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Phase 2a > Cardio investigations and treatments > Flashcards

Cardio investigations and treatments Flashcards

1
Q

Aortic stenosis
Mitral stenosis

Murmur
Investigations
Treatment

A

Aortic stenosis -
- Ejection systolic, crescendo decrescendo murmur radiating to the carotids
- Chest x-ray, (ECG), GS - TOE
- Young stable patient –> Aortic valve replacement
- Older unstable patient –> Transcatheter Aortic valve implant (TAVI)

Mitral stenosis
- Rumblind, low pitched Mid diastolic murmur at the apex
- Chest X-ray, (ECG), GS - TOE
- Percutaneous balloon valvotomy, mitral valve replacement

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2
Q

Aortic regurgitation
Mitral regurgitation

Murmur
Investigations
Treatment

A

Aortic regurgitation
- Early diastolic blowing (decrescendo) murmur
- Chest X-ray, (ECG), GS - TOE
- Usually IE prophylaxis and serial echocardiogram monitoring (Acute - surgical aortic valve replacement)

Mitral regurgitation
- Pansystolic murmur radiating to the axilla
- Chest X-ray, (ECG), GS - TOE
- Rate control - BB, CCB (if not severe)

(Severe - valve replacement)

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3
Q

Stable Angina

Investigations
Treatment

A

Investigations
FL - Resting ECG - Normal
GS - CT Coronary Angiograph –> Shows stenosed atherosclerotic arteries

Treatment
Symptomatic - GTN spray
Lifestyle modifications - Increase physical activity, smoking cessation

Pharmacological
1st line - BB (CI in asthma - give CCB instead)

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4
Q

ACS

Investigations
Treatment

A

Investigations
1st line - ECG
UA - Normal ECG (possible ST depression)
NSTEMI - Normal ECG - Possible ST depression and T wave inversion
STEMI - ST elevation in at least 2 contiguous leads

Serum troponin
UA - Normal
NSTEMI - Elevated
STEMI - Elevated

GS - CT coronary angiogram

Treatment
Initial Acute treatment (MONA)
Morphine, oxygen, GTN, aspirin

If NSTEMI/UA –>
Dual antiplatelet therapy with aspirin and clopidogrel
If it doesn’t work, LMWH

STEMI –>
PCI - If a PCI can be done within 2 hours of reaching hospital
(Overall within 12 hours from symptom onset)

Thrombolysis with alteplase if >12 hours of symptom onset

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5
Q

Long term prevention treatment of ACS

A

Beta blocker

Aspirin + Clopidogrel

Statin - Atorvastatin

Ace inhibitor - Enalapril

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6
Q

Abdominal Aortic Aneurysm

Investigations
Treatment

A

Investigations
1st line + GS - Abdominal Ultrasound

Treatment -
Asymptomatic + Unruptured –>
Manage the risk factors (smoking cessation, decreasing BMI)

Growing rapidly, >5.5cm + unruptured –> EVAR (endovascular aneurysm repair), or Open surgery

Ruptured
- Immediate resuscitation with ABCDE
+ EVAR

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7
Q

Heart failure

Investigations
Treatment

A

1st line - BNP levels elevated

ECG - Abnormal (signs of LVH/RVH)

Chest X-ray
A - Alveolar oedema
B - Kerly B lines - interstitial oedema
C - Cardiomegaly
D - Dilated vessels
E - Pleural effusion

GS - TTE

Treatment
Conservative - Lifestyle changes (smoking cessation, exercise, decrease BMI)

Pharmacological (ABAL)
- Ace inhibitors (first)
- Beta blocker
- Aldosterone antagonist
- Loop diuretic (furosemide)

Chronic/worsening heart failure - Ivabradine

Last resort - revascularise, heart transplant

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8
Q

Aortic dissection

Investigations
Treatment

A

Investigations
1st line - Chest X-ray –> Widened mediastinum

GS - TOE (shows intimal flap and false lumen)

Treatment
(Via Stanford classification of Type A or B)

Type A - Open surgery
Type B - Endovascular aneurysm repair
+
Special beta blocker –> Labetolol

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9
Q

Atrial fibrillation

Investigations
Treatment

A

Investigations
1st line + GS
ECG - Showing an irregularly irregular QRS complex with absent P waves (Narrow QRS complex)

Treatment
Acute –> Synchronised DC cardioversion

Chronic/Stable long term treatment –> Beta blockers or CCB (verapamil)
+
DOAC if CHADSVASC score more or equal to 2

Last resort - radiofrequency ablation

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10
Q

Atrial Flutter

Investigations
Treatment

A

Investigations
First line + GS –> ECG
Saw toothed pattern (F wave?), often with a 2:1 block (2 P waves for 1 QRS) - atrial rate at about 300bpm

Treatment
Acute (shock, syncope, MI)–> Synchronised DC cardioversion

Chronic/Stable long term treatment –> Beta blockers or CCB (verapamil)
+
DOAC if CHADSVASC score more or equal to 2

Last resort - radiofrequency ablation

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11
Q

Atrioventricular re-entry tachycardia (AVRT) - Wolff-Parkinson White syndrome

Investigations
Treatment

A

INVESTIGATIONS
1st and GS - ECG
- Short PR interval
- Delta waves (in QRS complex) - slurred upstroke in V1-V6
- Wide QRS

TREATMENT
1st line - Vagal maneuvers
- Carotid massage
- Valsalva maneuver

2nd line - IV adenosine (CI in asthma, give verapamil)

Definite - last resort - Radiofrequency ablation of bundle of Kent.

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12
Q

Hypertension

Investigations
Treatments

A

INVESTIGATIONS
If BP in hospital >140/90 mmHg, do Ambulatory blood pressure monitoring to confirm diagnosis (135/85 mmHg throughout the day)

Assess for end organ damage
- Fundoscopy - Papilloedema
- Urinalysis + eGFR - Kidney function
- Echo - LVH

TREATMENT
If <55 YO or T2DM (Not a black African)
1) Ace inhibitor or ARB
NO MATTER WHAT AGE/ETHNICITY, if patient has T2DM give Ace-Inhibitor

If >55 YO or Black African
1) CCB

2) Ace inhibitor + CCB
3) Ace inhibitor + CCB + Thiazide

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13
Q

Atrioventricular nodal reentrant tachycardia (AVNRT)

Investigation
Treatment

A

Paroxysmal supraventricular tachycardia due to the presence of a re-entry circuit within the AV node

MOST COMMON SVT

ECG - Absent P waves as p wave is buried within QRS complex

TREATMENT
1st line - Vagal maneuvers
- Carotid massage
- Valsalva maneuver

2nd line - IV adenosine

Definite- Radiofrequency ablation

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14
Q

Deep vein thrombosis

Investigation
Treatment

A

INVESTIGATIONS
If Wells Score is 1 or less (Unlikely DVT) –> Do a D-dimer test
- If its normal - DVT excluded
- If its elevated do a venous duplex ultrasound - where a reduced or absent spontaneous flow CONFIRMS the diagnosis

If Wells score is 2 or more (likely DVT) –> Do a venous duplex ultrasound (Diagnostic)

TREATMENT
1st line - DOAC (Apixaban, rivaroxaban)
LMWH if CI (renal impairment)

Non pharmacological treatment
- Physical activity - mobilisation, walking exercises
- Compression stockings

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15
Q

Pulmonary embolism

Investigations
Treatments

A

INVESTIGATIONS
1st line
If Wells score >4 (likely PE) –> CT pulmonary angiogram (diagnostic)

If Wells score 4 or less (unlikely PE) –> D-dimer test :
- If raised –> CTPA
- If not raised –> Not PE

ECG - Sinus tachycardia + S1Q3T3 (also sign of cor pulmonale)
T wave inversion of anterior and inferior leads + new RBBB

Chest X-ray - normal

TREATMENT
Non massive PE (usually this)
1st line
DOAC - Apixaban
LMWH if CI (renal impairment)

Massive PE
Thrombolytics e.g. alteplase, streptokinase

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16
Q

Peripheral vascular disease

Investigations
Treatments

A

INVESTIGATIONS
First line - Ankle brachial pressure index. (ratio of BP)
<0.9 = intermittent claudication
<0.5 = Chronic limb ischemia

Buerger’s test - elevate leg at 45 degree angle for 1-2 minutes, if there is pallor, test is positive

TREATMENT
Intermittent claudication
- Graded exercise therapy
- RF modification - Stop smoking, balanced diet, increase physical activity
- Pharmacological: Atorvastatin, clopidogrel

Chronic limb ischaemia
- Revascularisation surgery
PCI - if small
Bypass surgery - if bigger

ALI-
If non viable limb (Sign of tissue loss, nerve damage or significant sensory loss)
–> Amputate

If limb is viable on assessment –> Urgent revascularisation
within 4-6 hours (Endovascular thrombolysis/thrombectomy, bypass surgery)

17
Q

Pericarditis

Investigations
Treatments

A

INVESTIGATIONS
FBC - ESR elevated, leukocytosis
GS - ECG - Localised PR depression + Global Saddle shaped ST elevation

TREATMENT
NSAIDS + colchicine

18
Q

Pericardial effusion + pericardial tamponade

Investigations and treatments

A

INVESTIGATIONS
1st line - ECG

Chest X-ray - Big heart
GS - Transoesophageal echocardiogram

Treat pericardial effusion with NSAIDS + colchicine

Treat cardiac tamponade with URGENT PERICARDIOCENTESIS

19
Q

Infective endocarditis

Investigations and treatments

A

INVESTIGATIONS
1st line - 3 sets of blood cultures at 3 different sites over 24 hours

GS - Transoesophageal echocardiogram

DIAGNOSIS MADE WITH MODIFIED DUKES CRITERIA
(2 major, 1 major 3 minor, 5 minor)

Major
- Blood culture positive for organisms typical of IE in at least 2 samples
- Evidence of IE on TOE

MINOR
- Predisposing factors - Prosthetic heart valves, IVDU
- Fever
- Vascular phenomenon - Janeway lesion, septic emboli
- Immunologic phenomenon - Osler node, roth spots
- Blood culture positive - but not an organism constant with IE.

TREATMENT
S.viridans (S.bovis) - Benzylpenicillin (Pen G) + Gentamicin

S.aureus - Flucloxacillin

Enterococci –> Amoxicillin + Gentamicin

20
Q

Hypertrophic cardiomyopathy

Investigations and treatment

A

INVESTIGATIONS
1st line - ECG –> Abnormal

GS - Transeosophageal echocardiogram

Genetic testing (mutations in Troponin T and I)

TREATMENT
BB, CCB, amiodarone

21
Q

Rheumatic fever

Investigations and treatment

A

INVESTIGATIONS
1st line - Chest X-ray –> Cardiomegaly
(because of over working heart) - signs of mitral stenosis

GS - TOE - shows valvular damage

DIAGNOSE WITH JONES CRITERIA
Recent S.pyogenes infection + 2 major or 1 major 2 minor
Major - Polyarthritis, carditis, sydenham’s chorea, erythema nodosum, new murmur

Minor - fever, arthralgia, elevated ESR/CRP

TREATMENT
1st line - phenoxypenicillin for 10 days

Haloperidol for sydenham’s chorea

Phase 2a (29 decks)

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