cardio Flashcards
What ECG findings suggest brugada syndrome?
Elevated J point
Coved/saddleback ST elevation
Whats are patients with brugada syndrome at risk of?
Going into VF/ sudden cardiac death
What is the only available tx for brugada syndrome?
ICD
Which artery is affected in an inferior stemi?
Posterior descending artery
What should you assume a broad complex tachycardia to always be in exams?
VT
What drug do you give if VT with no adverse signs?
Amiodarone
Define the classes of antiarrythmic drugs and give examples?
I - sodium channel blockers (fleicanide)
II - Beta blockers (bisoprolol)
III - prolong action potential (amiodarone)
IV - CCBs (verapamil, diltiazem)
What are the three presenting features of typical angina?
1) Constricting heavy discomfort in chest, jaw, neck, arms
2) Sx brought on by exertion
3) Relieved within 5 mins by rest/GTN
Which two patient groups are at risk of silent MI?
Elderly
Diabetics
Mx for angina
1) low dose aspirin
2) statin
3) GTN spray
4) beta blocker and/or amlodipine (diltiazem on own)
5) long acting nitrate
What test is now first line for diagnosing angina? (in patients lower than 90% probability)
CT coronary angiography
Give two examples of non-invasive functional testing for diagnosing angina?
Stress myocardial perfusion scintigraphy
Stress echo
Cardiac MRI stress test
Exercise ECG testing
Which nerve innervates the pericardium?
Phrenic nerve
What are the roles of the pericardium?
Fixes heart
Prevents overfilling
Lubrication
Protection from infection
What does left anterior hemiblock look like on an ECG?
L axis deviation
What does bifascicular block look like on ECG?
RBBB and left axis deviation
What does trifascicular block look like on ECG?
Bifascicular block and 1st degree heart block
What is a normal cardiac axis?
-30-90 degrees
How do you calculate rate from an ECG?
300 divided by no. of large squares
Whats a normal PR interval?
120-200ms (3-5 small squares)
What signs on an ECG suggest WPW?
Short PR interval
Delta wave
Widened QRS
What could tall T waves be a sign of?
Hyperacute STEMI
hyperkalaemia
What type of drug is atropine?
Muscarinic receptor antagonist
Define 1st degree heart block
PR constant but greater than 0.2s
Define Mobitz type one heart block (2nd degree)
PR prolonged until QRS dropped
Define Mobitz type 2 heart block (2nd degree)
Dropped QRS random
PR is constant and prolonged
Which Mobitz type carries greatest risk of progression to complete heart block?
Mobitz 2 (need pacing if bradycardic)
How is third degree heart block managed?
Admission to hospital and pacing
What is the most likely cause of sudden onset palps and chest pain in a young woman. ECG shows SVT. Previous ECG had no abnormalities.
AVNRT
How is AVNRT managed long term?
Beta blockers
Ablation of accessory pathway
What is the accessory pathway called in WPW?
Bundle of kent
What must be fulfilled before you can consider an AF patient for cardioversion?
Onset < 48h or already anticoagulated for 3 weeks
How is SVT managed?
Vagal manoeuvres
Adenosine
What are the three types of AF?
Paroxysmal (stops within 7 days)
Persistent (>7 days)
Permanent (over 1 yr)
What are the classic causes of AF?
Alcohol intoxication
Thyrotoxicosis
Rheumatic heart disease
HTN
Heart failure
Which drugs can be used for rate control in AF?
Beta blockers or CCB
Long term what scoring system is used to determine if a pt on rate control for AF needs anticoagulation
CHADS-VASC
What is used to assess the risk of bleeding when starting a patient on anticoagulation?
HASBLED
What factors contribute to poor warfarin control?
Impaired cognitive function Poor adherence to tx Illness Interacting medications Diet Alcohol consumption
What are the risk factors for atrial flutter?
CAD HTN Hyperthyroid Obesity Alcohol
How long must you anticoagulated before you can cardiovert an AF or atrial flutter patient?
3 weeks
What can prolong QT?
Drugs
Congenital
Electrolyte abnormality (hypohalaemia, hypomagnaesaemia)
What ECG abnormality is seen in hypercalcaemia?
Decreased QT interval
How do you manage torsades de pointes?
Congenital - beta blockers
Acquired - stop precipitant, correct hypokalaemia and give magnesium sulphate
What are the side effects of chronic use of amiodarone?
Sun sensitivity Pneumonitis AV Block grey discolouration Hypothyroidism optic neuropathy
What sign on ECG indicates digoxin toxicity?
ST segment depression (reverse tick sign)
Can you use verapamil with a beta blocker?
No - risk of severe bradycardia
When are beta blockers CI?
Asthma
How can you grade murmurs?
Levines scale
What valve disorder does a loud S1 indicate?
Mitral stenosis
What is an Austin flint murmur?
Rumbling diastolic murmur heard best at apex
Due to severe AR
What signs on exam suggest aortic stenosis?
Slow rising pulse
Narrow pulse pressure
Apex thrill
Systolic murmur
What criteria are used to dx rheumatic fever?
Jones criteria
What forms the jones criteria for diagnosing rheumatic fever?
Carditis Arthritis SC nodules Erythema marginatum Sydenhams chorea
+ evidence of recent strep infection e.g. positive ASOT or throat culture
How do you ix for carditis in rheumatic fever?
Doppler USS
Mx for rheumatic fever
Bed rest
IV benzylpenicillin
Aspirin
Which organisms cause IE most commonly?
S.viridans
S.aureus (IVDU)
What can be used to classify disability/functional limitation due to heart failure?
New York heart association classification
Name a diagnostic criteria used for heart failure
Framingham criteria
Ix for heart failure
ECG
BNP
Echocardiography
CXR
CXR signs of HF
Alveolar oedema kerley B lines Cardiomegaly Dilated upper lobe vessels pleural Effusion
What should you monitor when putting a heart failure pt on diuretic therapy in the hospital?
Renal function
Weight
Urine output
What is the acute mx of heart failure?
O2 and IV diuretics (+NIV)
How is chronic heart failure managed?
Lifestyle modification Flu vaccine and pneumococcal vaccine Inform DVLA LOOP DIURETICS (e.g. furosemide) ACE-I BETA BLOCKERS (+digoxin)
What is the main side effect of loop diuretics such as furosemide?
Hypokalaemia (therefore monitor U & Es)
Renal impairment
Which drug might you switch to if furosemide is causing hypokalaemia?
Spironolactone
What are the causes of secondary hyperlipidaemia?
nephrotic syndrome
Cushing’s syndrome
Hypothyroidism
cholestasis
Who would you start treatment with a statin?
Known CVD
CKD
type 1 DM
Qrisk > 10%
When are statins CI?
Pregnancy
Cholestasis
When should you discontinue statins?
If liver enzymes greater than 3 times the upper limit of normal range
What blood tests should you do before starting a patient on a statin?
Lipid profile
LFTs
CK
What drug can be given if a patient cannot tolerate a statin?
ezetimibe
What Ix would you do in hypertension for evidence of end organ damage?
Urine dipstick
U & Es
12 lead ECG
Fundoscopy
What Ix would you do in htn for a secondary cause?
U & Es (low K+ in Conns) Ca (increased in hyperparathyroidism) renal US (renal artery stenosis) 24h urine for metanephrines (phaeochromocytoma) urinary free cortisol (cushings) MRI aorta (coaractation)
What drugs is a patient discharged on post ACS?
Aspirin lifelong
Clopidogrel 12 months
Beta blocker (12months/ lifelong if LV dysfunction)
ACE-I
statin
spironolactone if evidence of heart failure
How long are you not allowed to drive post ACS?
1 month (technically 1 week if successful PCI)
What triad is associated with cardiac tamponade?
Becks triad:
Falling BP
Rising JVP
Muffled heart sounds
What ECG changes are seen in cardiac tamponade?
Low voltage QRS +- electrical alternans (alternating QRS amplitude)
Diagnostic Ix for cardiac tamponade
echo
Tx for cardiac tamponade
pericardiocentesis
What classification is used for PAD?
Fontaine classification
What is buergers disease?
Pattern of thrombophlebitis and ischaemia seen in young heavy smokers
Mx for PAD?
Clopidogrel
Supervised exercise
Naftidofuryl (if sx don’t improve with exercise)
sx of aortic dissection
SUDDEN tearing chest pain neurological deficit Acute limb ischaemia paraplegia angina
Hyperkalaemia ECG changes
Tall, peaked T waves
P wave flattens
Wide QRS
Hypokalaemia ECG changes
Small T waves
Prolonged PR
Depressed ST
Prominent U waves
What condition should you suspect in a hypertensive, hypokalaemic pt not taking diuretics?
Conn’s syndrome
How does hypomagnesaemia px on an ECG?
Prolonged QTc
Generally what length of QT is concerning
> 0.5s (about 12 squares)
Comps of MI
Cardiac arrest Shock LV failure Arrythmia Pericarditis Systemic embolism Cardiac tamponade MR VSD
What is the first test you undertake on a suspected angina pt?
Calculate their pre-test probability
How does aspirin act?
COX inhibitor
Decreases THROMBOXANE and prostaglandin synthesis
How does clopidogrel act?
P2Y12 inhibitor
What are side effects of ACE-I?
Cough
Hypotension
Acute renal failure
Hyperkalaemia
What are the side effects of CCBs?
Flushing
Headache
Oedema
Palps
How do thiazide diuretics act?
Inhibit sodium-chloride transporter in distal tubule
What side effects are associated with nitrates?
Headache
Syncope
Which viruses most commonly cause pericarditis?
coxsackievirus
echovirus
What are the features of tetralogy of Fallot?
1) VSD
2) Pulmonary stenosis
3) RV hypertrophy
4) Overriding aorta
What is the gold standard Ix for IE?
TOE
What is P mitrale and what is it a sign of?
Notched P waves
Classically a sign of left atrial enlargement due to mitral stenosis
What is P pulmonale a sign of?
Peaked P wave
Due to PULMONARY HTN
(e.g. from chronic lung disease (cor pulmonale) or congenital heart disease or primary pulmonary htn)
