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med / surg > cardio > Flashcards

cardio Flashcards

1
Q

ECG territories

A

II, III, AvF: inferior, R coronary artery
V1-V4: anterior, LAD
I, V5-V6, AvL: lateral, L circumflex

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2
Q

aortic stenosis causes

A
  1. mostly calcification from increasing age
  2. congenital bicuspid aortic valve (20%)
    other:
    rheumatic fever
    infective endocarditis
    CKD (hyperphosphataemia)
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3
Q

aortic stenosis signs on exam

A 
ejection systolic murmur 
radiation to carotids
loudest at R upper sternal edge at end expiration
soft S2
narrow pulse pressure 
heaving apex beat
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4
Q

indications for aortic valve replacement

A 
symptomatic 
dilated LV
BP drop on exercise 
LVEF < 50% 
valvular gradient > 40mmHg
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5
Q

aortic stenosis treatment options

A

conservative (RF optimisation, serial echo)
open aortic valve replacement
TAVI (transcatheter aortic valve implantation)
balloon aortic valvuloplasty

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6
Q

systolic murmur differentials

A
  1. aortic / pulmonary stenosis
  2. mitral / tricuspid regurgitation
  3. VSD
  4. HOCM
    5, mitral valve prolapse
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7
Q

heart failure CXR findings

A 
A: alveolar oedema (bat wings) 
B: kerley B lines 
C: cardiomegaly
D: dilated upper lobe vessels 
E: pleural effusion
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8
Q

L heart failure signs

A 
gallop rhythm (presence of S3) 
displaced apex beat (LV dilatation)
pleural effusion 
bibasal creps (end-inspiratory) ± wheeze
L sided murmurs (aortic / mitral)
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9
Q

R heart failure signs

A 
raised JVP
tender hepatomegaly (pulsatile w tricuspid regurg)
peripheral pitting oedema 
ascites 
facial engorgement 
R sided murmurs (tricuspid / pulmonary)
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10
Q

immediate management acute cardiac failure

A
  1. ABCDE
  2. sit pt upright
  3. 15L high flow oxygen 60-100%
  4. diuretics: furosemide (also venodilates initially)
  5. GTN → venodilation → ↓preload
  6. diamorphine → venodilation
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11
Q

pharmacological Tx chronic cardiac failure

A

symptomatic: furosemide
prognostic:
1. ACE inhibitor + β-blocker (LVEF < 55%)
2. + ARB / spironolactone (LVEF < 35%)
3. entresto (delay 36hrs after stopping ACEi/ARB)
4. digoxin
cardiac resynchronisation therapy

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12
Q

beta blocker contraindications

A

severe heart failure
asthma / COPD
bradycardia

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13
Q

heart failure contraindicated drugs

A

• Pro-anti-arrhythmics w potentially negative inotropic effects e.g. flecainide
• CCBs e.g. verapamil, diltiazem (only amlodipine is advisable)
• Tricyclic antidepressants
• Lithium
• NSAIDs and COX-2 inhibitors
• Corticosteroids
• Drugs prolonging QT interval and potentially precipitating ventricular arrhythmias e.g.
erythromycin, terfenadine
• β-blockers contraindicated in severe heart failure

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14
Q

cardiac failure complications

A
  • Pleural effusion
  • Acute renal failure/chronic renal insufficiency
  • Anaemia
  • Sudden cardiac death
  • Cardiogenic shock
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15
Q

what is cor pulmonale

A

R heart failure caused by chronic pulmonary HTN

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16
Q

pulmonary hypertension signs on examination

A

raised JVP (prominent “a” wave)
L parasternal heave (R ventricular hypertrophy)
loud pulmonary component of S2

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17
Q

causes tricuspid regurgitation

A
  • R ventricular pressure overload (pulmonary HTN, L sided heart failure)
  • Pacemaker
  • Infective endocarditis
  • Rheumatic heart disease
  • Connective tissue disease e.g. Marfan’s
  • Ebstein’s anomaly (malpositioned tricuspid valve)
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18
Q

signs tricuspid regurg

A

pansystolic murmur
loudest at left lower sternal edge on inspiration
irregular pulse (atrial flutter / fibrillation)
large “v” waves of JVP
pulsatile hepatomegaly

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19
Q

complications tricuspid regurg

A

atrial arrhythmias: flutter / fibrillation
liver disease
myocardial infarction

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20
Q

atrial fibrillation causes

A 
infection
thyrotoxicosis 
ischaemic heart disease
rheumatic heart disease 
alcohol
pulmonary embolism
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21
Q

atrial fibrillation ECG findings

A

irregularly irreguarly rhythm
loss of P waves
fibrillatory waves

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22
Q

atrial fibrillation management

A

rate control: beta-blockers / CCBs
rhythm control within 48hrs: DC cardioversion / flecainide / amiodarone + anticoagulation: LMWH + IV heparin
if > 48hrs: anticoagulate for 3-4 wks with warfarin + heparin then DC / chemical cardioversion

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23
Q

atrial fibrillation Sx + signs

A 
palpitations 
dizziness / syncope
irregularly irregular rhythm
hypotension 
tachycardia
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24
Q

scoring systems for AF complications (2)

A

CHADSVASc: risk of stroke → >2 = anticoagulate

HAS-BLED: risk of haemorrhage → >2 = do not anticoagulate

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25
Q

1st degree heart block ECG changes

A

prolonged PR interval (>5 small squares/0.2s)

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26
Q

Mobitz type 1 ECG changes

A

progressive prolongation of PR interval until dropped QRS

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27
Q

Mobitz type 2 ECG changes

A

constant PR interval, occasional dropped QRS

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28
Q

type 3 heart block ECG changes

A

complete dissociation between P waves + QRS complexes

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29
Q

management chronic stable angina

A

conservative: exercise, smoking cessation, improved diet
medical:
anti-anginals:
1. beta-blocker
2. CCBs
3. beta-blocker + CCB (but not verapamil - risk of complete heart block)
4. long-acting nitrate, nicorandil (K-channel activator), ranolazine, ivabradine
+ statin + aspirin
GTN spray: pt should call ambulance if no relief 5min after 2nd dose
surgical: PCI (angioplasty) / CABG

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30
Q

stanford classification

A

for aortic dissection
A: ascending aorta (requires surg)
B: descending aorta (after L subclavian) (non-operative management)

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31
Q

varicose veins RFs

A 
obesity 
DVT 
pregnancy
COCP 
prolonged standing
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32
Q

signs of venous insufficiency

A

varicose veins
lipodermatosclerosis
corona phlebetatica
venous ulcers

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33
Q

varicose vein management

A

cons: weight loss, reduce standing, raise legs, compression stockings
minimally invasive: endothermal ablation (radiofrequency / laser), USS-guided sclerotherapy
surgical: ligation + stripping (under GA)

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34
Q

mitral regurgitation causes

A

acute: papillary muscle rupture due to MI / endocarditis
chronic:
functional: heart failure → LV dilatation → separation of valve leaflets
congenital: connective tissue disease e.g. EDS, Marfan’s
acquired:
infective endocarditis
IHD
assoc w atrial fibrillation

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35
Q

venous ulcer presentation

A 
painless wet ulcer 
irregular sloped edges
haemosiderin deposition 
oedema 
gaiter region (around medial malleolus) 
lipodermatosclerosis
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36
Q

arterial ulcer presentation

A

painful dry ulcer
well-demarcated
between toes / lateral aspect of foot / ankle
reduced / absent pulses

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37
Q

hypertensive retinopathy grades

A
  1. silver-wiring (tortuous vessels with shiny thick walls)
  2. grade 1 + AV-nipping (narrowing of arteries crossing veins)
  3. grade 2 + flame haemorrhages + soft exudates
  4. grade 3 + papilloedema
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38
Q

signs on examination infective endocarditis

A 
Osler's nodes: painful
Janeway lesions: painless, thenar eminence
splinter haemorrhages 
Roth spots (fundoscopy) 
new murmur
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39
Q

most common causative organisms infective endocarditis

A

strep viridans (subacute)
staph aureus → IVDU (acute, RH valves, no chronic signs)
staph epidermidis → prosthetic valves

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40
Q

diagnostic criteria for infective endocarditis

A

Duke criteria
major: persistently +ve cultures w typical organisms
+ve echo
new regurgitation

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41
Q

mitral regurgitation signs

A 
pansystolic murmur 
loudest over apex on expiration 
radiates to axilla 
soft S1 
chronic → LV dilatation → displaced apex beat
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42
Q

mitral regurgitation management

A

cons: monitor w serial echo
medical:
for functional MR: ACEi, beta-blockers, diuretics
treat AF if present (rate, rhythm, anticoagulation)
surgical: annuloplasty / valve replacement

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43
Q

indications for valve replacement in mitral regurg

A

acute severe MR
symptomatic
LV dysfunction: LVEF < 50% / LV dilatation
complications: new onset AF / pulmonary HTN
mod / severe MR already undergoing CABG

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44
Q

definition critical limb ischaemia

A

> 2 wks of:

  1. pain at rest
  2. tissue loss: arterials ulcers, gangrene
  3. ankle pressure < 40mmHg
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45
Q

signs chronic peripheral vascular disease

A 
reduced pulses 
dry shiny cracked hairless skin
brittle nails 
auscultation → bruit
Buerger's angle < 20
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46
Q

management chronic peripheral vascular disease

A

cons: exercise, smoking cessation, improve diet
med: treat CV RFs (HTN, dyslipidaemia, diabetes)
surg: angioplasty, endarterectomy, bypass

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47
Q

complications acute limb ischaemia

A

rhabdomyolysis → AKI

ischaemia → lactic acidosis, hyperkalaemia (→ cardiac arrest)

48
Q

management acute limb ischaemia

A

bolus IV heparin
urgent referral vascular surg:
surgical revascularisation: embolectomy / thrombolysis / angioplasty (for larger thrombus)
non-salvageable limb (paraesthesia, paralysis) → amputation

49
Q

presentation acute limb ischaemia

A 
Pain
Pulseless
Perishing cold
Pale
Paralysis
Paraesthesia 
(final 2 indicate non-salvageable limb → amputation required)
50
Q

classification for severity of heart failure

A 
NYHA classification 
1. asymptomatic
2. mildly symptomatic on activity
3. moderately symptomatic w activity
confortable at rest 
3. severely symptomatic
unable to carry out physical activity
Sx at rest
51
Q

pharmacological management HTN

A 
< 55yrs / T2DM: ACEi
> 55yrs / Afro-Caribbean: CCB
2. ACEi + CCB / ACEi + thiazide diuretic
3. ACEi + CCB + thiazide 
4. K < 4.5: low-dose spironolactone
K > 4.5: alpha / beta-blocker
5. specialist review
52
Q

causes postural hypotension

A

hypovolaemia
autonomic disturbance: diabetes, Parkinson’s
drugs: antihypertensive, L-dopa, diuretics, antidepressants
alcohol

53
Q

signs on exam aortic regurgitation

A

early diastolic murmur loudest over aortic area on expiration
wide pulse pressure
collapsing pulse
extras:
austin flint murmur: rumbling mid-diastolic murmur (turbulent blood hits mitral valve leaflets)
quincke’s sign: capillary pulsation in nail bed
de musset’s sign: head nods in time w pulse
corrigan’s sign: visibly pulsating carotids

54
Q

causes aortic regurgitation

A

congenital: bicuspid, connective tissue disease (Marfan’s), aortitis (ank spond, vasculitis)
acquired: endocarditis, type A aortic dissection

55
Q

management aortic regurgitation

A

cons: serial echo, CV risk optimisation
med: CV risk optimisation
vasodilators: ACEi / ARBs / CCBs (reduce TPR + afterload)
beta-blockers reduce aortic root dilatation in marfan’s
diuretics for Sx relief
surg: AVR

56
Q

CXR findings aortic regurgitation

A

cardiomegaly
widened mediastinum (aortic dilatation)
signs of L heart failure (pulmonary oedema, effusion)

57
Q

signs on exam mitral stenosis

A 
mid-diastolic murmur 
loudest on expiration over mitral region 
loud S1, opening snap 
tapping apex beat 
malar flush 
AF (irregularly irregular pulse)
58
Q

causes of mitral stenosis

A

most common: rheumatic fever
prosthetic valve malfunction
inflammatory conditions: SLE, RA

59
Q

complications of mitral stenosis

A

atrial fibrillation

pulmonary HTN → R heart failure (cor pulmonale)

60
Q

management mitral stenosis

A

cons: serial echo + patient follow-up
med: optimise CV RFs
treat AF / heart failure
diuretics for Sx relief
surg: percutaneous transvenous mitral commisurotomy (PTMC)
2nd line mitral valve replacement

61
Q

diagnostic criteria rheumatic fever

A

evidence of GAS + 2 major / 1 major + 2 minor
GAS: +ve throat culture, rapid Ag test +ve, high strep Ab titre
major: carditis, arthritis, sydenham’s chorea, erythema marginatum, subcutaneous nodules
minor: fever, raised ESR, leukocytosis, arthritis, prolonged PR on ECG, prev rheumatic fever

62
Q

management rheumatic fever

A

cons: bed rest, immobilisation of arthritic joints
med: aspirin + corticosteroids
ABx: benpen IV STAT then PO pen V for 10 days
treat chorea w diazepam / haloperidol
surg: may require valve replacement

63
Q

management infective endocarditis

A

treat w empirical IV ABx based on clinical suspicion:
acute → fluclox / vanc + gent
subacute → benpen + gent
surgery: removal of infected tissue, valve repair / replacement if decompensated heart failure, abscess, fungal endocarditis, repeated emboli

64
Q

mechanical vs bioprosthetic valves

A

mechanical: require lifelong anticoag

last longer ~20years

65
Q

types of mechanical valve

A 
starr-edward's: ball &amp; cage (high risk of clots - no longer used) 
tilting disc (bjork-shiley)
st jude's: bileaflet (two tilting discs)
66
Q

pacemaker indications

A

symptomatic bradycardia
tachyarrhythmias: SVT, VT
heart block: complete, Mobitz type II, AV block after anterior MI
biventricular pacing (CRT)

67
Q

types of pacemaker

A

single chamber: RV
dual chamber: RV + RA
biventricular (CRT): RV + RA + LV

68
Q

pacemaker complications

A

pneumothorax
infection
lead dislodgement
tricuspid regurg

69
Q

types of ICD

A

single chamber: RV (ICD)
dual chamber: RV (ICD) + RA, for concurrent arrhythmia (AF)
CRT(D): RV (ICD) + RA + LV, for heart failure (cardiac desynchrony)

70
Q

indications for ICD

A

primary prevention:
previous MI +
a. LVEF < 35% + non-sustained VT + positive electrophysiological study
b. LVEF < 30% + broad QRS (>120ms)
familial conditions w risk of sudden cardiac death: HOCM, long QT

secondary prevention following:
VT / VF causing cardiac arrest
haemodynamically unstable VT
VT w LVEF < 35%

71
Q

signs on exam aortic coarctation

A

radio-femoral delay, weak femoral pulse
BP in UL > LL
ejection systolic murmur
signs of Turner’s: short stature, neck webbing, wide-spaced nipples

72
Q

types of dextrocardia

A
  1. dextrocardia of embryonic arrest: heart placed further R in thorax than usual
  2. dextrocardia situs invertus: heart position mirrored from usual
    (situs invertus totalis = all visceral organs)
    assoc w Kartagener’s syndrome: primary ciliary dyskinesia
73
Q

management unstable angina

A 
acute: MONA
beta-blocker + statin
anticoagulation: heparin
consider coronary angiogram
ongoing: dual antiplatelet therapy (aspirin + clopi OD)
statin + ezetimibe
treat CV RFs
74
Q

management STEMI

A

acute: MONA
heparin + PCI (ideally within 90min)
thrombolysis if PCI not acessible (IV alteplase)
failure of PCI (continued chest pain / haemodynamic instability) → CABG

75
Q

management NSTEMI

A

acute: MONA
admit for at least 24-48hrs
fondaparinux / LMWH if undergoing angio
GRACE risk score
high → glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) + coronary angio within 96hrs of admission
low risk → close monitoring, consider angio

76
Q

MONA (incl doses)

A

diamorphine (5-10mg IV)+ metaclopramide (10mg IV)
oxygen if sats < 90
nitrates (sublingual)
dual antiplatelet therapy (oral): aspirin 300mg + clopidogrel 300mg / ticagrelor (reduced risk of stent thrombosis)

77
Q

post MI management

A

cons: exercise, diet
med: long-term dual antiplatelet (aspirin + clopi / ticagrelor)
statin for all pts
echo to assess damage to myocardium:
LVEF < 40% → beta-blocker
LVEF < 40% + HTN, DM, HF → ACEi
LVEF < 35% + HF / DM → spironolactone

78
Q

differentials for midline sternotomy

A

CABG
open valve replacement
less common: heart / lung transplant, atrial myxoma excision

79
Q

indications for CABG

A 
multivessel disease
single vessel disease + 
failed PCI
left main artery disease 
pt unsuitable for long-term dual antiplatelet Tx
80
Q

graft site options for CABG

A
  1. internal mamillary / internal thoracic artery
  2. long / short saphenous veins
  3. radial artery
81
Q

indications for heart transplant

A

dilated / ischaemic cardiomyopathy (most common)
congenital heart disease
NYHA class III / IV
LVEF < 30%

82
Q

causes of raised JVP

A 
R heart failure
tricuspid regurg 
pericardial effusion
SVC obstruction 
complete heart block 
constrictive pericarditis
83
Q

management ventricular tachycardia

A

stable → amiodarone
unstable → call crash team, electrocardioversion
consider ICD if recurrent

84
Q

causes of ventricular tachycardia

A

ACS
cardiomyopathy
electrolyte imbalance
long QT

85
Q

definition torsades de points + management

A

polymorphic ventricular tachycardia assoc w long QT

IV magnesium sulphate

86
Q

signs on exam aortic dissection

A 
collapsing pulse 
aortic regurg (mid-diastolic murmur) 
BP differential between L / R (>20mmHg) 
hypotension 
wide pulse pressure
87
Q

investigations aortic dissection

A

bedside: BP, ECG
bloods: FBC, U+Es, LFTs, D-dimer +ve, X-match 10 units
imaging: initial CXR → widened mediastinum
CT angio → visualisation of dissection + intimal flap
TOE → intimal flap

88
Q

management aortic dissection

A 
ABCDE
type A: urgent vascular surgical referral + control BP (100-120mmHg systolic) 
type B: control BP 
IV labetalol, nitroprusside 
opioid analgesia
89
Q

complications aortic dissection

A

aneurysm dilatation + rupture
occlusion of branch vessels (coronary → MI)
cardiac tamponade
aortic regurgitation

90
Q

cardiovascular causes of clubbing

A

endocarditis
cyanotic heart disease
aneurysms
atrial myxoma

91
Q

types of AF

A 
paroxysmal = self-terminated at least once
persistent = > 48hrs 
permanent = cannot be terminated w drugs / DC
92
Q

management wolff-parkinson white

A

cardiovert if haemodynamically unstable
IV adenosine
treat assoc arrhythmias
radiofrequency ablation of bundle of Kent (definitive)

93
Q

wolff-parkinson white associated conditions

A 
HOCM
mitral valve prolapse 
thyrotoxicosis
Ebstein's anomaly 
secundum ASd
94
Q

management supraventricular tachycardia

A

IV adenosine uncovers underlying pathology
beta-blocker, CCB, amiodarone
DC cardioversion if haemodynamically unstable

95
Q

management atrial flutter

A

if diagnostic uncertainty: IV adenosine / carotid sinus massage
rate control: beta-blocker, CCB, amiodarone
rhythm control: DC cardioversion
anticoagulation (CHADSVASc / HAS-BLED)
catheter ablation

96
Q

management atrial flutter

A

if diagnostic uncertainty: IV adenosine / carotid sinus massage
rate control: beta-blocker, CCB, amiodarone
rhythm control: DC cardioversion
anticoagulation (CHADSVASc / HAS-BLED)
catheter ablation

97
Q

causes of hypertension

A 
primary / essential: most common
secondary: 
renal disease: renal artery stenosis, PKD 
endo: conn's, cushing's, phaeo
pregnancy 
drugs: steroids, OCP 
aortic coarctation
98
Q

management of abdominal aortic aneurysm

A

cons / med: CV RF modification
surg: for > 5.5cm OR enlarged by >1cm / year OR rupture
EVAR (endovascular AAA repair): stenting for older pts / unable to tolerate open surg
complications: endoleak, need for further procedures
open repair: younger pts, longer recovery

99
Q

abdominal aortic aneurysm screening

A

for all men > 65 years: one-off abdo USS
>5.5cm OR enlarging by >1cm / year → elective repair
4.4 - 5.5cm → 3mthly USS
3 - 4.4cm → annual USS
< 3cm → discharge

100
Q

true vs false aneurysm

A

true: all layers of vascular wall + > 50% of normal diameter
false: collection of blood around vessel wall that communicates w vessel lumen
dissecting: tear in tunica intima creates false lumen

101
Q

indications for amputation

A

peripheral vascular disease: gangrene, acute limb ischaemia
trauma
malignancy
severe pain

102
Q

complications of amputation

A

infection, bleeding, site / phantom limb pain, disability, decreased mobility (difficulty fitting prostethesis if poor stump shape)

103
Q

dry vs wet gangrene

A 
wet: tissue necrosis + infection
offensive odour, swelling, discharge
dry: tissue necrosis due to chronic impairment of blood flow (PVD) 
dry, pulseless 
both: skin colour changes to black
104
Q

causes acute pericarditis

A

idiopathic
viral (most common): coxsackie, mumps
bacterial: TB, strep
post-MI: early (12-96hrs) / late (Dressler’s syn; 2-10wks)
connective tissue tissue: RA, systemic sclerosis

105
Q

investigations acute pericarditis

A

bedside: ECG
bloods: FBC, CRP, cultures, BNP, troponin
imaging: CXR, TTE (definitive)

106
Q

management acute pericarditis

A

cons: exercise restriction
med: IV ABx, NSAIDs + PPI, corticosteroids + colchicine
surg: pericardial aspiration / pericardiectomy
follow-up echo to assess for myocardial involvement

107
Q

complications acute pericarditis

A

pericardial effusion
cardiac tamponade
constrictive pericarditis

108
Q

types of cardiomyopathy

A

dilated: inefficient pumping of blood
HOCM: autosomal dominant
restrictive: rigid walls → poor filling (caused by infiltration: sarcoid, haemochromotosis, amyloid)

109
Q

presentation HOCM

A

syncope, chest pain, SOBOE, palpitations
ejection systolic murmur
jerky carotid pulse
pulsus bisferiens (double tapping apex beat / carotid pulse)

110
Q

management venous ulcers

A 
cons: CV RF modification, compression bandaging (if ABPI > 0.8)
bed rest + leg elevation 
med: analgesia
topical antiseptics e.g. manuka honey
oral pentoxifylline (peripheral vasodilator) 
desloughing w larval therapy
treat varicose veins 
surg: split-thickness skin grafts
111
Q

causes of long QT

A 
electrolyte abnormalities: low Mg, K, Ca 
antibiotics: macrolides, ciprofloxacin
antiarrhythmics: amiodarone, sotalol
lithium, SSRIs, TCAs
antipsychotics: quetiapine, clozapine
hypothermia
112
Q

investigations for DVT

A 
well score 
2 or more: leg USS within 4 hrs 
D-dimer if -ve
1 or less: D-dimer 
leg USS if +ve 
if cannot perform leg USS within 4 hrs then give LMWH and USS within 24hrs
113
Q

management heart block

A

1st degree / Mobitz type 1
conservative (ECG monitoring + review meds) if asymptomatic
consider pacemaker insertion if symptomatic

Mobitz type 2 / 3rd degree:
haemodynamically unstable: atropine + external pacing
stable: pacemaker insertion

114
Q

complications mitral regurgitation

A 
atrial fibrillation (→ stroke) 
pulmonary HTN (→ cor pulmonale)
115
Q

complications aortic stenosis

A

L heart failure

arrhythmias

116
Q

risk factors for heart block

A 
increased age 
ACS
drugs:
AV node-blocking: b-blockers, CCBs, adenosine 
anti-arrhythmias: sotalol, amiodarone
cardiomyopathy
117
Q

interpretation of ABPI

A

> 0.9 = normal
0.5 - 0.9 = intermittent claudication
0.3 - 0.5 = rest pain
< 0.3 = critical limb ischaemia

med / surg (15 decks)

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