Cardio Flashcards
JVP: Location & features
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.
JVP Wave form
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 = TSInferior MI
Leads II, III, aVF
Anteroseptal MI
Leads V1-4
Anterolateral MI
Leads V4-6, I, aVL
Posterior MI
Tall R waves
ST depression in V1-2
ECG findings in pulmonary embolism
Sinus tachycardia RAD RBBB Right ventricular strain pattern = dominant R waves, T wave inversion/ST depression in V1 and V2 Classic pattern (rare) = S1Q3T3
Definition of ACS
Includes: unstable angina, STEMI, NSTEMI
Management of ACS with ST elevation
- 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.
Treatment of hypertension
Monotheray:
- If > 55 yrs or black of any age - CCB or thiazide.
- If < 55 yrs - ACEI is first choice; ARB if ACE CI,
- 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.
Doses of anti-hypertensive drugs
Thiazide: Chlortalidone 25-50mg
CCB: Nifedipine 30-60mg/24hrs
ACEI: Lisinopril 5-20mg/24 hr (max 40mg)
BB: Bisoprolol 2.5-5mg/24hrs
ECG Leads: Anteroseptal infarct
LAD
V1+V2
ECG Leads: Anterior infarct
LAD
V3+V4
ECG Leads: Anteriolateral
LAD artery involved
I, aVL, V3-V6
ECG Leads: Inferior infarct
RCA involved
II, III, aVF
Right ventricle
RCA involved
V3R, V4R (right sided chest leads)
ECG Leads: Posterior MI
RCA involved
V1, V2, prominent R waves
ECG Leads: Lateral MI
Circumflex artery
I, aVL, V5-V6
ECG changes: HyperK+
Mild hyperK+ (5-7mmol/L): tall peaked T waves
Severe hyperK+: P wave flattening, QRS widens.
ECG changes: HypoK+
ST segment depression
Prolonged QT interval
Prominent U waves
ECG changes: HyperCa++
Shortened QT interval
ECG changes: HypoCa++
Prolonged QT interval
Digitalis: Side effects
Palpitations Fatigue Vision changes - yellow vision Decreased appetite Hallucinations Confusion Depression
Digitalis: ECG changes
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
Cardiac biomarkers
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
SVT: Types & management
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.
Ventricular tachycardia: Types & management
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.
- Stable:
- Reg rhythm: Amiodarone (as above)
- Irreg: Synchronized DC shock
A-Fib: Management
RACE
1. Rate control
- BB, diltiazem, verapamil.
- In patients with HF give digoxin,
amiodarone.
- Anticoagulate
- Assess stroke risk with CHADS2.
- No risk = Aspirin 81-325mg
- 1 RF = aspirin or warfarin
- > 1 RF = warfarin
- 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
- Etiology
- HTN, CAD, valvular disease,
pericarditis, cardiomyopathy, PE,
COPD, thyrotoxicosis, SSS, alcohol,
lone AFib.
- HTN, CAD, valvular disease,
Newly discovered AF
- Rate control + anticoagulate
- 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.
Ventricular fibrillation: management
ACLS
Defibrillation
WPW: management
Electrocardioversion
IV procainamide
IV amiodarone
Avoid BB, CCB, digitalis
Torsades: management
Mg++
Temporary pacing
Electrical cardioversion if unstable
Pulmonary edema: Treatment
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.
Acute coronary syndrome: Risk factors
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
Criteria for diagnosing STEMI
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.
Reperfusion in STEMI
- 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.
- 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.
- Administered if symptom onset is
Management of STEMI
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
Contraindications to thrombolysis
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
PCI; Explain procedure and risks
- 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
Definition: Unstable angina vs. NSTEMI
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.
Management of NSTEMI / Unstable Angina
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.
CABG versus PCI
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.
Thrombolysis complications
- Bleeding 10%
- Hypotension
- Allergic reaction
- Intracranial hemorrhage 0.3% with SK,
- 6% with rt-PA.
- Reperfusion arrythmia.
- Systemic embolization.
Pericardial effusion: Causes, Sign & symptoms
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.
Classic 4 signs of cardiac tamponade
- Hypotension
- Increased JVP
- Tachy
- Pulsus paradoxus.
Beck’s triad
Cardiac tamponade
- Hypotension
- Increased JVP
- Muffled heart sounds
DDx of Pulsus paradoxus
Inspiratory fall in systolic BP > 10mmHg during quite breathing.
Occurs in:
- Constrictive pericarditis/tamponade
- Obstructive lung disease = asthma
- Tension pneumo
- PE
- Cardiogenic shock
Causes of Mitral Regurgitation
- Post MI due to papillary muscle rupture.
- HOCM
- Marfans
- Ehler Danlos
- Osteogenesis imperfecta
- Dilated cardiomyopathy caused by
alcohol - Rheumatic fever.
Mitral stenosis: Cause, signs & symptoms, treatment
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.
Types of pulses and the associated conditions
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
Causes of wide pulse pressure
- Aortic regurgitation
- PDA
- AVF
- Thyrotoxicosis
- Fever
- Anemia
- Pregnancy
- Anxiety
- Heart block
- Aortic dissection
- Endocarditis
- Raised intracranial pressure
Constrictive pericarditis: SIGNS
- 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
Third heart sound: Causes
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.
A-Fib: Recognized causes
- 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.
Benzafibrate
Used to lower triglycerides
Ezetimibe
Second line agent for hyperlipidemia
ECG diagnostic features of acute MI
- ST segment elevation of at least 1mm in
two adjacent limb leads. - ST segment elevation of at least 2mm in
two adjacent precordial leads. - New LBBB
Conditions known to be associated with aortic regurgitation
- Ulcerative colitis
- Ankylosing spondylitis
- Rheumatoid arthritis
- VSD
Causes of load first heart sound
- Thin person
- Hyperdynamic circulation = anemia,
thyrotoxicosis. - Mitral stenosis
- Short PR interval
Canon waves
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
Mid-diastolic murmur
- Mitral stenosis
- Tricuspid stenosis
- Austin flint murmur
Early diastolic murmur
- Aortic regurgitation
- Pulmonary regurgitation
- Graham steel = due to pulm reg in PHTN.
Ejection systolic murmur
- Aortic stenosis
- Pulmonary stenosis
- ASD
- HCM
- Fallot of tetralogy
- Flow murmurs from AR or PR
Pansystolic murmur
- Mitral regurgitation
- Tricuspid regurgitation
- VSD
Late systolic murmur
- HOCM = loudest on standing
- Mitral valve prolapse
- CoA
Down syndrome is associated with what heart defect?
- ASD
- TofF
- PDA
Marfans is associated with what heart defect?
- Aortic regurgitation
- VSD
- ASD
Features of tetralogy of fallot
- Overriding aorta
- RVH
- Pulmonary stenosis
- VSD
Placement of ECG leads
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
Collapsing pulse
Definition:
- Large volume pulse with brisk rise and
fall.
Associated with:
- High cardiac output states.
- Anemia, thyrotoxicosis, aortic
regurgitation, PDA.
Complications of coronary angiography
- 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
