Cardio Flashcards
What is unstable angina?
Cardiac chest pain, with or without ECG changes in the absence of biochemical markers of cardiac damage.
How is ACS diagnosed
Dependant on cardiac symptoms of chest pain with ECG changed and serial rises in troponin.
Definition of STEMI?
persistent ST-segment elevation in 2 or more anatomically contiguous ECG leads
When to offer fibrinolysis?
Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.
When to give PCI?
presentation is within 12 hours of onset of symptoms and primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
Size of ST elevation?
≥1 mm (limb leads) ≥ 2mm (chest leads)
ECG changes in leads V1-V4? Where and which artery?
Anteroseptal- LAD
ECG changes in leads II, III,aVF? Where and which artery?
Inferior- Right coronary
ECG changes in leads V4-6 I and aVL? Where and which artery?
Anterolateral LAD or Left circumflex
ECG changes in leads I, aVL +/- V5-6? Where and which artery?
Lateral, Left circumflex
Tall R waves in V1 and V2 may point to an MI where? Which artery?
Posterior, usually left circumflex but may be right
Saddle shaped St elevation often seen in which condition?
Pericarditis
Posterior Mi causes what with St segments?
Depression not elevation
For a person < 80, with stage 1 hypertension, only treat medically if?
diabetic, renal disease, QRISK2 >20%, established coronary vascular disease, or end organ damage
A third heart sound is one of the possible features of ?
LVHF
Aortic stenosis - most common cause: Young and old?
younger patients < 65 years: bicuspid aortic valve older patients > 65 years: calcification
How might ACS present in females and or diabetics?
Atypical, often vague, silent or abdo pain
What is kussumauls sign?
In constrictive pericarditis, the JVP will rise on inspiration
If patient is intolerant of ACEi give what?
ARB
In diagnosis of hypertension NICE now recommends?
24 hr BP
Breathing problems with clear chest?
Think PE
To cardiovert AF patients must be what?
Anticoagulated or symptoms <48hrs
Which cardiac drug can reduce awareness of hypoglycaemia?
B-Blockers
Acute mitral regurgitation may be caused by?
Rupture of papillary muscle
ACS: Nitrates are contraindicated in patients with ?
Hypotension <90mmHg
Cardiac asthma refers to?
Wheeze in heart failure
Drug that may cause gout also sues for HF?
Thiazides
Suspected PE with a Wells PE score ≤4 next investigation?
D-dimer
When is digoxin a preferred treatment for AF rate control?
Co-existent HF
What is the evidence for diuretics in HF? (furosemide/indapamide)
Only improve symptoms not mortality
Drugs shown to improve mortality in HF?
ACE inhibitors spironolactone beta-blockers hydralazine with nitrates
Third heart sound in <30?
Normal
10 year CV risk >10% offer?
Atorvastatin 20mg od
Known ischaemic heart disease or cerebrovascular disease PVD offer what statin dose?
Atorvastatin 80mg od
Type 1 diabetics over 40 nephropathy or diagnosed greater than 10 years should be given … type 2 assessed by Qrisk
Atorvastatin 20mg od
Thiazide diuretics can cause which calcium problems?
hypercalcaemia and hypocalciuria
U waves on ECG?
↓K+
Prolonged QT abx?
Erythromycin
Provoked vs unprovoked treatment times for PE?
NICE advise extending warfarin beyond 3 months for patients with unprovoked PE. This essentially means that if there was no obvious cause or provoking factor (surgery, trauma, significant immobility)
Complete heart block following a MI?
Right coronary artery lesion
Ototoxicity with which diuretics?
Loop
Acute coronary syndrome (ACS) which is medically managed, which antiplatelet?
aspirin 75 mg daily plus ticagrelor 90 mg twice a day for 12 months
For people with ACS who are undergoing PCI
aspirin (75–100 mg) in combination with Prasugrel 10 mg daily (or 5 mg daily if the person weighs less than 60 kg, or if the person is 75 years of age or older). Ticagrelor 90 mg twice a day. Clopidogrel 75 mg daily (if prasugrel or ticagrelor are not suitable). This treatment is usually continued for up to 12 months after the procedure, then aspirin is continued alone.
Mitral valve prolapse associated with which genetic condition?
Polycystic kidneys
First line treatments in pericarditis?
Naproxen
Which aortic dissection managed medically?
Type B descending
Infective endocarditis in intravenous drug users most commonly affects
Tricuspid
Blood pressure target (> 80 years, clinic reading)
150/90 mmHg
Acute pulmonary oedema is a complication of which acute presentation?
MI
An atrial septal defect allows ?
Stroke
Tosades de pointes often seen in which H of the resuscitation H’s?
Hypothermia
Signs of right-sided heart failure?
raised JVP, ankle oedema and hepatomegaly
Sotalol is known to cause ?
long QT
Young male smoker with symptoms similar to limb ischaemia?
buergers
Alcoholics are at risk of which heart problem?
Dilated cardiomyopathy
Grey skin appearance?
Amiodarone
Post Mi driving?
4 weeks if had heart attack and no angioplasty or angioplaty unsuccesful
If had successful PCI can drive after 1 week if well
Murmur of Mitral stenosis? Eccentuated how?
Mid diastolic rumbling pateint in left lateral decubitas expiration
Murmur of mitral regurg?
Pansystolic radiates to axilla, best in left lateral position during expiration
Aortic stenosis murmur? Signs?
Ejection systolic radiates carotids sitting forward in expiration
Non-displaced, heaving apex beat
Slow rising pulse with narrow pulse pressure
Aortic regurg murmur? and associated findings?
Early diastolic murmur sit forward expire
characteristic collapsing pulse
Corrigan’s sign – visible distention and collapse of carotid arteries in the neck
De Musset’s sign – head bobbing with each heartbeat
Management of NSTEMI?
Morphine, o2 if needed nitrates, either buccal or spray. Aspirin 300mg and ticagrelor 180mg consider lmwh if cardio involved.
Management of STEMI?
Morphine, o2 if needed nitrates, either buccal or spray. Aspirin 300mg and ticagrelor 180mg (discuss cardio) LMWH Primary PCi if ongoing ischaemia within 12 hrs.
For all patients- STEMI and NSTEMI which drugs should be used?
ACEi indefinitely, BB for 12 months and consider CB if not. Aspirin plus ?ticagrelor for 12 months but aspirin continued.
Atypical MI symptoms? Who?
Dyspnoea, epigastric pain, syncope, confusion. Female, elderly diabetic
When to offer fibrinolysis?
Presents within 12hrs and PCi can not be undertaken in 2hrs. If ecg still bad after 60 mins consider PCi anyway.
>12hrs after MI but still ischaemia?
Consider PCI
T wave inversion normal where?
aVR and V1
New LBBB should be treated as?
STEMI
How long for stable angina pain to be “unstable”?
>20mins
Post MI heart failure what is used?
Aldosterone antagoinist eg: eplerenone
What is dresslers syndrome?
2-6 weeks after MI pericarditis NSAIDs used
Transmural MI can cause what?
Approx 48hrs pericarditis, typical pain and may have effusion on echo
Persistent ST elevation following MI may mean what?
Left ventricle aneurysm
1-2 weeks after MI, acute heart failure raised JVP and pulsus paradoxus?
Left ventircular free wall rupture
VSD after MI how and when?
Usually first week, pansystolic murmur, surgical correction echo needed to exclude Mitral regurg
Mitral regurg after Mi more common in which types?
Infero-posterior, early mid systolic murmur
Most common cause of death after MI?
VF
Following inferior MI which bradyarrythmia common?
AV block
Heart failure with reduced ejection fraction (HFrEF): defined as?
Heart failure with an ejection fraction less than 40%.
Most common causes of heart failure UK?
Coronary heart disease and hypertension are the most common causes of heart failure
HF symptoms?
Dyspnoea on exertion, orthopnoea, PND, Fluid rention, nocturnal cough/wheeze
HF signs?
here may be a gallop rhythm due to presence of S3 Bilateral basal end-inspiratory crackles ± wheeze (‘cardiac asthma’). Tender hepatomegaly - pulsatile in tricuspid regurgitation, with ascites. Pleural effusions.
Patients should have what measured if suspect HF?
NT-proBNP level or just BNP if not available
NT pro BNP >2000 or BNP >400?
Urgent referall for transthoracic echo (2 weeks)
NT pro BNP 400-2000 or bnp 100-400?
Echo within six weeks
Noirmal NT pro BNP <400 or bnp <100 ?
HF unlikely consider other diagnoses, or discuss with specialist if concerned.
BNP levels high in other conditions except HF?
>70, sepsis, renal problems, ischaemia, LVH diabetes COPD
Why arrange ECG in HF?
potential aetiological factors (for example, myocardial infarction or arrhythmias normal ECG makes HF very unlikely
Drugs initially offered to HF with reduced EF?
ACEi and BB, can use ARB if intolerant of ACEi Titrate BB if needed along with diuretics. Aldosterone antagonist considered in all patients.
Which B-Blockers useful in HF?
Bisop, carve and metop
CXR signs in HF?
Bat wings, Kerley B, cardiomegaly, diversion upper lobe, Plueral effusions, pulmonary oedema.
Acute treatment of pulmonary oedema?
Oxygen high flow, sit up, diuretics - Loops IV 40-80 furosemide, caution if BP low for high dose or nirates.
NYH stage 3 is?
MArked limitation of physical activity, comfortable at rest.
Right sided/cor pulmonale?
JVP↑ Weight gain, peripheral oedema, ↑↑liver and spleen, ascites
Left ventricular failure?
PND, Orthopnoea, Tachy, Pulmonary congestion, cyanosis, dyspnoea on exertion
When to start anti-HTN treatment immediately?
If BP >180/110
What is accelerated HTN?
recent increase in blood pressure to very high levels (≥180 mm Hg systolic and ≥110 mm Hg neurological (eg, encephalopathy), cardiovascular or renal damage
Malignant vs accelerated HTN
Malignant usually has pappiloedema
Causes of accelerated HTN?
Renal artery stenosis, phaeochromocytoma, vasculitis, eclampsia, Drugs/cocaine, thyroid disorder Aldosteronism
Presentation of accelerated HTN?
Headache. Fits. Nausea and vomiting. Visual disturbance. Chest pain.
Treatment accelerated HTN?
Nitroprusside is often used as an IV drug but labetolol or nicardipine are alternatives , Phentolamine for phaeochromocytomas
First line treatment angina?
Beta blocker or calcium channel blocker + GTN
Second line for angina?
Consider BB +CB or switching between
Angina, not controlled on BB and Cb?
Consider nitrate long acting, or ivabradine
Other treatment for angina other than BB, Cb and nitrates?
Give aspirin, consider ACEi if diabetes
Advise on GTN use for pain?
Stop what they are doing and rest. Use their glyceryl trinitrate spray or tablets as instructed. Take a second dose after 5 minutes if the pain has not eased. Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose
Thrombolysis contraindications?
Haemorrhagic stroke, ischeame stroek <6m neoplasms cns, recent surgery or trauma, aortic dissection, bleeding issues.
Non-cardiac troponin rises?
PE, renal, COPD, diabetes, drugs and toxins
Driving and angina?
No notification, dont drive with pain!
Most common AF causes
coronary heart disease, hypertension, valvular heart disease and hyperthyroidism.
Non cardiac AF causes?
Alcohol, infection, PE, cancers, caffeine
Signs and symptoms of AF?
Breathlessness/dyspnoea. Palpitations. Syncope/dizziness. Chest discomfort. Stroke/transient ischaemic attack (TIA).
Av nodal blockade in WPW?
Can cause rapid ventricular rates
Distinguishing feature of AF on ECG?
The distinguishing feature of AF is variability in the R-R intervals lack of p waves
Investigations in AF except ECG?
Bloods, lft, fbc, thyroid, CXR u&es
Considering rhythm control in AF what investigation?
Echo
Always offer rate control first line for AF except?
Reversible causes, Heart failure caused by AF, new onset
Initial rate control drugs AF?
Offer either a standard beta-blocker (a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker as initial monotherapy to people with AF (bb contr in asthma CCB contra in heart failure)
Monotherapy not controlling AF?
Consider b blocker and digoxin/ditiazem
Monotherapy not controlling AF?
Consider b blocker and digoxin/(ditiazem specilist advice)
If can’t anticoagulate consider what?
Dual antiplatelets- clop and aspirin
Treatment of superficial thrombophlebitis?
supportive, pain relief, elastication etc unless high risk or previous thrombotic events
NSAID first line
Define 1st degree heart block?
Prolonged PR interval >200ms (5 small squares) asymptomatic nothing done
2nd degree heart block type 1 mobitz/wekebach?
Progressively lengthening PR intervals until a qrs complex is dropped.
2nd degree heart block type 2 mobitz?
PR lengthened but regular, and regularly dropped QRS complexes.
Which heart blocks should be treated?
Type 2:2 and third degree
3rd degree heart block?
Regular P waves no relation to QRS complexes. Usually brady
Stokes-adams attack?
Temporary collapse unconscious due to heart slow or conduction problem
Max dose of atropine in symptomatic bradycardia, given in increments of?
3mg, 500mcg at a time
Define SVT?
Narrow complex <120ms and >100bpm
SVT risks?
Alcohol, thyroid↑ caffeine
Adverse features of SVT?
Shock, syncope, MI, Dizziness Hypotension
When DC cardiovert SVT?
If unstable adverse features up to 3 shcoks
Treatment of SVT if stable?
Vagal manouvres, and adenosine 6, 12, 12 rapid flush after, wary of wpw or asthmatics.
5 p’s of limb ischaemia?
Pulseless, pallor, perishingly cold, parasthesia, paralysis.
Monomorphic VT?
Identical broad >120ms qrs complexes regular
Polymorphic VT?
Also known as torsades, irregular and beat variation
VF, pulseless VT or symptomatic VT treatment?
Shock
VT which is stable?
Amiodarone 300mg over 20-60mins 5mg/kg then 900mg over 24hrs correct electrolytres
Torsades treatment?
↑qt consider stopping antiarryhtmics, give magnesium 2g IV over 10mins.
Fever with new onset murmur?
Infective endo until proven otherwise
Causes of infective endo?
Rheumatic valves, HCOM, IVDU, poor dentition, structural problems.
Usual microbes for infective endo?
Staph aureus IVDU, Strep viridans, dental, staph epidermis on prosthetic valves
Infective endo signs?
Acute- fever >38 HF, chills and rigors or emboli Subacute, oslers nodes, splinter haemorrhages, janeways, murmur (aortic regurg), clubbing
Criteria for infective endo?
Dukes
which criteria met for a diagnosis in dukes criterias for IE?
2 Major, 1 major 3 minor or 5 minor
Major criteria for IE?
persistent +ve cultures, typical organism in 2 separate cultures, +ve echo, or valvular regur
Number of blood cultures from sites?
3 different sites peak of fever
Management of IE?
Blind therapy, gent and amox or vanc and gent
How long prior to surgery do you stop cocp?
4 weeks
Wells score for DVT of 0 or 1 ?
offer d-dimer but diagnosis unlikely if this is +ve have USS
Wells dvt score of 2 or more?
USS of leg if cant be done in 4 hrs offer parenteral anticoagulant
Q waves usually normal even >2mm in which leads?
iii and avf but isolated Q waves in any usually no problem unless entire territory
ABPI 0.8-1?
Normal
When is AAA screening ?
All men aged 65 given USS
Diameter greater than what considered aneurysmal for AAA?
>3cm under this no further scan needed
High rupture of AAA size of aneurysm?
>5.5cm or >1cm/yr
4.5-5.4cm aneurysms when to re-scan?
3 months
3-4.4cm aneurysm when to re-scan?
1 year
What is buergers test?
Arterial sufficiency test, leg raised and if goes pale at <20degrees severe problems, normal leg should stay pink at 90 degrees for a minute.
Define stage 1 HTN?
Clinic 140/90 and ambulatory average > 135/85
Stage 2 HTN?
160/100 clinic and 150/95 ambulatory
Stage 3 HTN?
Clinic pressure 180sys or dia >110
When to treat stage 1 HTN?
<80 years and organ damage, renal or CVS disease, diabetes, 10year qrisk >20%
When to treat stage 2 HTN?
Always
Target BP for treated HTN? for <80 and >80yrs
<80 140/90 >80 150/90
Inferior MI may be associated with?
Right sides failure, raised JVP no pulmonary oedema
Causes of acute heart failure?
Arrhythmia, MI, Tamponade, Mitral regurg
ABPI in critical ischaemia?
<0.5
Normal ABPI?
1-1.2
>1.2 ABPI?
Usually diabetes
0.8-0.9 ABPI?
Mild claudication
0.5-0.79 ABPI?
Severe claudication
Conservative vs Medical vs surgical management of claudication?
Lifestyle, statins, clopidogrel diabetic control Angioplasty, bypass and amputation (incurable)
Symptoms of critical ischaemia? 6 P’s
Pain Pallor Paraesthesia Paralysis Perishingly cold Pulseless
Bloods & investigations in limb ischaemia?
Lactate, CK, G&S, ECG, CTA
Management of critical ischaemia?
IV heparin even if going to surgery. embolectomy, thrombolysis, thrombectomy, amputation long term anticoagulation
Reperfusion of ischaemic limb problems?
Acidosis, AKI, Hyperkalaemia, arrhythmias
Risks for venous ulcers?
Age, varicosity, pregnancy, obesity
Characteristics of venous ulcers?
Shallow, Irregular, Granulating, Medial malleolus, varicose eczema
Characteristics of arterial ulcers?
Small, Deep and well defined, necrotic base, associated symptoms such as claudication. Lateral malleoulus
Neuropathic ulcers characteristics?
Variable size and depth, often in pressure areas such as soles of feet, burn and tingle
Venous ulcer management?
Emollients, Leg elevation, Dressings and compression
Arterial ulcer management?
Statin, antiplatelet, diabetic optimisation etc arterial ops
Neuropathic ulcer management?
Debridement and footwear!
Which ulcers painful?
Venous and arterial, diabetic is painless.
BP target in AAA?
<100 as long as cerebrally perfusing
Stable vs unstable treatment of AAA?
Stable CT unstable straight to theatre
Type of stroke to consider endarterectomy?
Symptomatic anterior TIA /Stroke
Within how long to do endarterectomy after stroke?
14 days
Triad of aortic stenosis? What are differentials?
Angina, Syncope Heart Failure Differentials- Cardiomyopathy, vasovagal
CXR signs of heart failure?
Batwing (alveolar oedema) Kerley B line Cardiomegaly Dilated upper lobe Effusions
Aortic stenosis management?
Cons-Avoid exertion Medical- Treat CCF and risk factors Surgical- Definitive replacement
Aortic stenosis prognosis?
Not good 5 years
Differentials of palpitations?
Arrhythmia, valvular, Endocrine Anaemia Anxiety Drugs
What does this ECG show?
Typical pattern of atrial flutter
What does this ECG show? How would you calculate the rate?
AF, count complexes on strip and multiply by six (average HR) do not use the r-r method as irregular heart rate
Causes of mitral regurgitation?
Degenerative
Left ventricular dilatation
Ruptured chordae tendinae
Papillary muscle rupture
Rheumatic heart disease
Infective endocarditis
Mitral valve prolapse
Connective tissue disease
Clinical presentation of varicose veins? Symptoms?
lower extremity pain, fatigue, itching and/or heaviness, which often worsen with prolonged standing, haemosiderin deposition
Investigation og choice for varicose veins?
Duplex ultrasound
Varicose veins risk factors?
Age +
Female
FHx
++Births
DVT
What is this test, why is it used and how?
Buerger test, for arterial sufficiency, patients leg is raised until it becomes pale and angle noted then allowed to drop and noted if turns blue then red on return. (hyperactive hyperaemia)
When is trendelenburg test used in vascular conditions?
Venous insufficiency- torniquet is used
How to define orthstatic hypotension?
Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.
Orthostatic hypotension inadequate response to non-pharmacological measures?
Fludricortisone with Sodium chloride
Anticoagulation of confirmed DVT/PE?
DOAC, recommended over Warfarin which is in turn reccomended over LMWH (still used to bridge the gap between the therapeutic INR of warfarin)
What does the ECG show, what is the treatment if stable and unstable?
Narrow complex tachycardia- likely SVT
Stable- valsalva manouvres then adenosine
Unstable- DC cardioversion
Signs of shock in SVT and VT?
Hypotension
Heart failure/SOB
Syncope
Chest pain
What is the ECG showing what is the treatment?
If stable consider amiodarone or lidocaine
If unstable/pulseless- DC cardioversion
What does the ECG show?
Deep s waves in V1-3 and st depression and t wave inversion in V5-6
Likely LVH
What does the ECG show?
ST depression left precordial leads V4-6 plus leads I, II and aVL.
St elevation in aVR
What does ECG show? ?Cause
St depression downsloping, t wave flattenng and U waves associated with Hypokalaemia
What does the ECG show?
RBBB pattern V1-V3 upwards defelction and M
What does the ECG show?
LBBB
Causes of LBBB
Acute MI, Aortic stenosis, Dilated cardiomyopathy, coronary artery disease
How to tell axis from ECG?
Use lead I and AVf
Normal axis both positive.
Right axis I negative AVf positive
Left axis I positive Avf Negative
What is shown? Which condition?
Roths spots, Infective endocarditis
Cardiac tamponade triad?
Becks- Muffled heart sounds, hypotension and raised JVP
Normal JVP height?
<4cm
Causes of dilated cardiomyopathy?
Alcohol, hypertension, Haemachromatosis, cocaine, thyrotoxicosis, post partum
Systolic failure
Causes of hypertrophic cardiomyopathy?
Intraventricular septum increased in size, Atheletes, usually genetic though.
Harsh ejection systolic murumur although diastolic failure
Pembertons sign?
Hands above head for a minute causes sob, cyanosis and stridor +raised JVP
Superior vena cav obstruction
