Cardio Quickfire 4 Flashcards
Statins and fibrates
a) which is used for hypercholesterolaemia and which is used for high triglycerides?
b) LDL Target for high risk and medium risk patients
c) add on therapy to statins
a) statins for cholesterol, fibrates for triglycerides
b) <1.8 in high risk, <3 in medium risk
c) ezetimibe
Posterior STEMI
a) Arteries affected with associated ST changes (other than V7-9)
a) PDA (branch of RCA in most - associated inferior STE, branch of LCxA in some - associated lateral STE)
Acute heart failure:
a) Acute management
b) What to do about beta blockers?
c) Other treatments
a) - Reducing preload: Diuretics, (nitrates only used in Level 2 care if coexisting ACS, severe HTN, or aortic/mitral regurgitation)
- Improvement of LV function: ACE inhibitors (once BP stabilised)
- BP support: inotropes
- Respiratory support: Oxygen, CPAP
- CRT/cardioversion/transplant etc.
- Angiography + PCI/CABG
b) Beta blockers:
- If already taking beta‑blockers, continue unless HR <50, 2nd/3rd AV block or shock
- Start BBs when stabilised (e.g. no longer needing IV diuretics)
- Ensure stable for 48 hours after starting or restarting beta‑blockers before discharging from hospital
c) - Start ACE-inhibitors and MRA if reduced LVEF
HFpEF
a) Define
b) Risk factors
c) Management
a) High LV filling pressures with preserved systolic function (LVEF >50%)*
*Note that heart failure with EF 40-49% is considered mid-range = HFmrEF. These patients are often treated as for HFrEF with BBs/ACE/MRA, etc.
b) - Hypertension
- Fibrillation (AF)
- Pulmonary hypertension
- Elderly
- Fat (obesity)
c) - SGLT2 inhibitors and aldosterone antagonists (if NYHA class 2-3 and raised BNP)
- Symptom control - diuretics, fluid restriction, etc.
- Control of other risk factors - e.g. BP, cholesterol, diabetes, AF, obesity
ICD
a) NICE indications
b) Explain what CRT-C and CRT-D are
a) - Previous VT or VF arrest
- Spontaneous sustained VT causing syncope or significant haemodynamic compromise
- Sustained VT with LVEF <35% and NYHA I-III (not IV)
- Familial cardiac condition with a high risk of sudden death, such as long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome or arrhythmogenic right ventricular dysplasia
- Surgical repair of congenital heart disease.
b) CRT-P is CRT with pacing. Usually given for NYHA class IV with long QRS
- CRT-D is CRT with defibrillation. Usually given for NYHA class I-III with long QRS and LBBB (if just QRS <150ms, give ICD alone)
Vasopressors + Inotropes
- NorAd, Ad, Dob, Dop, Pheny (order)
- NAd - vasopressor + weak inotrope
- Ad vasopressor + strong inotrope
- Dob - inotrope and vasodilator
- Dopamine - vasopressor and inotrope (better in cardiac arrhythmia)
- Pheny - vasopressor
Indications for a PPM
- Sinus pauses >3 seconds
- Symptomatic Mobitz type 1
- Mobitz type 2
- Complete HB
- In CCF - CRT-P for NYHA class IV and long QRS
N.B. stop/reduce doses of any AV blocking drugs (e.g. adenosine, bisoprolol, CCBs, digoxin) beforehand to see if this removes need for PPM
Ventricular ectopics
a) What is considered a high frequency in 24h? (and sometimes requires treatment)
b) What is the potential risk of high frequency VEs?
a) >1000 in 24h
b) Cardiomyopathy, LV impairment
Aortic regurgitation
a) Presentation
b) Management
a) Usually asymptomatic
- Symptoms present late
b) - Annual review for mild/mod and severe
- Annual ECHO for severe AR (or more frequent)
- 2-3 yearly ECHO for mild-moderate AR
- ACE inhibitors likely prevent LV remodelling in AR
- Elective replacement if symptomatic AR, LVEF <50% or LV dilatation (LVED >50mm)
- Emergency replacement for acute severe AR (usually due to IE)
Angina:
a) Typical features (triad)
b) Diagnosis
c) Management
d) including when to consider revascularisation
a) 1. Central chest (or jaw/neck/arm) tightening
2. Precipitated by exertion
3. Relieved by rest
b) Initially do ECG and troponins if in ED. Then confirm with:
- 1st line - CT Coronary angiography
(significant = 70% stenosis of a main coronary artery i.e. one greater than 2mm, or 50% stenosis of the left main stem)
- 2nd line - Functional testing for REVERSIBLE myocardial ischaemia (SPECT, stress ECHO, stress cardiac MR)
- 3rd line - Invasive angiography
c) 1. GTN spray + advice for use
2. Anti-anginals. “Optimal” therapy is:
- 1st line is BB or CCB
- If not tolerated/CI, then offer monotherapy with ISMN, ranolazine, nicorandil or ivabradine
- 2nd line is BB + CCB, or BB/CCB + ISMN/R/N/I
3. Secondary prevention
- Aspirin 75mg OD
- Statin
- ACE inhibitor if diabetic
d) - Consider revascularisation when angina symptoms are not controlled on “optimal” angina therapy which means 2 anti-anginals (or 1 on ISMN/ ranolazine/ nicorandil/ ivabradine monotherapy).
- If revascularisation not appropriate, then add 3rd anti-anginal
- Also, while awaiting revascularisation, can add 3rd anti-anginal
- If main stem/complex 3 vessel disease or over 65 or diabetic, consider CABG
- Otherwise, PCI generally first line
Cardiac syndrome X
a) What is it?
b) How is it diagnosed?
c) How is it treated?
d) vs coronary vasospasm
a) - Anginal chest pain with no evidence of significant stenosis* on angiogram (microvascular angina)
- Most common in peri/post-menopausal females
- > 50% left main stem or >70% in main coronaries i.e. those bigger than 2mm
b) - Typical/atypical anginal pain with normal CT/invasive angiogram
- Pain/ ST depression/ reversible ischaemia on exercise stress testing or DSE
c) - Anti-anginals
- Also TCAs effective if BBs are not
- Not routinely offered secondary prevention
d) Coronary vasospasm generally occurs at rest (Prinzmetal angina) or with vasoconstricting agents (e.g. cocaine)
Carotid sinus hypersensitivity
a) Typical presentation
b) Management
a) Collapses following shaving, neck extension, or if wearing tight collared shirts. With quick recovery
b) - Avoidance of precipitants
- Fludrocortisone
- PPM
Duke’s criteria for IE
a) Major
b) Minor
c) How many of each are needed?
a) - 2x positive blood cultures with typical species for IE*
- ECHO evidence of IE**
*Or single positive blood culture for Coxiella burnetii
**Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or
Abscess; or
New partial dehiscence of prosthetic valve; or
New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)
b) - Predisposing factor (valve issue or IVDU)
- Temp >38C
- Vascular phenomena* ( major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions)
- Immunological phenomena (GN, Osler nodes, Roth spots, Rheumatoid factor)
- Positive blood cultures not meeting the major criteria
- ECHO evidence of endocarditis not meeting the major criteria
*Splinter haemorrhages NOT accepted here
c) - 2 Major, or
- 1 Major and 3 minor, or
- 5 minor
Congenital shunts
a) Which direction causes cyanosis?
b) What is Eisenmenger’s?
c) When do VSDs vs ASDs present
a) Right to left
b) Reversal of left-right shunt with PAH that causes right-left shunt and cyanosis
c) VSDs in childhood, ASDs in adulthood usually
Complications post-MI
a) Rapid deterioration with hypotension, acute heart failure (pulmonary oedema) and pansystolic murmur, 5-10 days post-MI
b) Further episode of chest pain with ECG change and troponin rise post-PCI
c) Hypotension and abdominal pain in 24h post-PCI
d) Pleuritic chest pain and diffuse ST elevation 1 week - 3 months post-MI
e) Tachycardia
f) Bradycardia
g) Persisting ST elevation 2 weeks post-MI
h) Post-PCI, livedo reticularis with blue toes, AKI, and eosinophilia
a) - Ventricular septal rupture or acute MR secondary to chordae tendinae rupture*.
- Diagnose each on ECHO with doppler.
- Treat with nitrates (reduce afterload), inotropes and surgery
*More likely in inferior or posterior MI
b) In-stent thrombosis, or new infarct - depends on territory affected on ECG.
May also be T2MI (check for anaemia, hypotension, etc.)
c) Retroperitoneal haematoma
d) Dressler syndrome.
Treat with high dose aspirin/NSAIDs
e) - If non-sustained (<30s) and haemodynamically stable –>Don’t treat
- If sustained, treat as per ALS. Note that reperfusion may be indicated
- If rate <110, likely an accelerated junctional rhythm, which is a sign of reperfusion post-MI
f) - Beta-blockade, increased vagal tone
- Inferior MI - transient heart block due to oedema, generally resolves in 1 week, generally managed conservatively
- Anterior MI - reflects widespread ischaemia and poor prognosis. Indications for tvPacing would be Mobitz 2/CHB, new LBBB or new bifascicular block
g) LV aneurysm
h) Cholesterol embolism
