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Cardiology Flashcards

1
Q

What is the initial management of acute coronary syndrome?

A

300mg aspirin
Oxygen if sats below 94%
IV Morphine if severe pain
Nitrates

ECG

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2
Q

What is the criteria for a STEMI on ECG?

A

> 2mm in two or more chest leads
1mm in two or more limb leads
New LBBB

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3
Q

How is a STEMI managed?

A

First decide whether PCI can be done in 120 mins

If yes - give prasugrel + aspirin (clopidogrel + aspirin if already on an anti-coagulant)

During PCI give unfractionated heparin + glycoprotein IIb/IIIa

If not - thrombolyse with alteplase. also give fondaparunix
After the procedure give ticagrelor + aspirin (or clopidogrel + aspirin if already anti coagulated)

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4
Q

How is an NSTEMI managed?

A

300mg loading dose Aspirin
Fondaparunix (unless immediate PCI)

Conduct a risk score e.g. Grace score
If risk = less than 3% - give ticagrelor + aspirin (if already on anticoagulant, clopidogrel + aspirin)

If risk = more than 3% = PCI within 72 hours
Unless haemodynamically unstable then immediate PCI.
+ Give prasugrel/ticagrelor + aspirin (clopidogrel if already on an anticoagulant)
+ Give unfractionated Heparin

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5
Q

What are the two types of tachycardia?

A

Narrow complex and broad complex

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6
Q

Which type of tachycardia is more serious?

A

Broad complex

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7
Q

What are causes of narrow complex tachycardia?

A

Sinus tachycardia
Supraventricular tachycardia
Atrial fibrilliation

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8
Q

What are causes of broad complex tachycardia?

A

If regular - ventricular tachycardia

If irregular - AF + BBB

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9
Q

How is supraventricular tachycardia managed?

A

1st line = Vagal manoeuvre (e.g. valsalva manoeuvre or carotid sinus massage)

2nd line = IV adenosine, 6mg then 12mg then 18mg

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10
Q

How is ventricular tachycardia managed?

A

If hypotensive/chest pain/heart failure - immediate cardioversion

Otherwise - Amiodarone (loading dose + 24 hour infusion)

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11
Q

How does atrial fibrillation present on an ECG?

A

Irregularly irregular rhythm
Absence of P wave
Narrow complex

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12
Q

What are the different types of atrial fibrillation ?

A 
First detected episode
Recurrent episodes
Paroxysmal AF
persistent AF
Permanent AF
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13
Q

What symptoms can atrial fibrillation present with?

A

Palpitations
SOB
Chest pain
Dizzines

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14
Q

What are indications for rhythm control over rate control in AF?

A

First presentation of AF
Coexisting heart failure
Obvious reversible cause

Or, still symptomatic despite rate control

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15
Q

Which medication is used for rate control AF?

A

First line = BB (Atenolol)

Second line = CCB (Verapamil/Diltiazem) - avoid in heart failure (not in combination with BB)

Third line = Digoxin (used for people who also have heart failure)

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16
Q

What drugs are used for pharmacological cardioversion in AF?

A

Amiodarone or Flecainide

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17
Q

When is Flecainide CI?

A

Structural heart disease
Post myocardial infarction
Atrial flutter

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18
Q

When can cardioversion be done immediately and when does it need to be delayed in AF?

A

If AF began less than 48 hours ago - immediate cardioversion

If AF began over 48 hours ago - anticoagulate for 3 weeks then cardioversion

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19
Q

How do you decide which people with AF require anticoagulation?

A

Cha2ds2vasc score

Congestive heart failure
Hypertension 
Age >75 = 2, age 65-74 = 1
Diabetes
History of stroke/TIA/embolism = 2
Vascular disease
Sex (female)

If men - anticoagulants with 1 point
Women - needs 2 points

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20
Q

What is the anticoagulant of choice in people with AF?

A

DOAC - rivaroxaban/apixaban/dabigatran/edoxaban

If valvular AF - Warfarin

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21
Q

If someone with AF has a cha2ds2vasc score of 0 (or 1 in women), what do you need to make sure before not anticoagulating them?

A

Conduct an echo

If they have a valvular heart disease they need to be put on an anticoagulant

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22
Q

ST elevation in leads V3 and V4 indicate what type of MI?

A

Anterior

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23
Q

ST elevation in leads I, avL, V5 and V6 indicate an MI in which territory?

A

Lateral

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24
Q

ST elevation in leads II, III and avF indicate a MI in which territory?

A

Inferior

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25
ST elevation in leads V1 and V2 indicate an MI in which territory?
Septal
26
What are the main causes of chronic heart failure?
Coronary heart disease or hypertension
27
How does chronic heart failure present ?
``` Dyspnoea Frothy pink sputum Orthopnoea Paroxysmal nocturnal Dyspnoea Pitting oedema Wheeze Weight loss ``` Bibasal crackles on examination Raised JVP Hepatomegaly
28
What is the first line investigation in chronic heart failure?
NT-proBNP
29
What is classed as a high NT-proBNP
>2000
30
What is classed as a raised NT-proBNP?
>400
31
What do we do with a raised/high NT-proBNP?
Raised - echo within 6 weeks (>400) High - echo within 2 weeks (>2000)
32
What ECG changes can be seen in chronic heart failure?
Left axis deviation | P wave abnormalities
33
What chest X-ray signs are seen in chronic heart failure?
``` ABCDE Alveolar oedema Kerley B lines Cardiomegaly Dilated upper lobe vessels Pleural effusion ```
34
What is the first line management for CHF?
Beta blocker (usually Bisoprolol) + ACEi
35
Which drugs may you need to consider stopping in CHF?
Calcium channel blockers - can depress cardiac function and exacerbate symptoms Tricyclic antidepressants NSAIDs - risk of decompensation Corticosteroids QT prolonging medication
36
What condition causes pleuritic pain, pleural effusion and fever 2-6 weeks after an MI?
Dressler’s Syndrome
37
How is Dressler’s Syndrome managed?
NSAIDs
38
How does a left ventricular free wall rupture present? How is it managed?
Raised JVP, pulsus paradoxus, diminished heart sounds 1-2 weeks after MI Urgent pericardiocentesis + thoracotomy
39
How is left ventricular free wall rupture managed?
Urgent pericardiocentesis + thoracotomy
40
How is angina managed?
Prescribe everyone a statin and aspirin 75mg daily (secondary prevention) Consider ACEi if diabetes + angina (secondary prevention) Prescribe GTN spray to use when needed First line treatment = BB or CCB (for the angina)
41
How does acute heart failure present?
Symptoms: Breathlessness Oedema Fatigue ``` Signs: Cyanosis Tachycardia Tachypnoea Raised JVP Displaced apex beat Bibasal crackles Wheeze S3 heart sound ```
42
How is acute heart failure managed?
IV Furosemide If oxygen sats below 94% - oxygen respiratory failure - CPAP
43
What is stage 1 hypertension?
A reading of >140/90 in clinic or >135/85 on home average
44
What is stage 2 hypertension?
A clinic reading of >160/100 or home average reading of >150/95
45
What is classed as severe hypertension?
A systolic of 180 or a diastolic of 110
46
When should you offer drug treatment for stage 1 hypertension?
If the patient is over 80 plus has one of the following: Target organ damage Established cardiovascular disease Renal disease Diabetes 10 year cardiovascular risk of 10% or over
47
What murmur is associated with aortic regurgitation?
Early diastolic murmur | Heard best with patient leaning forwards
48
What other features are seen in aortic regurgitation?
Collapsing pulse Wide pulse pressure Quincke’s sign (pulsation of nail bed) de Musset's sign - Head bobbing
49
What murmur is seen in aortic stenosis?
Crescendo-decrescendo ejection systolic murmur
50
What other features are seen in aortic stenosis?
``` Narrow pulse pressure Slow rising pulse Slow or absent S2 S4 sound Thrill ``` (Ejection systolic crescendo decrescendo murmur)
51
What is the most common cause of aortic stenosis in young patients under 60 years of age?
A bicuspid aortic valve
52
What is the most common cause of aortic stenosis in older patients over 60 years of age?
Degenerative calcification of the aortic valve
53
What is the most common cause of mitral stenosis?
Rheumatic fever
54
What murmur is characteristically seen in mitral stenosis?
A mid to late diastolic murmur of rumbling character
55
What other features are seen in mitral stenosis?
Loud S1 with opening snap Low volume pulse Malar flush Atrial fibrillation
56
What ECG signs are seen in mitral stenosis?
P mitrale(bifid P wave)
57
What murmur is characteristically seen in mitral regurgitation?
Pansystolic murmur with a blowing/whistling character
58
What other features are seen in mitral regurgitation?
Soft S1 Widely split S2 S3 sound
59
What is rheumatic fever?
Reaction to a recent strep pyogenes infection (2 to 6 weeks ago)
60
How is rheumatic fever diagnosed?
Evidence of recent strep infection + either.. 2 major criteria OR 1 major + 2 minor criteria
61
What classes as evidence of recent strep infection in rheumatic fever?
Increased strep antibodies | Positive throat swab
62
What are the major criteria in rheumatic fever?
JONES - Joints, carditis, nodules, erythema marginatum, Sydenham’s chorea Erythema marginatum (rash on body in shape of rings) Sydenham’s chorea (muscle jerking) Polyarthritis Carditis and valvulitis Subcutaneous nodules
63
What are the minor criteria in rheumatic fever?
Raised CRP or ESR Pyrexia Arthralgia Prolonged PR interval
64
How is rheumatic fever managed?
Oral penicillin V and NSAIDs
65
What murmur is seen in a ventricular septal defect?
Ventricular septal defect has a pansystolic murmur
66
What is the most common form of cardiomyopathy?
Dilated cardiomyopathy
67
What can cause a broad QRS complex ?
Ventricular tachycardia Bundle branch block (left or right) Wolff-Parkinson White Syndrome Hyperkalaemia Hypothermia Tricyclic poisoning
68
What is electrical alternans and what is the main cause of this?
QRS complexes alternate in height Main cause = massive pleural effusion and cardiac tamponade
69
What is torsades de pointes?
A polymorphic ventricular tachycardia caused by long QT
70
What can cause torsades de pointes? (I.e. what can cause long QT?)
Low calcium Low potassium Low magnesium Hypothermia Raised ICP Medications - tricyclic antidepressants, erythromycin
71
What can cause a short QT?
Hypercalcaemia Digoxin
72
What are causes of RBBB?
Right ventricular hypertrophy PE MI
73
How are palpitations investigated?
First line = ECG and bloods (U+Es, FBC, TFTs) 2nd line = Holter monitoring
74
How is acute Bradycardia managed?
If in shock/syncope - IV 500 micrograms Atropine (up to max 3mg) If atropine fails - 1) transcutaneous pacing 2) isoprenaline/adrenaline infusion 3) transvenous pacing
75
What are causes of acute bradycardia?
Sinus or AV node disease Drug induced - beta blockers, CCB Electrolyte abnormalities Hypothyroidism
76
How does an “innocent murmur” present?
Asymptomatic Systolic Loudest in pulmonary area Blowing Vary with position
77
Which anticoagulant is used in a patient with a prosthetic heart valve?
Warfarin DOACs are contraindicated
78
Which congenital conditions are associated with a ventricular septal defect?
Down’s Syndrome Edward’s syndrome Patau syndrome
79
What murmur is seen in an atrial septal defect?
Ejection systolic murmur loudest on inspiration Widely fixed splitting of S2
80
Murmur: ejection systolic murmur loudest on inspiration, fixed splitting of S2
Atrial septal defect
81
Murmur: ejection systolic murmur, crescendo-decrescendo
Aortic stenosis
82
Which murmur is associated with a narrow pulse pressure and a slow rising pulse?
Aortic stenosis
83
Murmur: early diastolic murmur, collapsing pulse and wide pulse pressure
Aortic regurgitation
84
Murmur: rumbling mid to late diastolic murmur with opening snap
Mitral stenosis
85
Which facial sign is seen in mitral stenosis?
Malar flush
86
Murmur: whistling pan systolic murmur with soft S1 and widely split S2
Mitral regurgitation
87
Which valve is most commonly affected by infective endocarditis?
Mitral valve In IVDU - tricuspid valve
88
What are risk factors for infective endocarditis?
History of rheumatic heart disease Prosthetic valve Congenital heart defects IV drug user
89
What is the most common causative organism of infective endocarditis?
Staph aureus In patients who have had recent valve surgery in last 2 months - staph epidermidis
90
Which criteria is used to diagnose infective endocarditis?
Modified Duke Criteria Need 2 major OR 1 major + 3 minor OR 5 minor
91
What are the 2 major criteria in infective endocarditis?
Positive blood culture Evidence of endocardial involvement (positive echo or new valvular regurgitation)
92
What skin signs can be seen in infective endocarditis?
Splinter haemorrhages Janeway lesions Petechiae Osler’s nodes
93
What are the minor criteria of infective endocarditis? (5)
Predisposing heart condition or IVDU Fever Vascular phenomena (petechiae, Janeway lesions) Immunological phenomena (glomerulonephritis, osler’s nodes, Roth spots) Microbiological evidence which does not meet major criteria
94
What is the antibiotic management used in infective endocarditis?
Initial (no blood cultures): Native valve = amoxicillin, prosthetic valve = vanco + rifampicin + gent Staph aureus: native valve = flucloxacillin, prosthetic valve = flucloxacillin + rifampicin + gentamicin MRSA: Vanc + Gent
95
What is the most common form of cardiomyopathy overall?
Dilated cardiomyopathy
96
What is seen on CXR in dilated cardiomyopathy?
Balloon appearance of heart
97
What are features of dilated cardiomyopathy?
Features of heart failure - breathlessness, oedema, raised JVP, paroxysmal nocturnal dyspnoea, orthopnoea Systolic murmur S3 sound
98
What is the most common congenital cardiomyopathy ?
Hypertrophic obstructive cardiomyopathy
99
What inheritance pattern does hypertrophic cardiomyopathy have?
Autosomal dominant
100
What murmur is seen in hypertrophic cardiomyopathy?
Ejection systolic murmur loudest at the lower left sternal edge
101
What signs are seen in hypertrophic cardiomyopathy?
Ejection systolic murmur Jerky pulse Displaced apex beat Apical thrill
102
Which medications should be avoided in hypertrophic cardiomyopathy? Why?
ACEi Nifedipine Nitrates These medications reduce preload or afterload and can possible aggravate outflow tract obstruction
103
What is Brugada syndrome?
A genetic condition caused by sodium channelopathies - common cause of sudden cardiac death
104
What is the diagnostic criteria for Brugada syndrome?
VF / polymorphic VT (torsades de pointes) Family history of sudden cardiac death Syncope Nocturnal agonal breathing (sounds like gasping/snorting)
105
What are risk factors for sudden cardiac death in Brugada syndrome?
Fever Excess alcohol intake Dehydration Hypokalaemia Hypomagnasaemia
106
What is pericarditis?
Inflammation of the pericardium
107
What are features of pericarditis?
Pleuritic chest pain (relieved by leaning forwards) Pericardial rub Fever Tachycardia Tachypnoea
108
What are causes of pericarditis?
Viral infections (e.g. Coxsackie) TB Trauma Post-MI Dressler’s Syndrome Hypothyroidism Malignancy
109
What ECG changes are seen in pericarditis?
Saddle shaped ST elevation PR depression ECG changes are global (not in a specific territory)
110
How is pericarditis diagnosed?
Transthoracic echo
111
How is pericarditis managed?
NSAIDs + colchicine Treat any underlying cause
112
What is constrictive pericarditis?
The pericardium becomes hard and thickened - this then interferes with ventricular filling
113
What causes constrictive pericarditis?
Any cause of pericarditis but especially TB
114
What are features of constrictive pericarditis?
Can present with symptoms of right sided heart failure - Dyspnoea, elevated JVP, Hepatomegaly, oedema Pericardial knock (loud S3) Positive Kussmaul’s sign (raised JVP that doesn’t fall on inspiration)
115
How is constrictive pericarditis managed? What if the initial management doesn't work?
NSAIDs + colchicine If no improvement -> pericardiectomy
116
What is a pericardial effusion?
Collection of fluid within the pericardial sac - commonly occurs with pericarditis Can be blood, fluid, exudate, air
117
What is a cardiac tamponade?
An accumulation of fluid in the pericardium which is putting pressure on the ventricles Associated with pericarditis
118
What triad is seen in cardiac tamponade?
Beck’s triad Hypotension, raised JVP, muffled heart sounds
119
What are signs of cardiac tamponade?
Hypotension Raised JVP Muffled heart sounds Dyspnoea Tachycardia Absent Y descent on JVO Pulsus paradoxus (abnormally large drop in BP during inspiration)
120
What ECG change is seen in cardiac tamponade?
Electrical alternans (alternating QRS amplitude)
121
How is cardiac tamponade managed?
Pericardiocentesis
122
Which DOAC can be reversed and what is used for reversal?
Dabigatran Reversed with Idarucizumab
123
What are contraindications to adenosine?
Asthma/COPD Heart failure Heart block Severe hypotension
124
How is torsades de pointes treated?
IV Magnesium sulfate, Cardioversion
125
How can raised ICP show on an ECG?
Long QT
126
What ECG change can be seen in rheumatic fever?
Prolonged PR interval
127
How does acute mitral regurgitation after an MI present? And what causes it?
Caused by ischaemia or rupture of the papillary muscle Can present with acute hypotension and pulmonary oedema Early to mid systolic murmur
128
If a patient has persistent ST elevation after their myocardial infarction what complication have they sustained?
Left ventricular aneurysm
129
Which medications can decrease INR in a patient taking warfarin?
Phenytoin, carbamazepine Rifampicin St John’s wort Chronic alcohol intake Smoking
130
Which medications can increase INR in a patient taking warfarin?
Ciprofloxacin Clarithromycin/erythromycin Isoniazid Omeprazole Amiodarone Allopurinol Ketoconazole/fluconazole SSRIs Sodium valproate Acute alcohol intake
131
What are indications for a pacemaker in a patient with acute bradycardia?
Complete heart block with broad complex QRS Recent asystole Mobitz type II AV block Ventricular pause of more than three seconds
132
Which murmur is associated with Marfan’s?
Aortic regurgitation Early diastolic murmur Collapsing pulse Wide pulse pressure
133
What ECG changes are suggestive of hypertrophic cardiomyopathy?
Left Ventricular hypertrophy Non-specific T-wave inversions and ST segment abnormalities Deep Q waves
134
What echocardiogram findings are found in hypertrophic cardiomyopathy?
MR SAM ASH Mitral regurgitation Systolic anterior motion Asymmetric hypertrophy
135
How does hypertrophic cardiomyopathy usually present?
May be asymptomatic Can be - exertional Dyspnoea, syncope typically following exercise, sudden death
136
What are the conditions is hypertrophic cardiomyopathy associated with?
Friedrichs ataxia Wolff-Parkinson white
137
What further drugs can you consider adding in heart failure?
Aldosterone antagonist (spironolactone) - symptomatic relief only Hydralazine + nitrate (especially in black/Caribbean) Digoxin Invabradine (if in sinus rhythm >75bpm and left ventricular fraction <35%)
138
What heart failure drug can be considered in black and Caribbean patients?
Hydralazine plus nitrate
139
What criteria must be met to prescribe ivabradine in heart failure?
>75bpm Left ventricular fraction <35%
140
Which vaccinations do those with heart failure require?
Annual influenza vaccine One-off pneumococcal vaccine
141
When do beta blockers need to be stopped in heart failure?
Heart rate less than 50 BPM 2nd or 3rd degree AV block Shock
142
What are adverse affects of adenosine?
Adenosine is used to treat supraventricular tachycardia Adverse effects include chest pain and bronchospasm Also transient flushing Feeling of impending doom
143
Which patients is adenosine contraindicated in?
Asthmatics due to bronchospasm
144
How is stable angina treated?
1. Beta blocker or Verapamil | 2. Beta blocker + Nifedipine
145
How is AV block managed?
2nd degree heart block Mobitz type II and complete heart block both need transcutaneous pacing 1st degree + Mobitz type I = no treatment needed
146
What type of cardiomyopathy are alcoholics at risk of?
Dilated cardiomyopathy
147
Which leads does left circumflex artery affect?
I, aVL, +/- V5 and V6
148
What are the main side effects of ACE inhibitors?
Cough Hyperkalaemia
149
What needs monitoring in patients taking ACE inhibitors and what are acceptable changes?
U&Es should be checked before treatment and after increasing dose Rise in creatinine and potassium may be seen Acceptable creatinine = 30% increase from baseline Acceptable eGFR = 25% decrease Acceptable potassium = up to 5.5mmol
150
What does significant renal impairment after starting an ACE inhibitor suggest? How would that be diagnosed?
Undiagnosed bilateral renal artery stenosis CT angio
151
What affect does ACE inhibitors have on the kidneys?
Vasoconstriction of afferent arteriole - Reduces glomerular blood flow Not directly nephrotoxic but should be stopped in an AKI Reno-protective in CKD
152
What is the major contraindication to Verapamil?
Ventricular tachycardia
153
Which valve is most commonly affected in infective endocarditis? What about in IVDUs?
Mitral valve or Tricuspid valve in IVDUs
154
What is the mitral valve?
Valve from left atrium to the left ventricle
155
What is the aortic valve?
Valve from left ventricle to the Aorta
156
What is the tricuspid valve?
Valve from right atrium to the Right ventricle
157
What is the pulmonary valve?
Valve from right ventricle to the pulmonary artery
158
What is Kussmaul’s sign and what is it seen in?
Raised JVP which rises or doesn’t fall on inspiration | Seen in constrictive pericarditis
159
What is Beck’s triad and what condition is it seen in?
Raised JVP, muffled heart sounds, hypotension | Seen in cardiac tamponade
160
What is pulsus paradoxus and which heart problem is associated with this?
Abnormally large decrease in BP during inspiration Cardiac tamponade Also can be seen in obstructive lung disease e.g. Asthma/COPD
161
What should you consider in someone with a stroke/TIA/PE and a fever?
Infective endocarditis
162
How does a ruptured papillary muscle post-MI present?
Acute hypotension Pulmonary oedema Mitral regurg murmur
163
Which position is an aortic regurgitaton murmur heard best?
Patient leaning forwards
164
What is Quincke’s sign and what is it a sign of?
Nailbed pulsation | Seen in aortic regurgitation
165
What is De Musset’s sign and what is it a sign of?
Head bobbing | Seen in aortic regurgitation
166
What should you consider in a patient with tachycardia and tachypnoea but no other signs?
PE
167
What should be given instead of Adenosine for SVT in asthmatics?
Verapamil
168
Which condition is associated with differences in BP in each arm? How is it investigated?
Aortic dissection – CT angiogram showing a false lumen
169
What is the first line treatment for HTN in diabetes?
Black – ARB | Non-black – ACEi
170
What marker is raised in Dressler’s syndrome?
ESR
171
How does coarctation of the aorta present?
Systolic murmur loudest at LLSE Weak pulses in the lower extremity In adults can present with hypertension and notching of the inferior border of the ribs
172
What to do after fibrinolysis in STEMI?
Repeat ECG in 60-90 mins | If ST elevation not resolved – urgent PCI
173
Which artery is associated with a lateral MI?
Left circumflex/LAD
174
How to differentiate between Mobitz type 2 and complete heart block?
In Complete heart block – P-P interval and R-R interval will always be the same In Mobitz type 2 – R-R interval will not be the same
175
How to manage a patient who has received a PCI but is still experiencing pain or haemodynamic instability?
Urgent CABG
176
When does infective endocarditis need surgical management?
If it is causing congestive cardiac failure
177
When does aortic stenosis require valve replacement?
Symptomatic | Asymptomatic + valvular gradient >40 + left ventricular systolic dysfunction
178
How to treat acute heart failure not responding to treatment?
Consider CPAP

Medicine Finals (32 decks)

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