Cardio Flashcards
How to calculate rate in ECG
300/number of squares (R-R)
how long should p-wave be
120-200ms
what does prolonged PR interval indicate
AV block
what does shortened PR interval indicate?
eg?
what other feature do you seen on ecg?
accessory pathway
eg WPW –> delta wave (slurred QRS upstroke)
QRS normal length?
80-120ms
where is the j-point?
where S wave meets ST segment
when is ST elevation significant?
> 1mm in >2 limb leads
> 2mm in >2 chest leads
what is t-wave?
ventricular repolarisation
when is a t-wave tall?
> 5mm in limb AND >10mm in chest
what does tall t-wave indicate
hyperacute STEMI
hyperkalaemia
which leads is inverted t-wave normal
V1
III
inverted t waves assos with?
ischaemia
PE
BBB
what is sinus brady?
<60bpm
every p-wave followed by QRS
physiological causes of sinus brady?
pathological causes?
Physiological: athletes, young
pathological: acute MI, drugs, hypothyroid, hypothermia, sick sinus, raised ICP
when do you treat bradycardia
<40bpm / symptomatic
mx of symptomatic brady
IV atropine
temp pacing wire
what is sick sinus syndrome?
causes?
result of SAN dysfunction - impaired ability to generate impulse
idiopathic fibrosis of node; ischaemia; digoxin
causes of AV block
MI
SLE
myocarditis
degeneration of His-Purkinje
define 1st degree heart block?
PR > 0.2s
PR interval constant
every P followed by QRS
define 2nd degree heart block?
intermittent failure of conduction from A to V
some P not followed by QRS
Mobitz I = failure at AVN - PR is progressively increased until QRS missed
Mobitz II = intermittent failure of P wave conduction. PR is constant + prolonged. Dropped QRS 2:1 / £:1
define 3rd degree heart block?
complete failure of conduction between atria and ventricles
cause of 3rd degree heart block?
myocardial fibrosis
causes of RBBB
Rheumatic heart disease RVH IHD myocarditis cardiomyopathy
ECG changes of RBBB
MarroW
QRS > 0.12s (broad)
causes of LBBB
CAD
HTN
dilated cardiomyopathy
anterior infarction
ECG changes of LBBB
WilliaM
QRS > 0.12s (broad)
ix in brady
ECG
electrolytes
TFT
mx of brady
treat cause
stop negative chronotropes
IV atropine 0.5mg
sinus tachy pres
angina like sx -> chest pain, faintness, sob
define sinus tachy?
HR > 100bpm
every P followed by QRS
causes of sinus tachy?
physiological: exertion, anxiety, pain
Pathological: fever, anaemia, hypovolaemia
Endocrine: thyrotoxicosis, phaeochromocytoma
Pharma: adrenaline, alcohol, caffeine, salbutamol
ix in sinus tachy?
ECG, cardiac enzymes, FBC, TFT
mx of acute sinus tachy
vagal manoeuvres: carotid massage, valsalva, cold water
mx of chronic sinus tachy
BB / CCB (diltiazem, verapamil)
egs of SVTs?
AF / flutter
sinus tachy
AV re-entry tachy
Mx of WPW?
vagal manoeuvres +/- adenosine
pharma: flecainide / sotalol
surgery: radiofrequency ablation is curative
mx of narrow SVT? (if BP<90, chest pain, HF, HR>200)
DC cardioversion with general anaesthetic
+/- IV amiodarone
mx of AF?
Rate: 1. BB/CCB 2. Dual therapy (NOT VERAPAMIL + BB)
Rhythm: if <48h -> DC cardioversion
if >48h -> Warfarin for 3w before cardioversion
Anticoag
Pharmacological cardioversion?
IV amiodarone
Mx of atrial flutter
Rhythm: cardioversion
- DC (if >48h ensure adequate anticoag)
- IV amiodarone
mx of broad complex tachy?
if unstable?
ABCDE
monitor ECG, BP, sats
Cardioversion - DC shock / amiodarone
what do you need to consider long term for VT? why?
requires maintenance anti-arrhythmics (BB/CCB) or implantable defibrillator
usually due to damage
What does TdP look like on ECG?
like a sound wave
varied axis + amplitude QRS
what can happen to torsades if untreated?
–> VF
mx torsades?
IV MgSO4
what does VF look like on ECG
chaotic (varying amplitudes)
no identifiable P, QRS or T
mx of acute VF?
long term?
defibrillation
BB and ICB
ECG finding in PE
sinus tachycardia
+/- S1Q3T3
ECG of hypothermia
bradycardia
J-wave (late delta wave, positive deflection at j point)
when do you use amiodarone?
tachyarrhythmias (AF, AFlut, SVT) when other drugs or DC shock dont work
SEs of amoidarone
hypotension during IV infusion
Chronic -> pneumonitis, AV block, hepatitis, thyroid
when do you use adenosine?
first line diagnostic and therapeutic in SVT
SE of adnosine?
patient feels like they are going to die!
mech of adenosine
blocks SA + AV node - causes bradycardia and asystole –> feeling of doom
Indications for Digoxin
Reduce ventricular rate (AF, AFlut) - after CCB or BB
Severe heart failure - 3rd line
important to remember in digoxin
low therapeutic index
interactions with digoxin?
loop / thiazide like diuretics -> hypokalaemia
amiodarone, CCB, spironolactone -> increase plasma digoxin
monitoring for digoxin toxicity?
monitor sx / ventricular rate + ECG + renal dysfunction + hypokalaemia
target blood conc of digoxin
1 - 1.5 nmol/L
>2 suggests toxicity
CCBs indication
rate control in SVT
BBs indication
IHD to reduce angina
CHF to improve prognosis
AF to reduce rate and maintain sinus
SVT to restore sinus rhythm
SEs of BBs
fatigue, cold extremities, headache, impotence
when are BBs CI?
what can you use?
Asthma - B2 block causes bronchospasm
Can use B1 selective (atenolol, bisoprolol, metoprolol)
MR murmur
pansystolic
MS murmur
loud S1 + mid-diastolic murmur
how to differentiate between MR and TR
both pan systolic
TR does not radiate to axilla
PS murmur
interesting fact
crescendo-decrescendo ejection systolic murmur
disappears on inspiration
PR murmur
early diastolic
when are aortic murmurs best heard
holding breath
AS murmur
crescendo-decrescendo ejection systolic murmur
AR best heard?
early diastolic
best heard leaning forwards + holding breath (PR disappears on holding breath)
usual cause of AS
senile calcification
triad of sx in AS
chest pain
HF
syncope
o/e AS
slow rising pulse
narrow pulse pressure
LVH-> apex thrill
Confirm dx of AS?
Echo
Mx of AS?
avoid heavy exertion, modify RFs for CAD
valve replacement
if not fit for surgery -> balloon valvluoplasty / TAVI
comps of mechanical heart valves?
predispose to IE
small emboli
how to prevent IE with new heart valves?
Abx prophylaxis
target INR in valve replacement
anticoag
INR 2.5-3.5 for aortic
causes of AR
bicuspid
rheumatic fever
IE
collagen [Marfans, E-D, Turners]
pres of AR?
SOBOE
non-specific sx of left heart failure [orthopnea, paroxysmal nocturnal dyspnoea]
o/e AR
early diastolic murmur, not transmitted to carotids
collapsing water hammer pulse
wide pulse pressure
CXR of AR?
signs of HF, volume overload
normal size of mitral valve?
4-6cm2
what sx does large left atrium cause?
hoarseness
dysphagia
o/e of MS
malar flush, raised JVP, RVH
signs of RHF
late diastolic murmur, loud S1 w opening snap
mx of MR?
surgery
cause of rheumatic fever
Group A beta haemolytic streptococci (pyogenes)
when does rheumatic fever occur?
what is affected?
2-4w post-strep pharyngitis / skin infection
joints, skin, heart, nervous system
blood test providing evidence of strep infection?
antistreptolysin O titre
or DNase B titre
What criteria to use for diagnosis of rheumatic fever?
Jones criteria: Required Criteria Evidence of antecedent Strep infection: ASO / Strep antibodies / Strep group A throat culture / Recent scarlet fever / anti-deoxyribonuclease B / anti-hyaluronidase Major Diagnostic Criteria Carditis Polyarthritis Chorea Erythema marginatum Subcutaneous Nodules Minor Diagnostic Criteria Fever Arthralgia Previous rheumatic fever or rheumatic heart disease Acute phase reactions: ESR / CRP / Leukocytosis Prolonged PR interval
ix rheumatic fever?
throat culture, ASO rise during 1st month
ECG: PR, ST elevation
CXR: ?HF
FBC, ESR, CRP
Doppler echo
mx of rheumatic fever?
how to eradicate strep?
treat HF?
for chorea?
enforce bed rest until inflam markers normal
Eradicate strep -> IV benzylpenicillin
Treat HF: diuretics, ACEi, digoxin
Suppress inflam: NSAIDs
Chorea: self-limiting. maybe haloperidol
fever + new murmur = ?
endocarditis until proven otherwise
IE RFs
valve disease/replacement congenital structural defect previous IE HOCM IVDU
pres of IE
fever + chills + poor appetite + wt loss
signs of IE
FROM JANE Fever > 38 + tachy Roth's spots Osler's nodes Murmur Janeway lesions Anaemia/arthritis Nail haemorrhage Emboli
cause of IE?
which murmur is classic?
S. aureus
tricuspid murmur
comps of IE
MI / pericarditis
glomerulonephritis
stroke
ix in IE?
FBC, ESR/CRP, RF TTE Blood cultures CXR ECG
how long to give Abx for IE?
which for staph / strep? / MRSA
4 weeks
staph - fluclox
strep - benpen
MRSA - vanc
ix for cardiomyopathy
Bloods: FBC, ESR, U+Es, LFT, cardiac enzymes, TFT
CXR
ECG
TTE
MRI; distinguish constrictive / restrictive
features of HF on CXR?
ABCDE Alveolar oedema B-lines; Kerley Cardiomegaly Dilated upper lobe vessels Effusion; pleural
cause of sudden cardiac death in young people?
hypertrophic cardiomyopathy
arrhythmia / LV outflow tract obstruction
cause of myocarditis
coxsackie
ix for myocarditis
FBC Viral serology **endomyocardial biopsy * ECG CXR
Sx of HF
breathless, fatigue, ankle swelling
signs of HF
tachyc, tachyp pulmonary rales pleural effusion raised JVP peripheral oedema hepatomegaly
difference between LHF/RHF in pres
RHF: peripheral oedema, ascites, facial engorgement, pulsing in neck (TR)
LHF: dyspnoea, fatigue, cold peripheries, muscles wasting, orthopnea, PND, noct cough - pink frothy sputum
if prev MI and new HF what ix? and when?
2WW for specialist + doppler echo
Ix for HF
BNP - if high -> 2WW for echo
ECG
bloods
CXR
Acute mx of HF?
when stable?
O2 + IV diuretics +/- NIV
when stable: BB + ACEi + spiro +/- digoxin
f/u in 2w
mx of chronic HF?
lifestyle
annual vaccinations
manage comorbs
how do statins work
HMG-CoA reductase inhibitors
when to prescribe statins
QRISK2 > 10%
history of CVD
hypercholesterolaemia
>85yo
SEs of statins
myalgia - stiff, weakness, cramps
what to monitor with statins
LFTs
secondary causes of HTN
renal endocrine coarctation pre-eclampsia drugs
signs of end organ damage in HTN
encephalopathy - seizure, vomiting, nausea dissection - delayed/weak femoral pulses pulm oedema nephropathy - proteinuria eclampsia papilloedema retinopathy
Mx of HTN
1. <55 - ACEi/ARB >55 - CCB 2. dual 3. + indapamide 4. resistant + spiro
SE of amlodipine
ankle swelling
target BP
<140/90
Which leads and arteries? anterior leads? lateral leads? inferior leads? septal leads?
anterior leads = V3/V4 - LAD
lateral leads = 1, V5, V6 - Cx
inferior leads = I, II, aVF - RCA
septal leads = V1, V2 - LAD
what to do with all new angina?
refer to rapid access chest pain clinic for confirmation of Dx and severity assessment within 2w
DDx angina
MI - pain over 5 mins Pericarditis - worse on inspiration, lying flat, swallowing MSK - worse on mvmt GORD Pleuritic pain - sharp on inspiration
Ix in angina
ECG - ST flattening FBC FBG Cholesterol LFTs TFTs
non-pharma mx of stable angina
modify RFs (?aspirin/statin) patient education
pharma mx of stable angina
acute - GTN
1st BB / CCB
2nd combination
3rd + ivabradine
what if angina not controlled by pharma
CABG / PCI
Ix in ACS?
ECG
cardiac enzymes - troponin, CK
bloods
CXR
mx for ACS
ABCDE
GTN + IV opioid with antiemetic
Antiplatelet - 300mg aspirin, ticagrelor
O2 if <94%
mx of STEMI
MONA Morphine Oxygen Nitrates Aspirin
reperfusion - PCI (if within 120mins) / fibrinolysis
drug used for fibrinolysis
alteplase
streptokinase
Pharma post MI?
ABSeeD ACEi BB Statin Dual antiplatelet (aspiri+clopidogrel)
driving post ACS?
4weeks off
dresslers syndrome?
post-ACS
late pericarditis -> inflam reaction to necrotic tissue
occurs at 2-8weeks
comps post MI?
DEPARTS + fails Death, dresslers Electrical: tachyc/bradyc Pericarditis, papillary muscle rupture Aneurysm Re-MI, rupture Thrombus Shock VSD Heart failure
unresponsive cardiac arrest
999 A+B C - CPR 30:2 D - defibrillator: AED 2 mins of CPR between defib, after 3rd shock give adrenaline + amiodarone
causes of pericarditis
Viral: coxsackie, EBV Rheum: SLE, sarcoid Post-MI Drugs: hydralazine Other: uraemia
what causes granulomatous pericarditis
TB, sarcoid, fungal, RA
pericarditis
aggravating pain?
relieving pain?
aggravated by inspiration, cough, swallow, lying flat
relieved by sitting up/fwd
o/e acute pericarditis
pericardial friction rub
tachypnoea, tachycardia, fever
Beck’s triad in tamponade?
hypotension
elevated JVP
muffled heart sounds
Ix in pericarditis?
ECG
CXR
bloods
Echo
mx of stable pericarditis
rest + treat cause + NSAIDs +/- PPI
when to admit pericarditis
if fever, tamponade, large effusion, fail to respond to NSAIDs
pericarditis with falling BP, what should you suspect?
cardiac tamponade
Mx of cardiac tamponade?
immediate pericardiocentesis
O2 + inotrope + increase venous return
mx of recurrent pericarditis
colchicine
pres of peripheral arterial disease
intermittent claudication [cramping in calf/thigh/buttock on walking -> relieved by rest]
ischaemic rest pain
o/e lower limb ischaemia
absent/reduced femoral pulses
trophic changes - pale, cold, hairless, skin change
ulcers
cap fill prolonged
ddx of lower limb ischaemia
sciatica
spinal stenosis
DVT
entrapment
ix in lower limb ischaemia
BP FBC ESR renal function **ABPI**
ABPI for mild/mod/severe PAD
normal = 1
mild <0.9
mod <0.8
severe <0.5 –> ischaemic rest pain
Ps of acute limb ischaemia
pale, pulseless, pain, perishingly cold, paraesthesia, paralysis
mx of acute lower limb ischaemia
requires re-vasc in 4-6h
comps of PAD
acute limb ischaemia
infection
poor healing
gangrene
general mx of PAD
modify RFs statin ACEi antiplatelet pain management
aortic dissection?
intimal tear -> disruption of media -> layers separate and form a false lumen
simple ix in aortic dissection
BP may be different in both arms
what must you differentiate from aortic dissection? why?
differentiate from MI
thrombolysis is fatal in dissection
imaging in aortic dissection
CXR - widened mediastinum
TTE
MRI
comps of aortic dissection
rupture + multi-organ failure + cardiac tamponade + hypotension
mx of aortic dissection
O2, morphine
ICU
IV labetalol + nitroprusside
Surgical repair
ix AAA? what sign could indicate imminent rupture?
FBC, clotting, U+Es, LFT, crossmatch, ECG, CXR
USS for initial assessment
CT for more detail -> crescent sign indicates blood within thrombus
mx of AAA
regular USS monitoring
lifestyle
Surgical repair if >5.5cm or rapid expansion
Triad in AAA rupture
hypotension
pulsatile abdo mass
flank/back pain
mx AAA rupture
large bore IV access group + crossmatch immediate theatre graft repair (death is highly likely)
organs at risk in sepsis?
kidney (acute tubular necrosis)
lungs (ARDS)
heart (MI)
brain (confusion, coma)
ix in hypovolaemic shock?
Hb, U+Es, LFT, group + crossmach, ABG, UO
Mx of hypovolaemic shock?
raise legs
ABCDE -> 2large bore cannulae, airway, high flow O2, fluid resus.
if haemorrhage -> give blood ASAP [O-ve]
cause of cardiogenc shock
acute MI
monitor in cardiogenic shock?
cardiac monitoring
BP - arterial line
venous pressuer
UO
mx cardiogenic shock?
ABCDE fluids O2 pain relief cardiac inotropes [dopamine or dobutamine] Revascularisation
mx of anaphylactic shock?
ABCDE
life flat
high flow O2 [+/- intubate]
IM adrenaline
IV fluids
IV chlorphenamine + hydrocortisone
Bronchodilators; salbutamol
signs of septic shock?
HAT
Hypotension < 100mmHg
Altered mental state GCS<15
Tachypnoea >22
mx of sepsis
Blood cultures + septic screen Urine output Fluid resus Abx - taz Lactate - ABG Oxygen
other ix in sepsis
FBC, U+Es, urinalysis, LFTs, glucose, clotting, CXR, AUSS
comps of sepsis?
DIC, renal railure, cardioresp failure
SEs of amiodarone
prolong QT
pseudohypothyroidism
cause of ST elevation in all leads?
pericarditis
SAH
mx of PE
Short term - LMWH
Long term - warfarin 3-6m
