cardio Flashcards
pathological q waves sign of
previous/ resolving MI. indefinite, hours to days
causes of ventricular tachycardia
hypokalaemia, hypo magnesaemia, (hyperkalaemia can too)
torsades de pointe
polymorphic VT precipitated by prolonged QT
treat with iv mag sulf
verapimil + betablocker
contraindicated due to bradycardia
management of stable angina
-betablocker
-dihydropyridine calcium channel blocker
- both
if not tolerated use:
A long-acting nitrate
Ivabradine
Nicorandil
Ranolazine
ivabradine side effects
visual disturbances including phosphenes and green luminescence
metabolised by oxidation through cytochrome P450 3A4 (CYP3A4) only. Therefore drugs that induce (e.g rifampicin) or inhibit (e.g erythromycin, itraconazole) CYP3A4, will decrease or increase the plasma concentration
INR:
- following VTE/ AF
- recurrent VTE
- when to give vitamin k
- 2.5
- 3.5
- 5-8 + bleed or 8+ or major bleed
management and doses of anaphylaxis
don’t discharge before observation for 6h due to biphasic reaction. can repeat adrenaline every 5 mins
Adrenaline Hydrocortisone Chlorphenamine
< 6 months 150 micrograms (0.15ml 1 in 1,000) 25 mg 250 micrograms/kg
6 months - 6 years 150 micrograms (0.15ml 1 in 1,000) 50 mg 2.5 mg
6-12 years 300 micrograms (0.3ml 1 in 1,000) 100 mg 5 mg
Adult and child > 12 years 500 micrograms (0.5ml 1 in 1,000) 200 mg 10 mg
ECG features of hypokalaemia
U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
eisenmengers syndrome definition
the reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension. This occurs when an uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension.
treatment of toursade de pointe
iv mag sulf
initial management of VF
1 shock then 2mins CPR
witnessed VF, up to 3 shocks
aortic coract associated with
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
causes of raised BNP
heart failure is the most obvious cause of raised BNP levels any cause of left ventricular dysfunction such as myocardial ischaemia or valvular disease may raise levels. Raised levels may also be seen due to reduced excretion in patients with chronic kidney disease.
loop diuretics side effects
hypotension hyponatraemia hypokalaemia, hypomagnesaemia hypochloraemic alkalosis ototoxicity hypocalcaemia renal impairment (from dehydration + direct toxic effect) hyperglycaemia (less common than with thiazides) gout
VT management
Drug therapy
amiodarone 300mcg: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
Verapamil should NOT be used in VT
If drug therapy fails electrophysiological study (EPS) implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV function
nitrates contraindicated in
aortic stenosis- profound hypotension
thiazide diuretics adverse effects
Common adverse effects dehydration postural hypotension hyponatraemia, hypokalaemia, hypercalcaemia* gout impaired glucose tolerance impotence
dipyridamole MoA
Dipyridamole is an antiplatelet mainly used in combination with aspirin after an ischaemic stroke or transient ischaemic attack.
Mechanism of action
inhibits phosphodiesterase, elevating platelet cAMP levels which in turn reduce intracellular calcium levels
other actions include reducing cellular uptake of adenosine and inhibition of thromboxane synthase
IE dukes major criteria
Pathological criteria
Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content)
Major criteria
Positive blood cultures
two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or
persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis, or
positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci, or
positive molecular assays for specific gene targets
Evidence of endocardial involvement positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves), or new valvular regurgitation
ecg changes hypothermia
bradycardia 'J' wave - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias
drugs to control rate in AF
beta-blockers
calcium channel blockers
digoxin (not considered first-line anymore as they are less effective at controlling the heart rate during exercise. However, they are the preferred choice if the patient has coexistent heart failure)
drugs to maintain sinus rhythm in AF
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
atorvastatin interacts with
macrolides- risk of rhabdomyolsis
when to stop statins
Treatment with statins should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.
takayasu features
large vessel vasculitis females aorta/ renal artery stenosis systemic features of a vasculitis e.g. malaise, headache unequal blood pressure in the upper limbs carotid bruit intermittent claudication aortic regurgitation (around 20%)
child pugh scale
liver cirrhosis
buergers disease features
small and medium vessel vasculitis that is strongly associated with smoking.
Features
extremity ischaemia: intermittent claudication, ischaemic ulcers etc
superficial thrombophlebitis
Raynaud’s phenomenon
anti coag vs antiplatelet in:
- 2ry prevention of MI
- 2ry prevention of MI with AF
- post ACS/PCI
- VTE
- anitplatelet
- anticoag monotherapy
- 2 antiplatelets and 1 doac
- if already on anti P go to anti C, if low HASBLED anti P
new onset AF less than 48 hours
more than 48 hourse
dc cardioversion
3 weeks of anticoagulation first
aortic regurge signs
Corrigan's - exaggerated carotid pulse Quinke's - nailbed pulsation De Musset's - head nodding Duroziez's - diastolic femoral murmur Traube's - 'pistol shot' femorals
ECG changes for thrombolysis or percutaneous intervention:
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
hocm management
Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*
dilated cardiomyopathy causes
Classic causes include alcohol Coxsackie B virus wet beri beri doxorubicin
amiodarone side effects
Bradycardia Hyper/hypothyroidism pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis jaundice taste disturbance persistent slate grey skin discolouration raised serum transaminases nausea constipation (particularly at the start of treatment)
pulsus paradoxus
greater than normal drop 10mmhg in systolic bp
asthma, cardiac tamponade
most common cause of drug induces angioedema
ace inhibitors
management of PE
LMWH or heparin initially for 5 days
warfarin within 24h to 3 months
tx of SVT
valsalva
adenosine 6mg 12mg 12mg
electrical cardioversion
ablation
causes of long qt
congenital: Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage
systolic murmur under left clavicle and on back
aortic coarct
haemodynamic instability and pain after PCI
urgent CABG
3rd heart sound
caused by diastolic filling of the ventricle
considered normal if < 30 years old (may persist in women up to 50 years old)
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
4th heart sound
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle
therefore coincides with the P wave on ECG
in HOCM a double apical impulse may be felt as a result of a palpable S4
ix for chronic heart failure
BNP
aldosterone antagonists, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.
st elevation without blockage on angiogram
takotsubo
mx angina
aspirin and statin
gtn spray
beta blocker or ccblocker (verapamil/diltiazem) 1st line
long acting nitrate 3rd line ivabradine, nicorandil or ranolazine
fondaparinux moa
activates antithrombin III
pulmonaryy artery pressure, cardiac output and vascular resistance in
hypovolaemia
cardiogenic shock
septic shock
low, low, high (decreased preload)
high low, high (hence venodilators for pulmonary oedema)
low, high, low (hence vasoconstrictors)
wellens sign
deep inverted t waves (critical stenosis of LAD)§
marker for second MI in quick succession
CK MB (remains elevated for 3-4 days) trop for 10 days
indications for emergency valve replacement
Severe congestive cardiac failure
Overwhelming sepsis despite antibiotic therapy (+/- perivalvular abscess, fistulae, perforation)
Recurrent embolic episodes despite antibiotic therapy
Pregnancy
MOA statin
HMG coa reductase inhibitor in hepatic synthesis
ix in PE and renal failure
v/q perfusion scan
bisferiens pulse
HOCM (happens in subaortic stenosis)
drug which only improve mortality in NYHA 3
spironolactone
pedunculated mass on echo leading to emboli and AF
atrial myxoma
when to stop warfarin before surgery
5 days
high grace score- what other drug
abciximab glp3a/2b inhib
when not to treat htn
over 80 and low qrisk
non cardiac pain but ECG changes - imaging?
coronary ct angio
mx of aortic dissection
Type A
surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type B*
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
An inferior myocardial infarction and AR murmur should raise suspicion of
ascending aorta dissection rather than an inferior myocardial infarction alone
Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.
eisenmengers
reversal of left-to-right shunt associated with ventricular septal defects, atrial septal defect and a patent ductus arteriosus.
severe mitral stenosis
p mitrale bifid p wave
carotid sinus hypersensitivity
ventricular pause of 4 secs, fall in SBP of 10mmhg
erythema marginatum
rheumatic fever, sydenha
hocm fx
often asymptomatic
exertional dyspnoea
angina
syncope
typically following exercise
due to subaortic hypertrophy of the ventricular septum, resulting in functional aortic stenosis
sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure
jerky pulse, large ‘a’ waves, double apex beat
ejection systolic murmur
increases with Valsalva manoeuvre and decreases on squatting
hypertrophic cardiomyopathy may impair mitral valve closure, thus causing regurgitation
statin monitoring
LFTs at 0,3 and 12 months
when to operate on aortic stenosis
aortic valve gradient > 40 mmHg or there is evidence of significant left ventricular dysfunction then surgery is sometimes considered in selected asymptomatic patients
kussmauls’s sign
JVP increase with inspiration, feature of contrictive pericarditis
mx of long qt
avo;id drug
betablocker
icd
when to treat HTN
stage 1 135/85 and <80 organ damage cvd renal disease diabetes qrisk 10%
or <60
or all stage 2
cor pulmonale
right heart failure
power of defib in VF
150 J
bi/trifascicular block
Bifascicular block
combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
Trifascicular block
features of bifascicular block as above + 1st-degree heart block
mx proximal aortic dissection
Proximal aortic dissections are generally managed with surgical aortic root replacement.
cha2ds2vasc
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
