Cardio Flashcards
ECG timings
PR - 0.12-0,2 secs
QRS - 0.1s
QT interval - 0.4 secs
QTc - <450ms
Causes of PR interval shortening and lengthening
• Shortening - WPW syndrome
Lengthening - beta blockers, type 1 heart block, fit pt
What is the timing of the ECG squares?
• Small square = 0.04 seconds
Large square = 0.2 seconds
State the arteries of the leads on ECG
I, aVL, V5, V6 - LCx or diagonal branch of LAD (lateral)
V1-V4 - LAD (anterior)
II, III, aVF - RCA or LCx (inferior)
Sequence of evolving MIs on ECG?
- In minutes - ST elevation and T wave bigger
- Hours - R wave begins to decrease and Q wave begins to deepen
- 1-2 days - T wave inverts and Q wave deeper.
- Days later - ST normalises
- Weeks later - normal except for Q wave persistence
How would posterior MI present on ECG?
Reciprocal changes - ST depression
ECG changes for NSTEMI?
• ST segment depression
• T wave flattening or depression
NSTEMI is more persistant than UA
How can you clinically differentiate between unstable angina and NSTEMI?
NSTEMI - ELEVATED BIOMARKERS. UA NO ELEVATION
ECG changes for pericarditis?
Widespread ST elevation with saddle back shape
ECG changes for pace makers?
paceing spikes before QRS.
ECG changes for wandering pacemeker? Patho of wandering pacemaker? Pts who get it?
• Atrial arrhythmia where cardiac pacemaker switches between SAN, atria, and AVN
• Pts with resp failure eg exacerbation of COPD
Varying PP and PR intervals. 3 distinct P wave morphologies in the same lead
Causes of long QT
• Antiarrhythmics - amiodarone, sotalol
• TCAs
• Erythromycin and azithromycin
Electrolyte - hypocalcemia, hypokalaemia, hypomagnesaemia
Patho of WPW
• Congenital accessory conducting pathway leading to atrioventricular re-entry tachycardia (AVRT)
Can degenerate rapidly to VF
ECG changes for WPW
• Short PR
Wide QRS complex with delta wave - slurred upstroke
Tx of WPW?
• Ablation of accessory pathway - definitive
Medical management - sotalol (avoid if AF), amiodarone, flecainide
Hypokalaemia on ECG?
- U waves
- Small or absent T waves
- Prolonged PR interval
- ST depression
- Long QT
“In hypokalaemia, U have no Pot and no T, but a long PR and a long QT”
Hyperkalaemia on ECG?
- Flattened P waves
- Widened QRS
- Tall tented T waves
ECG changes for hypothermia?
- Bradycardia
* J wave - size of wave is proportional to hypothermia
ECG changes for digoxin?
- Downsloping ST depression
- Flattened, inverted or biphasic T waves
- Shortened QT
Acute tx for STEMI?
Acute Treatment (MONA):
• M - Morphine + metoclopramide
• O - Oxygen (if O2 <94%)
• N - Nitrates (if hemocompromised DO NOT USE)
• A - Antiplatelets (aspirin + prasugrel)
Is PCI available within 120 mins?
a. Yes - pci
No- Fibrinolysis (tPA) with rescue PCI if not successful
ECG indications for PCI for STEMI
• ST elevation of >2mm in V1-V6 OR
• ST elevation of >1mm in inferior leads OR
New left bundle branch block
Post MI tx?
• Lifelong therapy of: ○ Aspirin ○ Antiplatelet eg clopidogrel ○ Beta blocker ○ ACEi ○ Statin • Lifestyle advice: ○ Mediterranean diet ○ Exercise - until slight breathlessness
PCI contraindications?
• Due to antiplatelets • High risk of bleeding • Allergy • Uncontrolled HT • Stroke Bleeding disorders
Acute tx of NSTEMI?
- Morphine +anti emetic (metoclopromide) + GTN (don’t use if hemocompromised)
- Antiplatelets - aspirin (300mg PO) + clopidogrel
- Beta blockers to limit ischemia (metoprolol) or verapamil if contra
- Fondaparindux to disrupt thrombus
- IV nitrate if pain continues
- Record ECG and stratify risk using GRACE + TIMI
a. High risk - infusion of GPIIb/IIIa antagonist + angiography referral
b. Low risk - Treat medically and arrange further investigation eg stress test
Pathology of STEMI/atheroma?
- Initial endothelial damage caused by smoking, HT, or hyperglycemia etc
- Results in inflammation and oxidative damage
- LDL particles infiltrate subendothelial space
- Macrophages infiltrate and phagocytose LDL and turn into foam cells. Macrophages die and propagate inflammation
Smooth muscle proliferation and migration into tunica intima results in formation of fibrous capsule covering fatty plaque
IHD RFs modifiable and non modifiable
HOPEFULS H - HTN O - Obesity P - PVD E - Elevated LDL F - FHx U - Up glucose (DM) L - Low HDL S - Smoking, Sex (male), Sedentary
S&S of ACS
Chest pain: • Typically central or left sided • May Radiate to jaw or left arm • Described as heavy or constricting Certain pts eg elderly or diabetics may experience no CP
Other symptoms:
• Dyspnoea
• Sweating
N&V
Examination:
• Cold and Clammy
All life signs may be normal
Diagnostic criteria for ACS?
2 of 3 needed:
• Clinical history
• ECG changes
Blood results
Ix for ACS?
ECG
Bloods - troponin
S&S of stable angina
• Chest pain on exertion
Relieved by rest or GTN spray
What must you remember about CCBs and why?
NEVER EVER MIX 2 TYPES OF CCB - causes complete heartblock
Ix for stable angina?
• ECG Exercise tolerance test shows:
ST depression
Tx for stable angina?
1st line - bisoprolol + aspirin + statin + glyceryl nitrate
2nd line - + CCB (nifedipine, amlodopine)
3rd line - + long acting nitrate or ivabradine
4th line - ? PCI or CABG
S&S of unstable angina
• Pain on exertion NOT relieved by rest
NO elevated serum biomarkers
Complications of MI?
- Cardiac arrest following V fib
- Cardiogenic shock
- Chronic heart failure
Arrhythmias
Qs to ask for cardiac history
• Chest pain - Does it hurt to touch? MSK likely.
• SOB
• Dizziness and syncope?
• Palpitations - abnormality in heartbeat causes conscious awareness
• Orthopnoea or PND?
Peripheral oedema
S&S of pericarditis pain
Sharp pain relieved by sitting forwards.
S&S of dissecting aortic aneurysm pain
Tearing chest pain radiating to back
Unequal upper limb blood pressure
Angina S&S and features of typical + atypical angina
Angina symptoms:
• Constricting Discomfort in front of chest, neck, shoulders, jaw or arms
• Precipitated by exercise
• Relived with rest or GTN in about 5 mins
All 3 features is typical angina. 2 features is atypical. 1 or less is non angina.
Chest pain referral criteria
• Current CP in past 12 hrs with abnormal ECG - Emergency admission
• CP 12-72 hrs ago - Refer to hospital for same day assessment
CP >72 hrs ago - ECG and troponin then assess
Signs of CVS instability?
• Pulmonary oedema
• Angina
Decrease BP
Investigation to be done for all possible cardiac problems?
TFT
Patho of S3 and S4?
S3 - • Caused by stiff or dilated ventricle which reaches sudden elastic limit and decelerates rush of blood,
S4 - • Atrial contraction into a non-compliant or hypertrophied ventricle
Where do the 4 common left murmurs radiate to?
• Aortic stenosis - to carotids
• Aortic regurg - 3rd ICS on left on expiration with pt leaning forward
• Mitral regurg - Left axilla
Mitral stenosis - little radiation
Classification of HF
Class I - no limitations
Class II - slight limitations
Class III - Marked limitations
Class IV - Symptoms at rest
S&S of HF
Pulmonary oedema, ankle swelling, exercise intolerance, raised JVP, PND, cardiomegaly
LT pharm tx of HF
1st line - ACEi + BB
2nd line - + Aldost antag OR +ARB +Hydralazine with nitrate
3rd line - +digoxin OR + ivabradine
Fluid overload - furosemide
Which drugs improve mortality and which only improve symptoms in HF?
Drugs which improve symptoms ONLY:
• Loop diuretics eg furosemide
Digoxin
Drugs which improve mortality in HF: • ACEi • Spironolactone • Beta blockers Hydralazine with nitrates
Non pharm tx of HF
Non drug management: • Cardiac resynchronisation therapy: ○ If HF and wide QRS ○ Biventricular pacing • Exercise training improves symptoms • Annual flu vaccine One off pneumococcal vaccine - if asplenic or CKD need booster every 5 yrs
S&S of acute HF
Symptoms:
• Dyspnoea
• Orthopnoea
Pink frothy sputum
Ix for acute HF
• CXR - ABCDE BNP • ECG - Signs of MI, arrhythmias • U&E, troponin, ABG Echo
Tx of acute HF
- Sit pt upright
- 100% oxygen non rebreath mask
- IV access and ECG. Treat arrhythmias
- Investigations whilst continuing treatment
- Diamorphine IV 1.25-5mg
- Furosemide 40-80mg IV
- GTN spray 2 puffs. DON’T GIVE IF HEMOCOMPROMISED
- If systolic >100mmHg, nitrate infusion eg isosorbide dinitrate
- If pt worsening, consider CPAP
Consider discontinuation of beta blockers in short term.
Ix for HF
Echo
Bloods - BNP, U&E, FBC to find underlying cause
CXR
LOOK FOR CAUSE OF HF.
Causes of HF cardiac and extra cardiac
Causes of HF:
1. Cardiac - IHD, congenital, valvular disease, cardiomyopathies
Extra Cardiac - HTN, pulmonary, iatrogenic
AF Tx
Rate control for older than 65 or history of IHD
Everything else rhythm control.
Rate control - atenolol, diltiazem or verapamil, or digoxin (if HF coexistant)
Rhythm control - if pt hemo stable:
• Flecainide - Flecainide if no structural heart disease
• Amiodarone - AMIODARONE ONLY THROUGH CENTRAL LINE
Sotalol
If pt not hemostable:
• Electrical cardioversion.
Give midazolam for sedation before shocking.
What is CHADSVASC?
Risk factor Points C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female) 1
What is HAS-BLED
Risk factor Points H Hypertension, uncontrolled 1 A Abnormal renal function 1 Or Abnormal liver function 1 S Stroke, history of 1 B Bleeding, history of bleeding 1 L Labile INRs 1 E Elderly (> 65 years) 1 D Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) 1 for drugs Or Alcohol Use (>8 drinks/week) 1 for alcohol
3+ = high risk
Diagnosing HTN?
If a clinic reading is >140/90mmHg, repeat. If still above:
• Offer ABPM - ambulatory blood pressure monitoring, or HBPM
When to treat HTN
○ If >135/85 mmHg - treat if <80 yo AND: § Organ damage § Established CVD § Renal disease § Diabetic § 10 yr CV risk of 20+% ○ If >150/95 mmHg - treat regardless
Tx of HTN?
If below 55:
1st line - ramipril
2nd line - ramipril + diltiazem
3rd line - + thiazide diuretic (indapamide)
4th line - K less 4.5 mmol add spiro if more increase dose thiazide diuretic
If above 55 or black:
1st line - diltiazem and then continue as usual
Consequences of HTN
• Increased risk of MI + Stroke • Aneurysms • HF • Retinopathy Nephropathy
Lifestyle advice for HTn
• Low salt diet - <6g/day
• Caffeine intake reduce
Stop smoking, less alcohol, balanced diet, exercise, lose weight
S&S of malignant HTN
• Headache
• +/- visual disturbance
Underlying causes may be present eg pain
Tx of malignant HTN
• Use oral therapy with short half life so you can monitor the drop in BP without taking ages
Reduce BP by not more than 25% to avoid stroke risk
Signs of hypertensive retinopathy?
Graded:
1. Tortuous arteries with thick shiny walls - copper wiring 2. A-V nipping (narrowing where arteries cross veins) 3. Flame haemorrhages and cotton wool spots 4. Papilloedema
After how many weeks gestation is pre eclampsia seen
20
Tx of pre-eclampsia
• Treat if above 160/110 mmHg
• Oral labetalol first line. Nifedipine and hydralazine may also be used
Delivery of baby is definitive step if gestation allows.
RFs for pre-eclampsia
• >40 yrs old • Multiple pregnancy • Fat • T2DM • FHx Pre-existing vascular disease eg htn
S&S of severe pre-eclampsia
• Hypertension above 170 systolic • Headache • Visual disturbance • Papilloedema • RUQ pain • Hyperreflexia Low platelet count
How many korotkov sounds are there
5
RFs for infective endocarditis
• Previous episode of endocarditis (strongest) • Rheumatic valve disease • IVDU • Immunocompromised • Congenital heart defects Prosthetic valve
S&S of IE
• Fever + New murmur = Endocarditis until proven otherwise
• Sepsis - fever, rigors, night sweats, malaise, weight loss
• Look at hands - janeway lesions (painless), oslers node (painful), splinter hemorrhages, clubbing
IE can cause emboli to occur anywhere in body. Janeway lesions and oslers nodes are emboli in the skin
MOs causing IE. What are they each associated with?
- Strep viridans - 50% cause - Usually following dental procedure or poor dental hygiene
- Staph epidermis - especially prosthetic
- Staph aureus - IVDUs, acute presentation
- Strep bovis - associated with colorectal cancer. MUST UNDERGO COLONOSCOPY FOR MALIGNANCY
S&S of aortic stenosis
• Exertional Syncope - Most severe symptom.
• Chest pain/Angina
SOB
ESM radiating to neck
Causes of aortic stenosis
- Degenerative calcification - most common if pt >65
* Bicuspid aortic valve - most common if pt <65
Tx of aortic stenosis
• If asymptomatic + valvular gradient <50mmHg - observe
• Asymptomatic but valvular gradient >50mmHg AND features eg LV systolic dysfunction consider surgery
If symptomatic - valve replacement
Pros/cons of mechanical or biological valve replacement?
• Biological - LT Anticoag not needed. Deteriorates faster
Mechanical - Need LT anticoag. Lasts longer
signs of severe aortic stenosis?
Signs of severe stenosis: • Narrow pulse pressure - small difference in pressures • Delayed ESM • Delayed radial pulse • Soft or absent S2 LVH or failure
Mitral regurg features
• Pan systolic murmur
• Soft S1, split S2
Mitral area/apex heard. Radiation to L axilla
Causes of mitral regurg
• Calcification
Endocarditis
Mitral stenosis causes
Rheumatic fever
Ix for mitral stenosis
echo
CXR - atrial enlargement
Symptoms of mitral stenosis
• SOBOE progressing to SOB at rest
PND with severe MS
Features of mitral stenosis
• Mid-late diastolic murmur louder expiration. Roll pt to their left and use the bell of the steth • Loud S1 • Low volume pulse • Malar flush AF
features of aortic regurge
• Early diastolic murmur - ‘blowing murmur’. Heard best when pt upright on expiration.
• Collapsing pulse
• Wide pulse pressure - big difference in pressures. Results in multiple signs:
○ Double impulse pulse
○ De Musset sign - head bobbing with each systole
○ Quicke sign - capillary pulsation visible at proximal nail beds
Aortic regurg causes
Valve disease causes: • Rheumatic fever • Infective endocarditis • Connective tissue disease eg RA/SLE Bicuspid aortic valve
Aortic root causes:
• Aortic dissection
• HTN
Marfans
S&S of cardiac tamponade
• Beck’s triad:
○ Low arterial BP
○ Distended neck veins - raised JVP with an abscent Y descent
○ Distant muffled heart sounds
• Tachycardia
• Pulsus Paradoxus (large fall in systolic BP on inspiration, due to additional pressure on heart)
Tx of cardiac tamponade
Pericardiocentesis under USS. Subxiphoid approach
Causes of pericardial effusion
• Infectious pericarditis • Uraemia • Post MI • Malignancy HF
S&S of pericarditis
- Chest pain may be pleuritic. Relieved by sitting forwards
- Dyspnoea
- Pericardial rub
- Non productive cough
- Tachypnoea and tachycardia
Causes of pericarditis
• Viral infections (coxsackie) • TB • Uraemia • Trauma Post MI
RFs for aortic dissection
- Hypertension
- Trauma
- Bicuspid aortic valve
- Collagen deficiency - marfans, ehlers danlos
Classify aortic dissection
- Type A - Ascending aorta, 2/3rd of cases
* Type B - descending aorta
Tx of aortic dissection
• Type A - Surgery (aortic root replacement), reduce BP
Type B - Conservative, bed rest, reduce BP
Ix for aortic dissection
• CXR - widened mediastinum, abnormal aortic knob, tracheal and oesophageal deviation
• CT angiography of thoracic aorta
MRI angiography
MO for rheumatic fever?
group a strep
What are the 2 types of CCB and give egs
Non-dihydropyridines - verapamil, diltiazem. Selective for myocardium
Dihydropyridines - nifedipine, amlodopine, felodopine. Non selective
How to treat non hemo compromised broad complex tachy peri-arrests
• Loading dose amiodarone followed by 24 hr infusion
IF torsades de pointes - magnesium IV
How to treat non hemocompromised narrow complex tachy peri arrests
• Use vagal maneouvre. Eg valsalva maneouvre
• If doesn’t work use IV adenosine (contra in asthmatics, use verapamil instead)
Electrical cardioversion
How to treat hemocompromised peri arrests if tachy or brady
Tachy - immediate synced DC cardioversion and thromboprophylaxis
Brady - atropine first line. Transvenous pacing second line.
Asystole Tx?
Transvenous pacing.
If there is a delay of transvenous pacing, administer:
• Atropine up to 3mg
• Transcutaneous pacing
Adrenaline titrated to response
Tx of TCA overdose
• IV bicarb
IV lipid emulsion
Describe JVP waveform
A - Atrial contraction C - RV Contraction. Tricuspid bulges into atria X - atrial relaXation and filling V - Venous filling Y - passive emptYing of atria into RV.
Define broad QRS. Patho of broad QRS?
QRS more than 160ms
• Re-entry caused by a blocked/slowed pathway resulting in a loop. Commonly after MI. Abnormal conduction caused by medication eg digoxin or abnormalities eg torsades and Mg.
Causes of VF
• MI
• Electrolyte abnormalities
• Cardiomyopathy
Long QT –> TdP –> VF
Tx of VF
IMMEDIATE DC SHOCK UNSYNCHRONISED (synchronised wont work as there isnt a rhythm to sync to so the machine will waste time trying to find a rhythm before delivering a shock).
S&S of AVNRT
- Sudden onset rapid regular palpitations
* Well tolerated and rarely life threatening
Tx of AVNRT
- Valsalva maneouvre
Adenosine
ECG changes of AVNRT
• P waves present BUT buried in QRS complex.
REGULAR RHYTHM
Tx of AVN block
Atropine A1 agonist
Give cyanotic congenital heart disease
TTT
Tricuspid atresia
Transposition of great arteries
Tetralogy of Fallot
Pattern of inheritance for HOCM?
Auto dom
Patho of HOCM?
- Common defect is gene encoding beta-myosin or myosin binding protein C
- 1 in 500
ECG changes of HOCM
• LVH
• Progressive T wave inversion
Deep Q waves
Echo changes of HOCM?
Echocardiogram - MR SAM ASH:
• Mitral Regurg
• Systolic Anterior Motion of anterior mitral valve leaflet
• Asymmetric Hypertrophy
S&S of HOCM?
• Young person presenting with unusual collapse or sudden death
• Often asymptomatic
• Dyspnoea, angina, syncope
• Double apex beat, jerky pulse, large ‘a’ waves
• Ejection systolic murmur which increases with Valsalva manoeuvre
Associated with WPW and friedrichs ataxia
Patho of aneurysm
• Dilatation of all layers of arterial wall
• Caused by degenerative disease
Dilatation of 50+% is aneurysm
S&S of aneurysm
• Silent. MAY cause abdo/back pain
Can burst leading to shock - hypovolemic
Ix of anuerysm
Investigations:
• USS - first line
CT with contrast
Common sites of anuerysms
• Aorta
• Iliac
• Femoral
Popliteal
