardia
PVC
VT
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25
Q

Cardiac biomarkers

A 
Troponin I&T
-  Peaks 1-2 days, stays elevated up to 2 
   weeks.
-  Check at presentation and 8hr later.
CK-MB
-  Peaks 1 day, returns to BL 3 days later
-  Can diagnose re-infarction.
AST and LDH
-  Increased in MI
-  Low specificity
BNP
-  Secreted in response to stretch.
-  Increased in MI, CHF, AF, PE, COPD
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26
Q

SVT: Types & management

A

Types:

  • Sinus tachycardia
  • AFib
  • A-flutter
  • Multifocal atrial tachycardia
  • AVNRT
  • AVRT (seen in WPW)
  • Paroxysmal atrial tachy

Management:
- ABC’s
- High flow oxygen
- Determine if rhythm is regular
- Irregular - treat as AFib - RACE
- Regular
1. Vagal manoeuvers - carotid massage,
valsalva.
2. Adenosine - 6mg bolus IV - followed
by 12mg bolus IV - another 12mg if
nec.
3. If adenosine doesn’t work - assess if
patient is stable.
4. Unstable - sedate - synchronized DC
CV 100J - 200J, 360J. Or Amiodarone
300mg IV over 20-60min.
5. Stable - try metoprolol, verapamil, etc.
6. If all above fails - DC cardioversion.

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27
Q

Ventricular tachycardia: Types & management

A 
Types:
-  VT
-  Torsades 
-  SVT with abberant conduction.
-  AV conduction through bypass tract  
   (WPW).
Management:
1.  Unstable:  
     -  Synchronized DC shock = 100J - 
        360J- 360J.
     -  Amiodarone 300mg IV over 20 to 
        60min - followed by 900mg over 24hrs.
  1. Stable:
    • Reg rhythm: Amiodarone (as above)
    • Irreg: Synchronized DC shock
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28
Q

A-Fib: Management

A 
RACE
1.  Rate control
     -  BB, diltiazem, verapamil.
     -  In patients with HF give digoxin, 
        amiodarone.
  1. Anticoagulate
    • Assess stroke risk with CHADS2.
    • No risk = Aspirin 81-325mg
    • 1 RF = aspirin or warfarin
    • > 1 RF = warfarin
  2. Cardiovert
    • AF < 48hrs CV without anticoag.
    • AF > 48hrs anticoag for 3wk before
      and 4wk after.
    • If patient unstable cardiovert after ruling
      out atrial clot with TEE
  3. Etiology
    • HTN, CAD, valvular disease,
      pericarditis, cardiomyopathy, PE,
      COPD, thyrotoxicosis, SSS, alcohol,
      lone AFib.

Newly discovered AF

  1. Rate control + anticoagulate
  2. Cardiovert
Recurrent/Permanent AF
1.  Rate control + anticoag.
2.  If symptoms are bothersome or 
     episodes prolonged use anti-arrythmic
     -  No heart diseae = flecainide
     -  Heart disease = amiodarone, BB.
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29
Q

Ventricular fibrillation: management

A

ACLS

Defibrillation

30
Q

WPW: management

A

Electrocardioversion
IV procainamide
IV amiodarone
Avoid BB, CCB, digitalis

31
Q

Torsades: management

A

Mg++
Temporary pacing
Electrical cardioversion if unstable

32
Q

Pulmonary edema: Treatment

A

LMNOPP
Lasix - Furosemide 40-500mg IV
Morphine - 2-5mg IV (decreases anxiety and venodilation = decreases preload)
Nitroglyceran - IV/SL
Oxygen
Posture -sit patient upright
Positive pressure ventilation - CPAP, BiPap = decreases preload and need for ventilation.

33
Q

Acute coronary syndrome: Risk factors

A

Non-modifiable risk factors:
- Age, male gender, family hx.

Modifiable risk factors (6):

  • Smoking
  • HTN
  • Hyperlipedemia
  • Obesity
  • DM
  • Sedentary lifestyle

Controversial risk factors:

  • Stress
  • Type A personality
  • Apoprotein A increase
  • Increased fibrinogen levels
  • Hyperinsulinemia
  • Elevated homocysteine levels
  • Cocaine use
34
Q

Criteria for diagnosing STEMI

A

ECG changes plus symptoms or elevated cardiac markers.

ECG changes:
- ST elevation > 2mm in 2 or more chest
leads.
- ST elevation > 1mm in 2 more more limb
leads.
- Posterior infarction = dominant R waves +
ST depression in V1-3.
- New onset LBBB.

35
Q

Reperfusion in STEMI

A
  1. PCI
    • Treatment of choice in STEMI.
    • If within 90min of patient arriving to
      hospital.
    • Most beneficial if carried out within
      24hrs from onset of symptoms.
  2. Thrombolytic therapy
    • Administered if symptom onset is
      within 12 hours.
    • Door to needle time < 30min.
    • Do rescue PCI in patients who do not
      respond.
    • Example: Streptokinase, Alteplase.
36
Q

Management of STEMI

A

Goal is to reperfus artery: thrombolysis
within 30 minutes or primary PCI within
90 minutes.

Acute management:
-  ABC's
-  Attache ECG record 12 leads
-  High flow oxygen (caution in COPD)
-  IV access
-  Bloods for FBC, U&E, cardiac marker, 
   glucose, lipids.

MONA:

  • Morphine 5-10mg IV
  • Oxygen
  • Nitrate GTN SL 2 puffs or 1 tablet prn
  • Aspirin 300mg

Thrombolysis:
- Streptokinase: 1.5million units in 100mL
0.9% saline IV over 1 hour.
- Alteplase: given as 2 IV boluses 2hrs
apart followed by heparin.

PCI:
- First choice if can be done within 90 mins
from admission.
- Start ASA, heparin.
- Start Gp IIb/IIIa (abciximab).
- Following stent placement give ASA and
clopidogrel for 12mo.

Additional medication to start:
- Atenolol 5mg IV (unless asthma, COPD,
LVF, bradycardia).
- Start ACEI in normotensive patient
(systolic > 120mmHG) within 24 hours =
Lisinopril 2.5mg

37
Q

Contraindications to thrombolysis

A

Absolute CI

  • Internal or heavy vaginal bleeding
  • Acute pancreatitis
  • Active lung disease with cavitation
  • Recent trauma or surgery < 2 wks
  • Severe HNT > 200/120mmHg
  • Suspected aortic dissection
  • Recent hemorrhagic stroke
  • Esophageal varices
  • Cerebral neoplasms

Relative CI:

  • HTN
  • Peptic ulcer
  • History of CVA
  • Bleeding
  • Recent delivery
  • Anticoagulants
  • SBE
  • Prolonged CPR
38
Q

PCI; Explain procedure and risks

A
  • Percutaneous coronary intervention also
    known as coronary angioplasty is a non
    surgical procedure to treat
    stenotic/narrowed blood vessels in the
    heart.
  • The procedure involves feeding a deflated
    balloon via a catheter through the femoral
    or radial artery all the way up to your
    heart.
  • XRY imaging is used to see the
    balloon.
  • At the blockage site the balloon is
    inflated and a stent is put in place.
  • The patient is awake for the procedure.

Risks:

  • Chest discomfort during procedure.
  • Bleeding from the site of insertion.
  • Bruising
  • Hematoma
  • Pseudoaneurysm
  • Infection at puncture site
  • Allergic reaction to dye.
  • Kidney failure

Serious complications:

  • Emergency CABG < 3%
  • Death < 0.5%
  • Stroke 1/1000
  • VF
  • MI 0.3%
  • Restenosis 20-30% in 6 months
39
Q

Definition: Unstable angina vs. NSTEMI

A

Unstable angina
- Chest pain that is new, accelerating or
occurs at rest.
- It signifies plaque instability and possible
impending infarction.

NSTEMI:
- Indicates myocardial necrosis with
elevation in cardiac markers.
- Defined clinically by 2/3 below
1. Symptoms of angina/ischemia
2. Rise/fall of markers of myocardial
necrosis
3. Evolution of ischemic ECG changes
without ST elevation or new LBBB.

40
Q

Management of NSTEMI / Unstable Angina

A

Basic principals

  • ABC’s
  • Admit to CCU for close monitoring.
  • Identify and modify risk factors
BEMOAN:  Acute management
-  BB:  Metoprolol 50-100mg/8hr po
           Atenolol 5-100mg/24hrs po
-  If BB CI give CCB:
           Verapamil 80-120mg/8hr po
           Diltiazem 6-120mg/8hr po
  • Enoxaparin (LMWH) 1mg/kg/12hr sc
  • LMWH preferred except in renal failure or
    if CABG planned within 24hrs.
  • Alternative: UFH 5000U IV bolus
  • Morphine 5-10mg IV
  • Oxygen high flow by face mask
  • Aspirin 300 mg po
  • Nitrates
    GTN spray or sL tablets prn
    Titrate to pain
    Maintain systolic BP > 100

High risk patients:
- Persistent or recurrent ischemia despite
therapy.
- Give clopidogrel 300mg loading dose,
then 75mg QD.
- Arrange urgent angiogram with intention
of performing angioplasty or CABG.

Low risk patients:
-  Pain resolving, normal ECG, neg 
   troponin.
-  May be DC if repeat troponin is neg at 
   12hrs
-  Treat medically.
-  Predischarge exercise test.  No signs of 
   ischemia = DC; signs of ischemia = 
   angiogram.
41
Q

CABG versus PCI

A

CABG:
- Performed in left main stem disease,
triple-vessel disease, patients unsuitable
for angioplasty, failed angioplasty,
refractory angina.
- When CABG and PCI are both valid,
NICE guidelines recommends PCI.
- Patients with single vessel disease +
normal LV function undergo PCI.
- Patients with triple vessel disease +
abnormal LV function = CABG.
- Studies have shown same outcomes with
both procedures.
- CABG probably gives better long term
relief of stenosis but is associated with
increased risk of stroke & longer hospital
stays.

42
Q

Thrombolysis complications

A
  • Bleeding 10%
  • Hypotension
  • Allergic reaction
  • Intracranial hemorrhage 0.3% with SK,
    1. 6% with rt-PA.
  • Reperfusion arrythmia.
  • Systemic embolization.
43
Q

Pericardial effusion: Causes, Sign & symptoms

A 
Types:
1. Transudate/Serous - CHF, 
    hypoalbuminemia, hypothyroidism.
2. Exudate/Bloody/Serosanguinous - 
    trauma, post-MI, myocardial rupture, AD.

Signs & symptoms:

  • Symptoms similar to acute pericarditis.
  • Dyspnea, cough
  • Recurrent laryngeal nerve irritation.
  • Raised JVP
  • Decreased PP
  • Distant heart sounds +/- rub.
44
Q

Classic 4 signs of cardiac tamponade

A
  1. Hypotension
  2. Increased JVP
  3. Tachy
  4. Pulsus paradoxus.
45
Q

Beck’s triad

A

Cardiac tamponade

  1. Hypotension
  2. Increased JVP
  3. Muffled heart sounds
46
Q

DDx of Pulsus paradoxus

A

Inspiratory fall in systolic BP > 10mmHg during quite breathing.

Occurs in:

  • Constrictive pericarditis/tamponade
  • Obstructive lung disease = asthma
  • Tension pneumo
  • PE
  • Cardiogenic shock
47
Q

Causes of Mitral Regurgitation

A
  • Post MI due to papillary muscle rupture.
  • HOCM
  • Marfans
  • Ehler Danlos
  • Osteogenesis imperfecta
  • Dilated cardiomyopathy caused by
    alcohol
  • Rheumatic fever.
48
Q

Mitral stenosis: Cause, signs & symptoms, treatment

A

Causes:

  • RF #1
  • Calcification of mitral leaflets
  • Rheumatoid arthritis
  • SLE
  • Malignant carcinoid
  • Congenital stenosis.
Signs:
-  SOB, orthopnea, palpitations.
-  Malar flush
-  Tapping apex beat
-  Loud first heart sound
-  Left parasternal heave = RVH
-  Murmur:  low pitched mid diastolic 
   murmur heard best in left lateral position    
   on expiration with bell.
Symptoms:
-  Dyspnea
-  Fatigue / weakness = due to decreased 
   CO.
-  Malar fush
-  Dysphagia = if LA gets large enough.

Treatment:
- Asymptomatic - just prophylaxis against
endocarditis.
- Mild symp: diuretics
- A-fib = rate control + anticoag.
- Balloon valvotomy/valvuoplasty.
- Complete valve replacement in patients
who are not good candidates for valve
repair or with severe MR + PHTN.

49
Q

Types of pulses and the associated conditions

A

Collapsing pulse:

  • Aortic regurgitation
  • PDA
  • AV fistula

Paradoxical pulse:

  • Cardiac tamponade
  • Left ventricular compression
  • Pericarditis
  • Severe asthma

Pulsus alterans: alternating strong & weak
- Severe heart failure

Slow rising pulse
- Mild to moderate aortic stenosis

50
Q

Causes of wide pulse pressure

A
  • Aortic regurgitation
  • PDA
  • AVF
  • Thyrotoxicosis
  • Fever
  • Anemia
  • Pregnancy
  • Anxiety
  • Heart block
  • Aortic dissection
  • Endocarditis
  • Raised intracranial pressure
51
Q

Constrictive pericarditis: SIGNS

A
  • Raised JVP
  • Kussmaul sign = increased JVP on
    inspiration.
  • Paradoxical pulse in 1/3 of patients
  • Pericardial knock = 3rd heart sound
  • Signs of right heart failure =
    hepatosplenomegaly, ascites.
  • Pericardial calcification
52
Q

Third heart sound: Causes

A

Definition:
- Low pitched diastolic sound - heart at the
left sternal edge.
- Usually associated with abnormal filling in
a dilated heart.

Causes:
- Normal in children, anemia, pregnancy.
- LVF
- MR, AR = due to ventricular dilation.
- Constrictive pericarditis but not heard in
uncomplicated pericarditis.

53
Q

A-Fib: Recognized causes

A
  • Ischemia
  • Hypertension
  • Rheumatic heart disease
  • Mitral valve disease
  • Heart muscle disorders = alcoholic,
    idiopathic cardiomyopathy.
  • Diabetes

NOTE:
Aortic stenosis is not a direct cause of A-Fib.

54
Q

Benzafibrate

A

Used to lower triglycerides

55
Q

Ezetimibe

A

Second line agent for hyperlipidemia

56
Q

ECG diagnostic features of acute MI

A
  1. ST segment elevation of at least 1mm in
    two adjacent limb leads.
  2. ST segment elevation of at least 2mm in
    two adjacent precordial leads.
  3. New LBBB
57
Q

Conditions known to be associated with aortic regurgitation

A
  • Ulcerative colitis
  • Ankylosing spondylitis
  • Rheumatoid arthritis
  • VSD
58
Q

Causes of load first heart sound

A
  • Thin person
  • Hyperdynamic circulation = anemia,
    thyrotoxicosis.
  • Mitral stenosis
  • Short PR interval
59
Q

Canon waves

A 
Cause:
-  Occurs when right atrium contracts 
   against a closed tricuspid valve.
-  Same timing as A-wave
Seen in:
-  Complete heart block; not 2nd degree HB
60
Q

Mid-diastolic murmur

A
  • Mitral stenosis
  • Tricuspid stenosis
  • Austin flint murmur
61
Q

Early diastolic murmur

A
  • Aortic regurgitation
  • Pulmonary regurgitation
  • Graham steel = due to pulm reg in PHTN.
62
Q

Ejection systolic murmur

A
  • Aortic stenosis
  • Pulmonary stenosis
  • ASD
  • HCM
  • Fallot of tetralogy
  • Flow murmurs from AR or PR
63
Q

Pansystolic murmur

A
  • Mitral regurgitation
  • Tricuspid regurgitation
  • VSD
64
Q

Late systolic murmur

A
  • HOCM = loudest on standing
  • Mitral valve prolapse
  • CoA
65
Q

Down syndrome is associated with what heart defect?

A
  • ASD
  • TofF
  • PDA
66
Q

Marfans is associated with what heart defect?

A
  • Aortic regurgitation
  • VSD
  • ASD
67
Q

Features of tetralogy of fallot

A
  1. Overriding aorta
  2. RVH
  3. Pulmonary stenosis
  4. VSD
68
Q

Placement of ECG leads

A

Yellow - Left arm
Green - Left leg
Red - right arm
Black - right leg = earth

V1 - 4th ICS right sternal boarder
V2 - 4th ICS left sternal boarder
V3 - 1/2 way between V3 and V4
V4 - Apex beat
V5 - Same plane as V4; AAL 
V6 - Same plane as V4; MAL
69
Q

Collapsing pulse

A

Definition:
- Large volume pulse with brisk rise and
fall.

Associated with:
- High cardiac output states.
- Anemia, thyrotoxicosis, aortic
regurgitation, PDA.

70
Q

Complications of coronary angiography

A
  • Mortality rate of 0.2%
  • Complications increase with severity of
    symptoms.
  • 0.1% risk of stroke.
  • 0.2% risk of MI
  • Femoral access injury > radial

Medicine (6 decks)

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