Cardiology Flashcards
bradycardia examples
sinus bradycardia
sick sinus (tachy-brady)
sinus arrest vasovagal
sinus bradycardia causes
athletes
drug toxicity - beta blockers, calcium channel blockers, digoxin
asymptomatic sinus bradycardia management
NIL
symptomatic sinus bradycardia management
permanent pacemaker
sinus bradycardia origin
SAN / atria
first degree heart block ECG features
elongated PR interval
1D HB management
check for drug toxicity (digoxin)
NIL management if asymptomatic
if symptomatic - prov cardiac monitoring
Type I second degree heart block ECG features
longer, longer, longer, drop!
PR gradually elongating, then dropped QRS complex
2D HB Type I causes
high vagal tone ie. young, fit, healthy
post inferior MI
2D HB Type I management
NIL
Type II second degree heart block ECG features
sudden failure of P wave to be conducted to ventricles
ie. randomly dropped QRS
Type II 2D HB management
permanent pacing
third degree heart block ECG features
no relationship between p waves and QRS complexes
can have broad complex escape (beneath AVN) or narrow complex escape (above AVN)
third degree heart block causes
digoxin toxicity
post inferior STEMI
sev hyperkalaemia
third degree heart block management
atropine IV
isoprenaline
calcium chloride IV (hyperkalaemia)
permanent pacing
what is the most common cardiac arrhythmia encounter in clinical practice
AF
AF presentation
not typically presenting with symptoms
BUT - will present as a complication of another condition eg.
haemodynamic instability (due tachy / brady)
ACS
CCF
cardioembolic stroke
complications of AF
cardioembolic stroke
cardiac instability
death
AF diagnosis
manual pulse checks
ECG
(SOB, palpitations, syncope/dizziness, CP, stroke, TIA)
? paroxysmal - cardiac monitoring (24 hour cardiac monitor)
AF classifications
paroxysmal > persistent > permanent
Echocardiogram indications
structural heart disease
consideration of rhythm control strategy (eg. cardioversion)
baseline needed for LT treatment
AF management
- anticoagulation (stroke / systemic embolism prophylaxis) eg. apixaban
- Rate control
- Rhythm control
- CHAD2S2 VASC Score / HAS-BLED Score
DOACS MOA
apixaban = inhibit factor Xa dabigatran = inhibit direct thrombin inhibitor
DOACs excretion
kidney
monitor renal function yearly
DOAC benefit
less need for regular monitoring (INR)
lower rates of bleeding (vs warfarin)
better reduction in strokes
Rhythm control options
Haemodynamically unstable = electrical cardioversion
Haemodynamically stable =
+ SHD = IV amiodarone
+ no SHD = IV flecainide
Rate control options
beta blocker
digoxin
supraventricular tachycardia pathophysiology
AVNRT (AVN reentry tachy)
AVRT (atria-ventricular reentry tachy)
first line treatment SVT
vagal manoeuvres
- breath holding
- Valsalva manoeuvre
- carotid massage
vagal manoeuvre MOA
slow AVN conduction > interruption of reentrant circuit
carotid massage risks
stroke / emboli
- always ascultate for bruits
- mostly used in younger patients
second line / 1st line drug treatment SVT
IV adenosine OR IV verapamil / diltiazem
adenosine = rapid IV bolus 6 mg stat + long saline flush in antecubital fossa
(if unsuccessful 12 mg stat, 12mg stat)
adenosine SEs
chest discomfort
transient hypotension
flushing
adenosine contraindications
reversible airways disease
significant bradycardia / tachycardias
adenosine MOA
reduces HR and conduction velocity @ AVN
atropine MOA
reduces vagal tone > ^ AVN conduction
synchronised cardioversion indication for SVT
SVT \+ hypotension \+ pulmonary oedema \+ chest pain and ischaemia \+ unstable Nb. under GA / sedation
verapamil contraindications
pts on BXs
flecainide MOA
Na channel blocker
flecainide contraindications
MI - past or present
2nd line drug treatment for SVT
flecainide
amiodarone
sotalol
HTN Target low-mod risk
<140 mmHg systolic
HTN target DM / stroke / TIA / IHD / CKD
< 130/80
HTN target >80 years old
140-150 systolic
HTN diastolic target
<90
HTN + DM diastolic target
<85
HTN first line tx <55 y/o
ACEi / ARB
HTN first line >55 y/o OR black (of any age)
CCB
HTN second step management
ACEi / ARB + CCB
HTN third step management
ACEi / ARB
CCB
Thiazide diuretic
Resistant hypertension definition
HTN sustained after three medical interventions
Resistant HTN management
ACEi / ARB CCB Thiazide diuretic Additional diuretic OR BB Seek expert advice
Complications of Hypertensive emergencies
encephalopathy LV failure aortic dissection unstable angina renal failure
HTN emergencies management
sodium nitroprusside
labetaolol
GTN 1-10mg/hr
esmolol
Hypertensive urgency features
sev HTN > damage over a period of days
diastolic >130
retinal damages
phaeochromocytoma triad of symptoms
episodic headache
sweating
tachycardia
sustained / paroxysmal HTN
phaeochromocytoma diagnosis
urinaary / plasma metanephrines and catecholamines
CT / MRI (adrenal tumors)
phaeochromocytoma management
(FIRST) alpha + beta blockers
eg. phenoxybenzamine
Primary aldosteronism signs
HTN
low serum potassium
high / normal sodium
HF causes
IHD HTN Valvular HD (Rheumatic fever) AF Chronic lung disease Cardiomyopathy Chemo HIV
assessment of LV function
echocardiogram
cardiac MRI
medication for HF
diuretics (furosemide) ACEi ARBs (candesartan) Angiotensin receptor-neprilysin inhibitor - ANRI (saubitril) Beta blockers
Complex device therapy for HF options
CRT (cardiac resynchronisation pacemaker)
implantable cardiac defibrillators (ICD)
CXR findings of HF
ABCDE Alveolar oedema (Kerley) B lines Cardiomegaly Dilated upper lobes pleural Effusions
why do HF patients develop peripheral oedema?
^ capillary hydrostatic pressure
v plasma oncotic pressure
> ^ fluid from IV > IT space
regular narrow complex tachycardias treatment
vagal manouveres
adenosine
adenosine contraindications
asthma
verapamil indicated instead
irregular narrow complex tachycardia management
MOST LIKELY Dx = AF
anticoagulation: apixaban
<48 hrs px: rhythm control ie. flecainide
>48 hrs px: rate control ie. bisoprolol
most likely pathogen in infective endocarditis (no existing cardiac pathology)
staphylococcus aureus
most likely pathogen in infective endocarditis with existing cardiac pathology
streptococcus viridans
secondary prevention and symptom control of stable angina
GTN spray
bisoprolol 5mg
aspirin 75 mg
atorvostatin 80mg
rheumatic fever presentation
recent streptococcal infection generalised rash fever arthritis pancarditis / murmur (MS) SC nodules
rheumatic fever management
eradication of group A beta haemolytic streptococcal infection =
STAT IV benzylpenicillin
10/7 phenoxymethylpenicillin
contraindications of digoxin
WPW (> VF)
WPW management
radiofrequency pathway ablation
amiodarone / sotalol (to prevent SVTs)
rare: open heart ablation
MS heart sounds
mid-diastolic rumbling + ‘opening’ snap
malar flush
AF
most common cause of MS
rheumatic valve disease
most common cause of AS
age related calcification
acute ischaemic stroke management
<4.5 hours presentation = alteplase (60mg IV)
aortic stenosis presentation
triad = angina, HF, syncope
+ v exercise tolerance / dyspnoea on exertion
aortic stenosis causes
age related
CKD
previous rheumatic fever
aortic stenosis auscultation
ejection systolic murmur
radiating to the carotid arteries
crescendo-decrescendo
best heard in aortic area = 2nd IC space on the RHS
aortic stenosis investigations
echocardiogram
assesses severity of stenosis + competency of rest of heart
aortic stenosis management
TAVI (transcatheter aortic valvular implantation)
via femoral artery
aortic stenosis indications for surgery
symptomatic
symptomatic / abnormal upon exercise test
left ventricular systolic dysfunction
abnormal at time of other surgery (CABG)
aortic regurgitation symptoms
can be asymptomatic for years
decreased exercise tolerance / dyspnoea on exertion
aortic regurgitation causes
congenital abnormalities of the aorta (progressive aortic dilatation)
rheumatic disease
infective endocarditis
Marfan syndrome
aortic regurgitation pathophysiology
progressive LV dilatation
HF
aortic regurgitation signs
early diastolic murmur
collapsing pulse
best heard in aortic area
DeMusset’s sign (head bobbing)
aortic regurgitation investigations
echocardiogram
assess severity + competency of rest of heart
aortic regurgitation management
ACEi - reduces after load + v LV dilatation
aortic regurgitation surgery indications
symptomatic
evidence of early LV systolic dysfunction
aortic root dilatation
mitral regurgitation management
diuretics
IF functional / ischaemic MR = ACEi
IF LV systolic dysfunction = ACEi + BXs (v sev.)
mitral regurgitation causes
Marfan's familial association rheumatic heart disease IHD infective endocarditis collagen vascular disease LV dilatation
mistral regurgitation auscultation
pan-systolic blowing murmur
radiates to auxilla
best heard over 5th ICD mid clavicular line
mitral regurgitation investigations
echocardiogram
mitral regurgitation surgery indications
symptomatic
mild-mod LV dysfunction
mitral regurgitation surgery options
mitral valve replacement / repair
common valvular pathology associated with AF
mitral regurgitation
O/E - decompensated HF, systolic murmur loudest at apex
cause of torsades de points
drugs: ondansetron / clarithromycin / methadone - > QT prolongation => polymorphic VT
leads for inferior changes
II III aVF
RCA
leads for lateral changes
I aVL (high lateral - circumflex a.) V5 V6 (low lateral)
leads for apex changes
V5 V6
distal LAD, RCA, circumflex a.
leads for septal changes
V1 V2
prox LAD a.
leads for anterior changes
V3 V4
LAD a.
torsades de points management
IV magnesium sulfate = stable pt
urgent DC cardio version = unstable pt
aortic regurgitation pulse characteristic
collapsing pulse
aortic coarctation clinical features
radial-femoral delay
hypERtension
differences in BP of upper and lower extremities
associated disease with streptococcus bovis IE
colorectal carcinoma
nb. s bovis is normal component of gut flora, therefore systemic presence may be sign of haematogenous spread due to gut wall breakdown
hyperkalaemia management
10ml of 10% calcium gluconate
IV fast acting insulin (10 units)
Iv dextrose 50% 50 ml
5-10 ml nebulised salbutamol
Nb. calcium resonium is LT management
hyperkalaemia management
10ml of 10% calcium gluconate
IV fast acting insulin (10 units)
Iv dextrose 50% 50 ml
5-10 ml nebulised salbutamol
Nb. calcium resonium is LT management
NSTEMI ECG changes
ST depression
T wave inversion
Q waves (late)
NSTEMI management
BATMAN BXs aspirin ticagrelor morphine anticoagulants: LMWH (enoxaparin) nitrates
Can consider PCI if high risk of mortality, schedule in 4 days
LT management for MI
Aspirin Atorvastatin Anti-platelet (consider clopidogrel) for 12 months ACEi Atenalol Aldosterone antagonist Lifestyle changes
Secondary complications of MI
DREAD Death Rupture of the papillary muscles Emoblism / oEdema Arrhythmias / aneurysms Dresler's syndrome (post-ACS pericarditis presents within 2-3 weeks)
Dresler’s syndrome diagnosis and management
Echo + ECG changes + infection changes
NSAIDs + steroids +/- pericardiocentesis
ECG changes in pericarditis
PR depression = most specific
saddle shaped syndrome
cardiac tamponade symptoms
BECK’S TRIAD: hypotension, muffled heart sounds, raised JVP
cardiac tamponade management
pericardiocentesis
IV fluids
management of acute heart failure and WHY
sit up - reduces preload
high flow oxygen - corrects hypoxia
IV furosemide - combats fluid overload
IV GTN - vasodilation: reduces preload and after load
chronic heart failure management
all HF = diuretic
HFpEF = lifestyle, treat underlying cause, cardiac rehabilitation programme
HFrEF = cardiac rehabilitation programme, ACEi + Bx
No improvement = swap ACEi for valsartan, add digoxin / nitrates / hydralazine (esp in black pts)
No improvement = CRT, ICD