Cardio 9.5 Flashcards
Deeply inverted or biphasic T waves in V2-V3 with chest pain?
Wellen’s syndrome
- critical LAD stenosis
- anterior wall MI
- at risk of imminent occlusion so should be admitted for coronary angiography & intervention
WPW syndrome is a congenital accessory pathway leading to a AV re-entry tachycardia
- as the accessory pathway doesn’t slow conduction, AF can degenerate rapidly to VF
Associations?
Rx?
- HOCM
- mitral valve prolapse
- Ebstein’s anomaly
- thyrotoxicosis
- secundum ASD
- definitive Rx = radiofrequency ablation of accessory pathway
- medical = amiodarone, flecainide or sotalol (avoid if AF as prolonging refractory period may increase rate of transmission through accessory pathway -> VF)
LQTS
LQT1/2/3?
Rx?
LQT1 - exertional syncope, e.g. swimming
LQT2 - syncope following emotional stress, exercise or auditory stimuli
LQT3 - often at night/rest
Avoid drugs/precipitants
- beta-blockers (not sotalol)
- ICD if high risk
Drugs that precipitate LQTS?
- amiodarone, sotalol, class 1a anti-arrhythmias
- TCAs, SSRIs esp citalopram
- methadone
- chloroquine
- erythromycin
- haloperidol
- ondansetron
- terfenadine (non-sedating antihistamine)
AIVR = accelerated idioventricular rhythm is benign ectopic ventricular rhythm that usually occurs after repercussion of an ischaemic myocardium, has a rate of 50-110 which helps differentiate from ventricular brady/tachy
Pathphys?
Causes?
ECG?
Rx?
- repercussion of ischaemic tissue, electrolyte abnormalities or drug toxicity -> increased depolarisation rate of ventricular myocytes
- when this depolarisation rate is faster than the rate produced by the SAN -> overriding rhythm (therefore sinus brady by vagal excess or reduced sympathetic activity can precipitate AIVR)
- haemodynamically stable usually
- reperfusion post-MI is commonest
- beta-sympathomimetics eg adrenaline
- drug toxicity: digoxin/cocaine
- electrolyte imbalance
- cardiomyopathy, congenital heart disease, myocarditis
ECG: gradual onset & termination so may be ventricular fusion beats, AV dissociation, wide QRS >120ms, rate 50-110
- self-limiting - but atropine can be used to overcome
2ry causes of HTN:
- endocrine?
- renal?
- drugs?
- others?
- Conns = commonest
- Cushings, Liddles, phaeochromocytoma, CAH (11-beta hydroxylase deficiency), Acromegaly
- renal disease e.g. ADPKD, GN, pyelonephritis, renal artery stenosis
- steroids, MAO-Is, COCP, NSAIDs, leflunomide
- pregnancy, coarctation of aorta
For pts in whom stable angina cannot be excluded by clinical assessment alone, what Ix are recommended by NICE? (e.g. Sx consistent with a/typical angina or ECG changes)
1st line CT coronary angio
2nd line non-invasive functional imaging (to look for reversible myocardial ischaemia)
3rd line invasive coronary angiography
Examples of non-invasive functional imaging:
- MPS with SPECT
- stress echo
- 1st pass contrast-enhanced MT perfusion
- MR imaging for stress-induced wall motion abnormalities
Signs of tricuspid regurg?
Causes?
- PSM, prominent v waves in JVP, pulsatile hepatomegaly, left parasternal heave
- RV infarct, pulm HTN, rheumatic heart disease, Epstein’s anomaly, carcinoid syndrome, IE (esp IVDU as it is the 1st valve reached by venous blood)
Which anti diabetic drug may be of benefit in heart failure?
SGLT2 inhibitors eg Empagliflozin - promotes sodium excretion with a thiazide-like effect
NICE guidelines angina?
1st ACE-i + beta-blocker
2nd AA, A2TB or hydralazine+nitrate
3rd if Sx persist then consider cardiac resynchronisation Rx or Digoxin. Or Ivabradine if on ACE-I, beta-blocker, AA, HR>75, LVEF <35%
- diuretics for fluid overload
- Sacubitril-valsartan is considered in heart failure with reduced EF who are Sx on ACE-I or ARBs
- Nb ACE-I & beta-blockers have no effect on mortality in HFPEF
Fatigue, dizziness & hypotension after pacemaker insertion?
Pacemaker syndrome - ass with a VVI pacemaker that results in simultaneous atria & ventricle conduction
DAPT for ACS for 12 months?
Aspirin 75 OD + Ticagrelor 90 BD
- Ticagrelor C/I if high risk bleed, Hx of intracranial bleed or severe hepatic dysfunction; caution in asthma/copd as higher rates of dyspnoea
Antiplatelet Rx for people with ACS undergoing PCI?
Aspirin + Prasugrel/Ticagrelor/Clopidogrel for 12 months
Nb PPIs reduce the effect of clopidogrel
Features of constrictive pericarditis?
(causes inc anything that causes pericarditis esp TB)
Rx?
- dyspnoea
- right heart failure: raised JVP, ascites, oedema, hepatomegaly
- prominent x & y descent of JVP
- loud S3 - pericardial knock
- Kussmaul’s sign +ve
- CXR: pericardial calcification
Rx = pericardiectomy
(diuretics if not suitable)
Turner’s syndrome 45X or 45XO
Features?
- short stature, shield chest, widely spaced nipples, webbed neck
- bicuspid aortic valve 15% coarctation 5-10%
- 1ry amenorrhoea
- cystic hygroma
- high-arched palate
- short 4th metacarpal
- multiple pigmented naevi
- lymphoedema in neonates esp feet
- gonadotrophin levels elevated
- hypothyroidism
- increased incidence of autoimmune esp thyroiditis
- can get a severe haemophilia (because of just 1 X)
When is IE prophylaxis indicated?
- prosthetic heart valve or material used for cardiac valve repair
- previous IE
- cardiac Tx with subsequent development of cardiac valvulopathy
- congenital heart disease under specific circumstances e.g. unrepaired cyanotic defects
High risk of IE?
- prev IE
- previously normal valves
- rheumatic valve disease
- prosthetic valves
- congenital heart defects
- IVDUs
Culture negative causes of IE?
- prior Abx Rx
- HACEK: haemophilus actinobacillus cardiobacterium eikenella kingella
- Brucella
- Bartonella
- Coxiella burnetii
Causes of IE:
- commonest?
- commonest in IVDUs?
- commonest in first 2 months after prosthetic valve surgery?
- linked with poor dental hygiene or post dental procedure?
- bowel cancer?
- non-infective?
- staph aureus
- staph aureus
- staph epidermidis
- strep viridans eg strep mitis/sanguinis
- strep bovis/gallolyticus
- SLE: Libman-Sacks, malignancy: marantic endocarditis
