Cardio Flashcards
What’s the physiology of Eisenmenger’s?
Associated with septal defects and patent DA. In a VSD, a left to right shunt exposes right ventricle to left v higher pressures, till the R ventricle hypertrophies enough that the shunt is reversed. This causes cyanosis and pulmonary hypertension.
Features of Eisenmenger’s and mx
Cyanosis, clubbing, murmur that disappears. Tx with heart-lung transplant
What is a globular heart a sign of?
ASD
What murmur does a VSD cause?
Blowing pan-systolic murmur
What psych drugs cause prolonged QT?
Anti-psychotics: haloperidol
TCAs: imipramine, noratriptylline, amitryptilline
SSRIs: citalopram
Seratonin receptor antagonists: ondansetron (also anti-emitic)
What AB can cause prolonged QT?
Erythromycin
What anti-arrhythmics can cause prolonged QT?
Amiodarone, sotalol
What electrolyte imbalances can prolong QT?
HYPOMg, Ca, K
Other causes of long QT
Hypothermia, subarachnoid haem
Mx of long QT
Beta blocker, avoid strenuous activity (can precipitate). Defib if high risk (implantable).
What investigation would you order for a patient with frequent collapse but normal resting ECG?
24 hour tape
What does long QT risk causing?
VT, then torsades (mono to polymorphic). Monomorphic VT is typically caused by MI.
Mx of VT
Adverse signs (CP, heart failure, hypotensive): immediate cardioversion. Stable: amiodarone. If drugs fail- DC shocks.
Is VT broad or narrow complex QRS?
Broad. SVT = narrow (s for small)
HOCM- demographic and inheritance pattern
Young, athletic individuals.
Autosomal dominant.
Causes thickened myocardium. LVH = reduced cardiac output.
Warfarin rules and targets for surgery
Stop warfarin 5 days prior to surgery. INR should be below 1.5.
Target for VTE and AF = 2.5
Target for recurrent VTE = 3.5
What can potentiate warfarin?
P450 inhibitors (amiodarone, ciprofloxacin).
Liver disease.
Anti-platelets.
Signs of heart failure
Third heart sound Displaced apex beat Bibasal crackles Pink, frothy sputum Raised JVP Oedema
Sx of heart failure
Sob, reduced exercise tolerance, swollen ankles/calves, fatigue.
Inv. for heart failure
ECG, bloods, BNP, echo, CX
Left V aneurysm appearance on ECG
Persistent ST elevation. Anticoagulate- stroke risk.
List complications after MI
VF (most common cause of death following CA)
Pericarditis, Dressler’s
LV Aneurysm or free wall rupture
Papillary muscle rupture (can cause mitral regurg and thus a murmur).
Cardiogenic shock
How does orlistat work?
Inhibits pancreatic and gastric lipase to reduce digestion of fat.
Unstable AF
Emergency: Immediate synchronised DC cardioversion
Bradycardia mx
Atropine 500mcg
If unsuccessful, repeat atropine or do transcutaneous pacing.
Beware of asystole.
What valve disease is PKD associated with?
Mitral valve prolapse. Beware of mitral regurg and arrhythmias
Side effects of amiodarone and baseline investigations
Pulmonary fibrosis, pneumonitis - CX
Hepatitis and fibrosis - LFTs
Thyroid issues either way- TFTs
Us and Es- can prolong QT so make sure they don’t have hypokalaemia
ECG changes for pericarditis
Saddle shaped ST elevation
PR depression
Investigations for pericarditis
ECG and echo if suspect
Mx of pericarditis
NSAIDs and colchine
Symptoms of pericarditis
CP relieved by sitting forwards, can be pleuritic.
May have flu-like symptoms, sob, np cough.
Pericarditis signs
Pericardial rub
Tachypnoe and cardia
ALS mx for asystole/pulseless-electrical activity
Adrenaline 1mg + 2 mins compressions. Rhythm check.
Reversible causes of cardiac arrest- The Ts
Thrombus (cardio or pulmonary)
Toxins
Tamponade (cardiac)
Tension pneumothorax
Tx pathway for hypertension
A (under 55 or T2DM) or C (55 or Afro)
A + C / A + D (A = ACE or aldosterone antagnoist). If Afro, aldosterone antag is preferable to ACE.
A + C + Thiazide Diuretic
Add beta/alpha blocker if k above 4.5, otherwise spiranolactone.
What is the most common cause of mitral stenosis?
What is the murmur associated with it?
Rheumatoid disease
Opening snap, followed by low pitched rumble.
Most common causative agent of infective endocarditis
Staph Aureus (especially among IVDU) Staph epidermis = prosthetic valve surgery, think indwelling lines
Anticoagulation post stroke with AF
300mg aspirin daily for two weeks, then lifelong anticoagulation.
Statin side effects and CI
Myopathies and liver impairment.
CI: pregnancy, macrolides like erythromycin and clarithromycin.
Statin doses for primary and secondary intervention
Atorvastarin 20mg
80mg for secondary
Indicated for established CVD or if QRISK is 10.
What factors favour rate vs. rhythm control?
RAte: A for AGE. Over 65, ischaemic heart disease.
Rhythm: under 65, first presentation, CCF, symptomatic, correctable precipitant like alcohol.
Drugs for rate control
Beta-blocker unless asthma
Ca blocker
Digoxin (first choice if heart failure)
Drugs for rhythm control
Sotalol, amiodarone, flecanide, catheter ablation last resort- doesn’t reduce stroke risk though so still need to anti-coag.
When would you cardiovert AF?
1) emergency
2) elective procedure
Af > 48 hours
3 weeks anticoagulation
Cardiovert (electrical preferred in this case)
4 week anticoagulation
AF < 48 hours
Heparin and early Cardioversion
Life threatening signs of hypertension
CP, new confusion, heart failure, AKI.
Others: pappiloedema or retinal harm
Stage 3 hypertension: mx options
1) Life-threatening signs: ED and admit
2) No sx: urgent end-organ damage investigations like fundoscopy, urine ACR,ECG
3) Phaechromacytoma?
Mx of angina
Give all patients GTN, statin and aspirin (unless CI)
1st line: beta or rate limiting Ca block (verapamil/diltiazem). Titrate to max dose.
2nd line: beta + Ca blocker (switch to long acting like nifedipine).
3rd) can’t tolerate above, use ivabradine or LA nitrate. Only add 3rd drug if on combo if awaiting PCI/CABG.
Advice for timing doses of standard-release isosorbide mononitrate
Asymmetric dosing (e.g. 6am, 10pm) Minimises development of nitrate tolerance
Characteristic sign of tamponade
Pulsus paradoxus
What is Beck’s triad? What investigation should you performed first if present?
C.tamponade: falling bp, muffled heart sounds, rising JVP. Perform echo.
Secondary prevention of MI
5 drugs Ace Beta Statin Dual anti-platelet
What should you use as an alternative if ACE aren’t tolerated in hypertension mx?
Angiotension blocker e.g. losartan
First line inv for heart failure
NT-proBNP
What does cor pulmonale describe?
Right sided heart failure (RVH) caused by pulmonary artery hypertension. Related to COPD causing pulmonary vasoconstriction.
Signs of RHF
Raised JVP, hepatomegaly, ankle oedema.
Signs of LHF
Dyspnoea on exertion, orthopnea, paroxysmal nocturnal dyspnoea, wheeze, cough.
Mx of heart failure
1) Ace + Beta (start one at a time)
2) Add aldosterone antagonist (spiranolactone)
3) Ivabradine, valsartan (both EF <35) , digoxin (AF, ionotropic), hydralazine with nitrate (for Afros), cardiac resync
Can use loop diuretics like furosemide but they don’t improve mortality.
One off pneumococcal, annual influenza.
What ventilation should be considered in acute heart failure/pulmonary oedema not responding to tx?
CPAP
Which beta blockers reduce mortality in heart failure?
Bisoprolol, carvedilol
What drug should be used to mx anxiety and dyspnoea in acute heart failure? + mechanism
Morphine- opioid with vasodilator properties, reduces sympathetic drive.
Mx options for acute heart failure
O's and I's O2 Opioids IV loop diuretics Ionotropes CPAP
What investigations should be performed prior to/with every dose increase of spiranolactone?
With any mineralocorticoid receptor antagonist, Na, K, renal function and bp should be performed.
Mx of major haemorrhage on warfarin
Stop warfarin.
PT complex concentrates (don’t give if INR under 8)
IV Vit K.
NSTEMI mx
Aspirin + GTN + morphine
Determine 6 month mortality risk (GRACE)
Ticagrelor (not high risk of bleeding) + fondaparinux
Clopi (intermediate/high risk > 3%) + unfractionated heparin
Coronary angiography + PCI if required:
- immediate if unstable
- within 72 hours if immediate risk/+
Differentiating ACS from pericarditis on ECG
Pericarditis = global changes, saddle shaped possibly. Ischaemia = territory changes
What ECG waves are seen in hypokalaemia and hypothermia?
Hypok - U waves
Hypothermia - J waves
Atypical presentation of a.dissection
Neurological sx
