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Cardiology Flashcards

1
Q 
JVP - a wave
Cause?
Absent?
Large?
Cannon?
A 
Cause = Atrial contraction
Absent = AF
Large = TS, R heart failure, pulmonary HTN
Cannon = AV dissociation (atrial flutter/tachycardia, complete heart block, VT)
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2
Q

JVP - v wave
Cause?
Giant?

A 
Cause = passive atrial filling against closed tricuspid
Giant = TR
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3
Q

JVP - x descent
Cause?
Steep?

A 
Cause = Downward heart movement with ventricular contraction --> atrial stretch
Steep = constriction (steep x & y) or tamponade (steep x only)
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4
Q

JVP - y descent
Cause?
Steep?
Slow?

A 
Cause = Tricuspid opening --> passive blood movement into ventricle
Steep = Cardiac constriction
Slow = TS
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5
Q

Raised JVP
Normal waveform?
Raise on inspiration & drop on expiration?
Loss of normal pulsation?

A 
Normal = HF, overload, severe bradycardia
Kussmaul's = Failure of R heart to inc. in size for venous return (constriction, pericardial effusion, tamponade)
Loss = SVC syndrome
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6
Q

Causes of loud S1

A

Open mitral leaflets at end of ventricular diastole which are shut forcefully on systole. Occurs when:

  • rapid flow at end of diastole e.g. MR, short diastole with tachycardia, L to R shunt
  • Short PR = open valve at time of ventricular contraction

Causes: AF, tachycardia, MS, premature atrial beat

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7
Q 
Mitral stenosis
Definition?
Causes?
Features (auscultation, CXR)?
Associated rhythm?
Management?
A

Valve area under 2cm^2 (severe <1cm) on echo

Causes: RHEUMATIC FEVER. Also: mucopolysaccharidosis, carcinoid, SLE

Auscultation: mid-late diastolic murmur, opening snap, loud S1
CXR: LA/RV enlargement, subcarinal angle >90 degrees

Associated = AF

Mx = balloon valvuloplasty in suitable cases

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8
Q

Mitral Regurgitation
Causes?
Signs?
COMPLETE THIS CARD

A

Causes = prolapse, myxomatous degeneration, ischaemic papillary muscle rupture, congenital, rheumatic HD, enddocarditis
Functional (caused by annulus stretch secondary to dilation)

Signs

  • Pansystolic murmur
  • Soft S1 (incomplete valve closure)
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9
Q 
Cardioversion in AF
Types?
When?
AF onset <48h?
AF onset >48h?
A

Electrical - DC cardioversion timed to the R wave
pharmacology - amiodarone if structural heart disease, flecainide/amiodarone without structural heart disease

When:

  • Electrical as an emergency when haemodynamically unstable
  • Electrical or pharmacological as an elective when rhythm control preferred

<48h
may electrical cardiovert. heparinise before. stroke risk factors = lifelong anticoagulation. Following electrical if onset definitely <48h then anticoagulation can be stopped

> 48h
Electrical preferred
Anticoagulation for at least 3/52 before OR perform TOE to exclude thrombus is L atrial appendage (they can then be heparinised and cardioverted)
High failure risk = 4/52 amiodarone/sotalol prior
Following cardioversion, anticoagulate for at least 4 weeks

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10
Q

Infective endocarditis aetiology

1) Most common?
2) Associated with poor dental hygiene/post procedure?
3) Most common following prosthetic valve surgery?
4) Associated with colorectal cancer?
5) culture negative?

A

1) Stapylococcus aureus
2) Stapylococcus mitis/sanguinis
3) Coagulase-negative Stapylococci e.g. epidermidis
4) Stapylococcus bovis
5) Prev Abx, Bartonella, Brucell, Coxiella burnetti, HACEK

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11
Q 
Hypertension management
Step 1?
Step 2?
Step 3?
Step 4?
A

1:
<55/T2DM = ACE-I/ARB
>55 + no T2DM/african ethnicity = Ca blocker

2:
Add in other step 1 or thiazide diuretic

3:
ACE-I/ARB + Ca blocker + thiazide diuretic

4:
K <4.5 = add spiro
K >4.5 = add alpha/beta blocker
Uncontrolled with 4 drugs = specialist review

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12
Q

Tricuspid regurgitation
Signs?
COMPLETE

A

Signs: pan-systolic murmur, prominent V wave, pulsatile hepatomegaly, L parasternal heave

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13
Q

Prolonged PR interval
Definition?
Causes?

A

Duration >200ms

Causes: MILD RASH
Myotica dystrophica
IHD
Lyme
Digoxin toxicity
Rheumatic fever
Aortic abscess
Sarcoidosis
Hypokalemia
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14
Q

VTE treatment
Agent of choice? In renal impairment?
Length of anticoagulation?

A

1st line = apixaban/rivaroxaban
2nd = LMWH followed by dabigatran/edoxaban/wafarin
Severe renal impairment = LMWH/heparin followed by warfarin
NB antiphospholipid syndrome = LMWH followed by warfarin

Length

  • All Pts at least 3 months
  • Cancer Pts = 3-6 months
  • Provoked VTE = ?stop after 3 months
  • Unprovoked = ?continue for 6 months
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15
Q

Statins
Indications & recommended doses?
Mechanism?
Adverse effects?

A

Indications

  • Established CVD
  • 10-year cardiovascular risk >= 10% (inc. Pts with T2DM)
  • T1DM diagnosed > 10 years ago/aged > 40/have established nephropathy

Primary prevention = 20mg atorvastatin
Secondary prevention = 80mg atorvastatin

Inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.

Adverse

  • Myopathy (Risk factors: thin old diabetic lady)
  • Deranged LFTs. Stop if persistently >3x upper limit
  • ?inc. risk of intracerebral haemorrhage. Avoid in Pts with Hx of of intracerebral haemorrhage
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16
Q

MI Complications?

A
  • Cardiac arrest
  • Cardiogenic shock
  • Chronic HF
  • Tachyarrythmia
  • Bradyarrythmia - AV block more common following inferior infarction
  • Pericarditis - Common in 48h following transmural MI. Dressler’s syndrome tends to occur 2-6/52 after ?due to autoimmune reaction to antigens as myocardium recovers
  • LV aneurysm - tends to be associated with persistent ST elevation + LV failure. Thrombus may form in aneurysm
  • LV rupture - tends to occur after 1-2/52. Presents with acute failure + tamponade
  • VSD - usually occurs in the first week. Features: acute heart failure associated with a pan-systolic murmur. mitral regurgitation presents in a similar way. Urgent surgery needed.
  • Acute MR - More common with infero-posterior infarction, may be due to ischaemia/rupture of papillary muscle. Acute hypotension + pulmonary oedema may occur. Early-to-mid systolic murmur typically heard. Treated with vasodilator therapy, often require emergency surgical repair.
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17
Q

ECG coronary territories
V1-V4?
II, III, aVF?
I, aVL +/- V5-6?

A

V1-V4 = anteroseptal = LAD
II, III, aVF = inferior = R coronary
I, aVL +/- V5-6 = lateral = left circumflex

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18
Q

Components of CHA2DS2-VASc?

A 
C - Congestive HF
H - HTN
A2 - age >75 (2), age 65-75 (1)
D - DM
S2  - prev. stroke
V - vascular disease
S - sex
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19
Q

Ventricular tachycardia
Main types?
Management?

A

Monomorphic - commonly caused by MI
Polymorphic - Includes torsades de pointes (caused by prolonged QT)

Management

  • Adverse signs (BP<90, chest pain, HF) = electrical cardioversion. Otherwise drugs
  • Drugs: amiodarone, lidocaine (caution in severe LV impairmen), procainamide.
  • DO NOT use verapamil (acts only on nodal tissue, inc. risk of VF)
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20
Q

Causes of prolonged QT

A

GENRALLY RELATED TO BLOCKAGE/LOSS OF K CHANNEL FUNCTION

Congenital

  • Jerval-Lange-Nielson syndrome (associated with deafness. Cause = K channel defect)
  • Romano-Ward syndrome

Drugs
- Amiodarone, TCAs, fluoxetine, chloroquine, erythromycin

Electrolyte abnormalities
- Hypo K/Ca/Mg

Other
- Hypothermia, MI, myocarditis, subarach haemorrhage

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21
Q

Pulmonary HTN management
Which test to perform?
Drug therapy?

A

Test = Acute vasodilator testing

+ve vasodilator response = Ca channel blockers

  • ve vasodilator response:
  • Prostacycline analogues (e.g. iloprost)
  • Endothelin receptor antagonists (e.g. bosentan, ambrisentan)
  • Phosphodiesterase inhibitors (e.g. sildefanil)
22
Q

Indications for implantable cardiac defibrillator?

A 
Long QT
HOCM
Prev. arrest due to VT/VF
Brugada syndrome
previous myocardial infarction with non-sustained VT on 24 hr monitoring, inducible VT on electrophysiology testing and ejection fraction < 35%
23
Q

LBBB

Causes?

A

Causes: MI, HTN, AS, cardiomyopathy, idiopathic fibrosis, digoxin toxicity, hyperkalaemia

24
Q

ECG changes in hypokalaemia?

A 
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT

U have no Pot and no T, but a long PR and a long QT

25
Patent ductus arteriosus Definition? Features? Treatment?
Connection usually between pulmonary trunk and descending aorta Features - Cont. machinery like murmur - L subclavian thrill - large volume, bounding, collapsing pulse - wide pulse pressure - heaving apex beat - Late: cyanosis in lower extremities Mx indomethacin/ibuprofen (inhibits prostaglandin synthesis) if associated with another congenital defect amenable to surgery then prostaglandin E1 to keep the duct open until after repair
26
Multifocal atrial tachycardia Definition? Management?
Irregular rhythm arising from at least three atrial sites (morphologically distinct P waves) Management - Correct hypoxia/electrolyte disturbance - 1st line = rate limiting Ca blockers (e.g. verapamil) - Not useful: cardioversion, digoxin
27
Peri-arrest: Bradycardia Adverse signs? Management? Asystole risk factors?
Shock, syncope, myocardial ischaemia, HF Mx - 1st line: Atropine 500mcg IV, repeated up to 6x - Transcutaneous pacing - Adrenaline infusion - ?transvenous pacing if no response to above or risk factors for asystole Asystole RFs - Complete block with broad QRS - Recent asystole - Mobitz type II AV block - Ventricular pause >3s
28
Ebstein's anomaly Definition? Associations? Features?
Congenital. Low tricuspid insertion --> large atrium, small ventricle Associations: WPW, PFO/ASD Features: Tricuspid regurg, prominent 'a' wave, hepatomegaly, RBBB
29
Ventricular septal defect Aetiology? Complications?
Aetiology - chromosomal disorders 9e.g. Down's), congenital infections, acquired (e.g. post MI) Complications - AR (poorly supported R coronary cusp --> prolapse) - IE - R heart failure - Pulmonary HTN - Eisenmenger's complex (prolonged pulm HTN from L to R shunt --> R vent hypertrophy + inc pressure --> exceeding LV pressure causing reversal of flow --> cyanosis)
30
``` Brugada syndrome Definition? Cause? Criteria? Management? ```
ECG abnormality with high incidence of sudden cardiac death in structurally normal hearts Cause: mutation in cardiac Na gene. Tends to be autosomal dominant Criteria for type 1 (BOTH ECG & CLINICAL) - ECG: coved ST elevation >2mm in >1 V1-3 followed by -ve T wave - Clinical: VF/polymorphic VT, coved ECG in family, FHx sudden cardiac death, syncope, nocturnal agonal respiration, inducible VT Mx = ICD
31
Atrial fibrillation: rate & rhythm control 1. When to not offer rate control? 2. Medication choice for rate? 3. Medication choice for rhythm? 4. Catheter ablation: anticoagulation, complications?
1. Reversible cause, HF caused by AF, onset <48h, flutter suitable for ablation 2. 1st line = beta-blocker. Digoxin if limited physical exercise (limited rate control during exercise) or other options ruled out Avoid Ca blockers in HFrEF due to -ve inotropic effect 3. beta-blockers, dronedarone, amiodarone (esp. if co-existing HF), flecainide 4. Anticoag: 4/52 before. Ablation does not reduce stroke risk even in sinus so Pts require anticoag based on CHADVASC score (0 = 2/12, >1 = longterm) Complications: cardiac tamponade, stroke, pulmonary vein stenosis
32
Angina medical management Prophylaxis? Avoiding nitrate tolerance?
All Pts on aspirin & statin SL GTN to abort attacks Prophylaxis (improve perfusion/reduce metabolic demand) 1st line: beta blockers, Ca antagonists CA antag monotherapy = verapamil/diltiazem (rate limiting) If used with BB then long-acting dihydropyridine NB: beta blocker + verapamil = complete heart block risk 2nd line: long-acting nitrate, ivabradine, nicorandil, ranolazine ? 3 drugs If uncontrolled with 2 drugs + awaiting revascularisation/revasc not appropriate Nitrate tolerance = asymmetric ISMN dosing interval to maintain nitrate free period
33
Broad complex tachycardia | Features suggestive of VT rather than SVT with abnormal conduction?
Suggestive of VT: - Absence of LBBB/RBBB - Extreme axis deviation - Very borad complex (>160ms) - AV dissociation - Capture beat (SAN “captures” ventricles in the midst of AV dissociation --> normal QRS) - Fusion beat (when a sinus and ventricular beat coincide to produce a hybrid complex) - Positive/negative concordance in precordial leads - Clinical: IHD, structural heart disease, Hx MI, FHx sudden cardiac death - marked L axis deviation - Hx of IHD - QRS > 160ms - AV dissociation - ``` Use Brugada algorithm Suggestive of VT: - Absent RS in precordial leads - RS interval >100ms in 1 lead - AV dissociation ```
34
High INR 1. Major bleeding 2. INR >8 minor bleeding 3. INR >8 no bleeding 4. INR 5-8 minor bleeding 5. INR 5-8 no bleeding
1. Stop warfarin, IV vit K 5mg, PCC (FFP if unavailable) 2. Stop warfarin, IV vit K 1-3mg. Start warfarin when INR <5 3. Stop warfarin, PO vit K 1-5mg. Start warfarin when INR <5 4. Stop warfarin, IV vit K 1-3mg. Start warfarin when INR <5 5. Withhold 1/2 doses. Reduce maintenance dose
35
``` Wolf-Parkinson-White Definition? ECG features? Management? Drugs to avoid? ```
Accessory pathway between atria/ventricles --> AV re-entry tachy ECG: short PR, wide QRS with slurred upstroke (delta wave), R axis deviation (L side pathway), L axis deviation (R side pathway) Mx - Definitive: ablation - Medical: sotalol (UNLESS AF: prolonging AV refractory --> inc. accessory pathway transmission --> inc. ventricular rate --> VF), amiodarone, flecainide AVOID: verapamil, digoxin. May precipitate VF/VT
36
MI secondary prevention Drugs? Another drug if signs of HF?
Drugs: DAPT, ACE-I, beta blocker, statin Aldosterone antagonist e.g. eplerenone
37
Arrythmogenic right ventricular cardiomyopathy Definition? Investigations? Management?
Inherited (autosomal dominant, variable expression), RV myocardium replaced with fatty & fibrofatty tissue Ix: - ECG: V1-3 TWI, epsilon wave (notch in QRS) - Echo: RV enlarged, hypokinetic/thin wall - MRI Mx - Drugs: sotalol - Catheter ablation - ICD
38
Infective endocarditis Indications for surgery? ECG change to monitor?
Severe CHF Overwhelming sepsis/Recurrent emboli despite Abx Aortic abscess Pregnancy ECG: PR prolongation, indicated aortic abscess
39
4th heart sound Cause? Seen in which conditions?
Atrial contraction against a stiff ventricle. Occurs in late diastole. Coincides with P wave on ECG (PS4) AS, HOCM, HTN
40
Atrial septal defect Features generally? Ostium primum features? Ostium secundum features?
Ejection systolic murmur, fixed split S2 Primum associated with abnormal AV valves ECG: RBBB with LAD, prolonged PR interval Secundum associated with Holt-Oram syndrome (tri-phalangeal thumbs) ECG: RBBB with RAD "something not RIGHT with the thumb"
41
Therapy required after insertion of a drug-eluting stent?
12 months of DAPT
42
Dilated cardiomyopathy | Associated valve abnormality?
Mitral regurg
43
Exercise tolerance test | Indications to stop?
23 rule ``` 2mm ST elevation 3mm ST depression SBP >230 SBP fall by >20 HR >20% of starting ```
44
Investigations of stable anginal chest pain?
1st line: CT coronary angiography 2nd line: non-invasive functional imaging (?reversible myocardial ischaemia) 3rd line: Invasive coronary angiography
45
``` Second heart sound Loud? Soft? Fixed split? Reversed split? ```
Loud = HTN Soft = AS Fixed split = ASD Reversed split = LBBB
46
Pregnancy and hypertension BP changes during pregnancy? Gestational hypertension definition? pre-eclampsia definition?
BP falls in first half of pregnancy before rising to pro-pregnancy levels before term Gestational HTN - HTN in second half of pregnancy (>20/40) - SBP >140/DBP>90 or rise of SBP>30/DBP>15 Pre-eclampsia - Pregnancy induced HTN + proteinuria - Occurs after 20 weeks
47
ECG changes in hypothermia?
J wave (hump at end of ORS) Irregular rhythm (long QT, arrythmias) Bradycardia First/other degree heart blocks "Jesus, It's Bloody Freezing"
48
Pulmonary embolism: indication for thrombolysis?
Massive PE + haemodynamic instability
49
Cyanotic congenital heart disease causes?
``` 5Ts: Tetralogy of Fallot Transposition of great arteries Trunctus arteriosus Total anomalous pulmonary venous return Tricuspid valve abnormalities & hypoplastic R heart syndrome ```
50
Ivabradine Indications? Mechanism? Common side effect?
Indications: symptomatic angina relief (HR >70), CHF (HR >75) Mechanism If channel inhibition (funny channel), found in SAN, triggered by hyperpolarisation, responsible for spontaneous myocyte activity. Inhibition --> delayed depolarisation --> selectively slowed HR. SE: visual disturbance e.g. bright spots
51
Valve replacement Types & who they are given to? Disadvantages? Anticoagulation?
Bioprosthetic - older Pts (>65/70) due to deterioration over time Mechanical Bio - degrade over time Mech - Inc. thrombosis risk Bio - Long term anticoag not usually needed ?3/12 warfarin depending on patient factor Mech - Long term. Warfarin > DOAC. INR 3 for aortic, 3.5 for mitral
52
``` Adult advanced life support Reversible causes? Defibrillation principles? Adrenaline principles? Amiodarone principles? ```
4 'H's - Hypoxia, Hypovolaemia, Hypokalaemia/calcaemia/glycaemia (other metabolic causes), Hypothermia 4 'T's - Thrombosis, Tension pneumothorax, Tamponade, Toxins Defibrilation - SIngle shock for VF/VT then 2 mins CPR - If on monitored Pt, can give up to 3 shocks then CPR Adrenaine - 1mg ASAP for non-shockable - VT/VF arrest: 1mg after 3rd shock then repeat every 3-5 mins Amiodarone - VT/VF: 300mg after 3 shocks. Further 150mg after 5 shocks - Lidocaine as an alternative

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