Cardio cards stems Flashcards
Duke’s criteria? (BE TIMER)
Most common murmur?
BE (major) TIMER(minor)
Blood culture x2 12 hrs apart
Echo
Temp 38+
Immunological signs (roth spots, osler’s)
Embolic diease (conjuctivial,
RF
DX: 2 major or 1 major+3minor or 3
Aortic regurg/ new murmur. early diastolic decrescendo murmur
Dressler’s syndrome?
2 -3 weeks post MI/ trauma. pericarditis (ST elevation and PR depression)- friction rub, low fever, pleuritic chest pain worse lying down, TX NAIDS/steroids.
Post MI complications?
structural ?
RF?
Arrhythmias (VT, VF, total AV block)
ISchaemia (CK-MB, recurrent chest pain)
LV dysfunction, heart failure - killip’s classifcation
Free wall rupture (bleeding into pericardium, tamponade)
Ventricle septal rupture (harsh pansystolic murmur left sternal edge, hypotension, shock, pulmonary oedema, do TOE)
Acute Mitral regurg (post infero-posterio MI, papillary muscle rupture/ necrosis)
Left ventricular outflow obstruction
dressler’s (2 to 4 weeks after)
DVT/PE (systemic)
RF for ventricle septal rupture/ free wall rupture post MI?
RF: female, non smoker, HTN, anterior infarction, first MI, 2-7 days after
HTN with t2DM first line drug?
after triple therapy?
ACEi/ ARB
already on ARB/ACIe and CCB and thiazide diuretic, give spironolactone if K <4.5 or alpha blocker/ BB if K5.5+
Hyperkalaemia ECG
Tall T waves, small p waves, wide QRS
Hypokalaemia ECg
small/ inverted T waves, U waves, long PR, depressed ST.
systolic murmur at apex of heart radiating to left axilla.
If person complains of dysopnoaa at rest?
MR, most common worldwide. LV blood backflows to LA
ACute MR (post MI/ rupture of chordae tendonae) presents as reduced CO, shock, dysopnoae at rest.
HF classification/ BNP values/ EF values?
TX summary?
BASSSHED
BNP refer at: 2000 - 2ww, 400-2000 6ww. , <200 - not confirmed
EF - preserved 50+, <40 severe, 41-49 mild to mod.
TX: acei (ARB candesartan i not toelrate) (UEs at baseline and 1-2 weeks), BB, then spironolactone (U-Es at 7 days)
Others: ivabradine, SGLT2i, digoxin, hydralazine, nitrate, valsartan/ sacubritil
post MI drugs TX?
dual antiplatelet (aspirin lifelong, pasugrel P2Y12 i 12 months)
ACE i (lifelong, reduced cardiac vascular resistance and afterload, lower preload.
BB 12 months 9lfielong (LV EF reduced)
DVT/ PE TX summary?
Risks/ complications of DVT
wells<2 do dimer. 2+ do USS.
TX: LMWH 5/7 and then dabigatran (crcl 30+)/edoxaban
Crcl 15-50 - apixaban/riveroxaban
<15- LMWH/ UFH (Risk HIT)
warfarin - preferred if 120kg+/liver dysfunction/ egfr <30.
Risk: post thrombotic syndrome (chronic venous hypertension pain swelling, lipodermatosclerosis within 2 yrs)
Flash pulmonary oedema post MI?
Post MI/MR
Cx of Heart block?
2nd degree HB?
flecanaide, BB, digoxin,
High K, Mg, Addisons,
SLE, scleroderma, RF, sarcoid, endocarditis
Post cardiac cauterization complication?
femoral pseudoaneurysm: pulsatile mass, bruit, compromised distal pulses
CI to exercise stress testing?
MI in last 2 days, severe AS, uncontrolled angina/ arrhythmias, HF, acute PE/ pericarditis, acute dissection
Aortic dissection pain and areas association?
neck and jaw?
anterior chest pain?
intracapsular region?
jawand neck: aortic arch
anterior chest: aortic arch or aortic root
intracapsular: descending aorta,
DVT TX
DOAC not recommended in?
When would you use fondaparinux?
when would you use warfarin instead of DOAC?
If rapid reversal needed/ high risk of bleeding?
APLS, pregnancy, breastfeeding, liver impairment, prosthetic heart valves, <40kg/120kg+ (use LMWH/UHF)
riveroxaban has increased risk of GI bleed compared to warfarin
fondap - reserved for people with known HIT
wardarin - if GFR <30, liver dysfunction or 120kg+
high bleeding risk - IV UFH (short half life and reversed with protamine)
61 YO female collapses after 1st MI with distended neck veins
Left ventricular free wall rupture (cardiac tamponade - low bp, JVP distended, muffled HS)
High K drug causes?
ACEi, BB, ARB, trimethoprim, heparin, digoxin
elderly women, Crushing retrosternal chest painr adiating to jaw, intermittent for 3 yrs. normal cardio ix
Oesophageal spasm - corckscrew appearance on barium swallow.
How to hear pericardial friction rub?
Sat forward, left sternal border on expriation.
https://youtu.be/-DB_8zyg9W8
ACS contraindication to thrombolytic?
Bleeding , recent haemorrhage, trauma, dental extraction, aortic Dissection, neoplasm (intracranial) HTN, stroke <3 months, pericarditis, dissection, endocarditis bacterial,
ST depression, V5, v6 inverted T waves?
digoxin toxicity
RAD, RBB, RV strain ECG signs?
St depression, t wave inversion
PE. RV strain - ST depression, T wave inversion on leads 1, 2, AVF, V1, V2
in PE. S1Q3T3 is rarer
Hypocalcaemia spot causes?
ECG features?
Acute panc, panc surgery, alkalosis (hyperventilation), rhabdomylisis, scepticaemia, osteolytic mets, Parathyroid gland surgery, bisphosponates, calcitonin, phenytoin, foscarnet, phosphate substitution
prolonged St and QT interval
Cardiac tamponade features?
Normal pericardial space- 20-50ml fluid
Beck’s triad - hypotension, distended JVP, muffled hs,
pulsus paradoxus
kussmal sign,
ewart/pin’s sign - bronchial sounds below angle of left scapula
CXR: bottle shaped heart.
RF: surggery, mets, end stage renal disease, trauma, TB
ALS: stable narrow complex, regular tachycardia?
likely SVT - trial vagal manouvers, then 6mg iv bolus adenosine, then 12mg, then 12mg, escalate
Stable patient, Broad complex, regular tachy?
IV amiodarone 300mg
Points when counselling on Af anticoagulation?
Do you offer anti-coagulation to <65YO with no other RF?
anticoagulation reduced risk by 2/3. Risk of stroke is x5 higher with AF and risk of severity is higher.
No dont offer if only score is for sex
Driving advice for Mi/ CABG/pacemaker/ angio?
no driving for 1 week after angio, pacemaker, successful angio
no driving for 4 weeks after STEMI/ NSTEMI/ CABG
Return to work within 2 months
no sex for 1 month
Cheyne stokes breathing?
progressively deeper and shallower in brainstem stroke/ raised ICP
30YO male south eastern patient with collapse? ECG shows?
Brugada sign - ST elevation 2mm+ in V1-3 and T wave negative
pansystolic murmur post MI?
Mitral regurg (damage to papillary muscle) - can be 3-5 days after/ VSD - can present1-2 weeks post mi
Features of mitral stenosis?
rumbling mis-diastolic murmur loud on expiration with patient on left side., malar flush, AF, fatiuge, SOB, palpatations
Causes of IE?
Staph A
Staph A (coagulase negative)
Streptococci (viridans, subacute)
Group D streptococcus (acutre and subacute)
strept intermedius
A, C, G - acute, high mortality
GBS - pregnancy, elderly
HACEK
fungi
enterococci
ECG: J waves, long PR, long QRS, long QT, AF
Hypothermia
24 YO footballer, LAD, sinus brady, LVH, SOB, chest pain, dizziness after training, systolic murmur on left sternal edge
Hypertrophic cardiomyopahty
AUtosomal D,exercsie testing to see severity,
Digoxin contraindicated in aF, anticoagulate, counsel, amiodarone for arrhythmias,
outflow obstruction - BB/verapamil. prophylactic abx bc raised risk of IE/
pulseless paradoxus seen in?
12+ raise in BP on inspiration (abnormal)
PE, constrictive pericarditis, rapid and laboured breathing, RV infarction with shock, restrictive cardiomyopathy, severe obstructive pulmonary disease,
Lone AF?
AF in <60 with no evidence of cardiac conditon
Advice to give when someone has 1st degree HB?
reassure, caution when using BB/ diltiazem, digoxin, declare on driving/ health insurance. small risk of aF developing.
Angina TX?
If using CCB with BB/ ivabradine?
1) BB or CCB (DHP, rate limiting verapamil/ diltiazem) if CI
2) Beta blocker + CCB (non-DHP - amlodipine/felodipine/nifedipine)
3) Add nitrate, ivabradine, nicorandil (ulceration risk) or ranolazine
Amlodipine can be used if HF
Verpamil and BB = very bad
Post Mi complications timing of conditions?
0-4hrs - Cardiogenic Shock, CHF, arrhythmia
4-24hrs - Arrhythmia
1-3 days - Pericarditis
4-7 days - Rupture of ventricular free wall, interventricular septum, or papillary muscle
Months - Dressler syndrome, aneurysm, mural thrombus
67 YO man, home BP is 145/95, QRISK is 8%. MX?
what if BP is 150/100?
stage 1 HTN - treat if end organ damage/ QRISK 10%, known CVD/DM.
If stage 2 treat regardless of age. (150/95+ at home)
PERC rule to rule out PE?
if all abscent can rule out:
age 50+, HR100+, unilateral swelling, on HRT/ COCP, o2<94, previous DVT/PEsurgery/ trauma in 4 weeks, haemoptysis
75 nocturnal sob, occasional palpitations and tight chest pain. collapsing pulse and a laterally shifted apex beat. head bobs in time with his pulse
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
Aortic regurgitation, early diastolic murmur increased when squeezing hand.
(backflow during ventricular diastole)
Causes of AR?
RF (common, developing world)
Marfans/ SLE/EDS/ ank spond/ bicuspid Aortic valve
Acute: infective endocarditis/ aoritc dissection
SE and CI of nicorandil?
headache
flushing
skin, mucosal and eye ulceration
gastrointestinal ulcers including anal ulceration
Contraindications
left ventricular failure
HF MX summary?
1st line: ACEi/BB(Bisoprolol, Carvedilol)
2nd line Aldosterone antagonist(Spironolactone, Eplerenone)/ SGLT2i
3rd line: involve a specialist for
-Ivabradine(SR, HR>75+ EF <35%)
-Sacubitril-valsartan( EF 35%+ Symptoms despite ACEi/ARB)
-Digoxin( if coexistent AF)
- Hydralazine+Nitrate( in Afro-Caribbean)
-Cardiac resynchronization therapy( Widened QRS e.g. LBBB)
Role of SGLT2i in preservd EF
Orthostatic hypotension - DX?
TX?
BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic
fludrocortisone, midodrine, compression, salt intake, head elevation
When to give 20 mg atorvastatin to t1dM?
40+, DM for 10 yrs+
Have established nephropathy
Have other CVD risk factors (such as obesity and hypertension)
Statin SE
monitoring
CI other drugs?
Myopathy, LFTs, CI- macroglides (clarithromycin) and pregnancy,LFTs at baseline, 3 months and 12 months - stop if 3x upper limit
History of asthma, Marfan’s etc
Sudden dyspnoea and pleuritic chest pain
pneumothorax
Central crushing pain with absent distal pulse?
If patient is too unstable for this imaging
unequal arm pulses?
Dissecting aorta
CXR - wide mediastinum
CT angio CAP
TOE - if unstable to get to CT scanner
Risk of backward tear - inferior MI/ AR
Risk of forward tear- unequal arm pulses, stroke, renal failure
Standford and debakey classification
Syncope, chest pain, SOB, ES murmur that reduces with valsalva manouver?
AS. CX:
<65 - bicuspid, >65 - degenerative calcification, post rF, HOCM
chjildren - balloon
Surgical AVR - if 40mmHG +/ symptomatic
TAVR - for high risk (transcatheter AVR)
CX of IE associated with colorectal cancer?
AF with indwelling lines?
Streptococcus bovis
staph epidermis
TX of IE for native valve?
suspected MRSA/ penicillin allergy or sepsis?
NVE with severe sepsis/ RF for gram negative?
Prosthetic valve endocarditis?
NVE): amoxicillin + gentamicin
sepsis/allergy/MSRA: vancomycin + gentamicin
NVE with severe sepsis and risk factors gram negative infection: vancomycin + meropenem
Prosthetic valve endocarditis: vancomycin, gentamicin + rifampicin
What drug reduced efficacy of clopidogrel?
omeprazole
PE causes resp acidosis or alkalosis?
alkalosis (hyperventilation)
NSTEMI tx?
DAPT ticegralor and aspirin 12 months
persistent ST elevation post MI, no chest pain?
left ventricular aneurysm
do echo after as thrombus can developFc
Post MI 2-5 days inferior MI, pulmoary oedaema sx?
papillary muscle rupture
2 weeks after MI, ST elevation with PR depression widespread, pleuritic chest pain, fever?
dressler’s syndrome
factors that can icnrease BNP?
LVH, ischaemia, PE, GFR <60, sepssi, COPD, DM, 70YO+, liver cirrhoris
factors that reduce BNP?
obestity, diuretics, Acie, BB, ARB, aldosterone antagonists
BB SE:
HF tx that causes ototoxicity?
nightmares, sleep disturbances, ED, cold peripheries, fatigue, CI: verapamil, asthma, uncontrolled hf
furosemide - ototoxic
Post MI, pansystolic murmur, reduced hs. after 1-2 weeks?
VSD 9do echo to exclude MR
posterior/ inferior MI with new pulmonary oedema, HTN post MI 3-5 days?
acute MR. due to papillary muscle rupture/ischaemia
most common cx of death inpost MI?
ventricular fibrillation
Conditions that predispose to pericarditis?
Dr Is TRUMP
DR Is TRUMP
Dressler, Radiotherapy, infection (coxsackie), SLE, TB, RA, Uraemia, Malignancy, Post MI
HCOM: most likely cx of death?
ECHO features? MR SAM ASH
ECG features?
ventricular arrhtymias,
echi: MR, systolic anterior motion of anterior mitral valve leaflet, asymmetric hypertrophy
ECG: LVH - deep ST depression, T waves inversions,
ace i SE:
angiodaema, CI b/l RAS, pregnancy, creatine rise 30%+ baseline
STEMI mx?
time for PCI
anticoagulation?
radial/femoral access?
fibrinolysis?
aspirin,PCI within 12 hrs of sx and 120 mins faster than med
give pasugel (if no other anticoagulant), chlopi (if on other blood thinners)
radial access - give UFH, with GIP bailout.
femoral access - give bivalirudin with bailout GPI
fibrinolysis - antithrombin and repeat ecg in 60 mins-90 mins. pci if still MI
NSTEMI MX
for immediate PCI?
for not immediate PCI?
conservative mx?
PCI MX? - what to give before
which one better for raised bleeding risk/ on other antivoagulants?
aspirin
fondaparinux - if not having PCI immediately, not at high risk of bleed
unfractionated heparin - if creatin 265+, immediate PCI plan
Conservative mx:
DAPT with ticegralor/ chlopidogrel
PCI within 72 hrs:
UFH before and DAPT after
STEMI dx values?
ACS sx 20 mins+ 2ECG leads :
2.5 mm (i.e ≥ 2.5 small squares) STEMI in V2-3 in men under 40 years, ≥ 2.0 mm (40 M +)
women: 1.5 mm STEMI V2-3
1 mm ST elevation in other leads
new LBBB
HTN Mx summary?
140/90+ do Home
tx stage 1 - if <80/ t2dm/ckd/end organ dysfunction
2) 150/90 at home/ 160/100 in clinic tx whatever age
3)180/120+
<55YO/ T2DM/ not black - give A over CCB
Acute HF Mx?
HF with BP< 85 - inotropic agents in ITU
if respiratory failrue - CPAP
continue regular meds unless BB - stop if HR <50
Post MI MX?
echo at 3 months (immediately after mi can giv efalse low EF)
give BB, ACe, high statin dose, DAPT - aspirin lifelong, other for 1 month
Vasculitis AF smoking and raynaud’s phenomenon/ intermittent claudication/ ischaemic ulcers/ superficial thrombophlebitis?
buerger’s disease
Major bleeding with warfarin - IC bleed?
mx if any bleeding?
if INR 8+
INR 5-8?
no bleeding?
regardless of INR, give iv vit K, prothrombin complex
if bleeding , give iv vit K, repeat in 24 hrs restart when <5.
INR 8+ - no bleed, give Po
5-8 - with-hold or give iv if bleeding.
when to start Af anticoagulaion in TIA and stroke?
TIA - start DOAC of warfarin asap
stroke - wait 2 weeks
post inferior MI, sx of left ventricular failur, drop in BP, eary-mid systolic murmur?
papillary muscle rupture causing acute mitral regurg
4 weeks post anterior MI with pulmonary oedema, persistent STEMI in anteiror leads?
left ventricular aneurysm
AS features?
narrow pulse oressure, slow rising pulse, LVH, soft S2, thrill over cardiac apex
ESMurmur decreased post valsalva manouver
ST change leads 2, 3 , AVF
RCA, inferior MI
AVN supply - also present with arrhythmia
ST changes anterolateral MI>
V1-6, lead 1, AVL
ST changes in V1-4?
LAD, anteroseptal
Left circumflex A ST changes?
1, AVL, V5-6
HF drugs that actually reduce mortality?
BB.ACEi/ARB, alodsterone antagonist, hydralazine and nitrates
Heart Block mneumonic?
longer longer, drop, wenchebech
if some Ps dont get through, you’ve got mobitz 2, if Ps and Qs dont agree, you’ve got 3rd degree
normal variant in athelete?
warrents urgent referral on ECG?
1st HB, mobitz 1 (wenchebach, junctional rhythm, sinus bradycardia
HCOM ECG:
secondary HTN CX: pregnant 10 weeks with K+ of 3.1?
primary hyperaldosteronism (most common cx of secondayr htn)
HTn, headahce,s excessive sweating, bitemp hemianopia?
acromegaly
HTN with asymmetrical kidney disease and IHD cx?
B/L renal artery stenosis
drug cx of secondary THN?
leflun0mide, NSAIDs, COCP, seeroids, MOAi
medical cardioversion of AF?
Structual?
flecainide
amiodarone - if any structural heart disease
Conservative mx of NSTEMI?
fondaparinux, ticegralor and aspirin
2nd line is chlopidogrel if high bleeding risk
BP targets for 80YO+
<80
150/90 at home: 145/85
<80: 140/0 (at home: 135/85)
if statin 20mg is started for primary prevention when would you increase it to 80mg?
if non HDL has not fallen by 40%
central chest pain with diastolic murmur. what is shown on angiogrpahy?
ascending aorta - giving AR.
aortic dissection shows false lumen
post tx of SVT, sudden chest pain after resolution?
adenosine used for SVT.
SE: flushing, chest pain, bronchospasm (CI asthma)
HTN already on indapamide, amlodipine, acie,. K is 4.5+ what can be added
doxazosin/ BB
if K <4.5, can add spironolactone
Low voltage QRS causes?
pericardial effusion, obesity, emphysema, pneumothorax, myxoedema, restrictive cardiomyopathy, scleroderma, constrictive pericarditis, MI previously
criteria used to diagnose familial hypercholesterolaemia?
TC 7.5+/ LDL 4/9+ tendon xanthomata in patient/ 1st/2nd degree relative
simon broome criteria
when should you stop statin before trying to conceive?
3 months before
definition of prolonged pericarditis?
recurrent - 4-6 weeks after fist ep
chronic - 3 months
admit after 1 week
when to admit for pericarditis?
fever, tamponade (risk), troponin, trauma, on anticoagulants, nsaids dont work, immunosuppression
pericarditis ECG changes?
saddle shapes ST elevtaion/ concave and PR depression acutely with reciprocal changes
then late stage t waves inversions
ejection systolic murmur that diappears when squatting
HCOM (auto. dom)
most common cardio genetic condition
ECG of HCOM?
LVh (increased voltages), dagger life deep narrow Q waves, left atrial enlargment (p mitrale), arrhythmias
IX for HTN?
ECG urinalysis,, hba1c, 12 lead ecg, U+Es
black person with HTn, no other sx and obese?
essential HTN
east asian man, intverted t waves in right pericordial leads and ST elevation? FH early death during day time car crash?
brugada syndrome (AF sudden unexplained noctunal dath syndrome/
sick sinus syndrome definition?
abnormal SAN function, bradycardia, cardiac insufficiency.
peripheral arterial disease tx?
level of ABPI?
structured exercise.
offer naftidrofuryl oxalate
ABPI <0.9
<0.5 is critical limb
1.4+ suggests calcification/ vascultiis/ dm
