Cardiology Flashcards
Which scoring system can be used to calculate the risk that a patient will have a stroke or MI in the next 10 years?
Q risk 3
What should all patients with CKD or DMT1 for over 10 years be offered?
Atorvastatin 20mg
What is the monitoring for statins? Why?
LFTs should be checked within 3 months of starting a statin. This is because statins cause a transient and mild rise in ALT and AST
What should be given as secondary prevention of CVD?
A- Aspirin and a second antiplatelet (clopidogrel)
A-Atorvastatin (80mg)
A-Atenolol (or bisoprolol)
A-ACE inhibitor (ramipril)
What are the common side effects of statins?
Myopathy (check CK)
Type 2 diabetes
What causes angina?
Ischaemia during times of high demand because there is a narrowing of coronary arteries
What is the difference between stable and unstable angina?
Stable is when symptoms are relieved by rest or GTN. Unstable is when symptoms come on randomly at rest
What is the gold standard investigation for angina?
CT angiography
What is the management of angina?
GTN spray (advise take one dose, repeat after 5 mins, if still pain then call 999)
Beta blocker or CCB (bisoprolol or amlodipine both 5mg daily)
4 As for CVD (aspirin, atorvastatin, ACE-i and atenolol)
What should be offered to people with proximal or extensive disease causing angina?
PCI
What does the right coronary artery supply?
Right atrium
Right ventricle
Inferior aspect of the left ventricle and
Posterior septal area
What does the circumflex artery supply?
Left atrium
Posterior aspect of the left ventricle
What does the left anterior descending artery supply?
Anterior aspect of the left ventricle
Anterior aspect of the septum
What are the 3 types of acute coronary syndrome?
Unstable angina
ST elevation myocardial infarction
Non-ST elevation myocardial infarction
What confirms a diagnosis of STEMI?
ST elevation or new left bundle branch block
What investigations should be done in ACS where there is no ST elevation on ECG?
Troponin.
If raised/ there are other ECG changes then the diagnosis is NSTEMI
If troponin is normal and there are no ECG changes then the diagnosis is unstable angina
What are alternative causes of raised troponin?
Chronic renal failure Sepsis Myocarditis Aortic dissection PE
What investigations should be done for ACS?
Physical exam Bloods (FBC,LFT,U&E, lipid, thyroid, HbA1C, troponin) ECG CXR Echo CT angio
What is the management of acute STEMI?
Primary PCI if <2 hours of presentation
Thrombolysis >2hours
BATMAN B-beta blockers A- Aspirin 300mg STAT T- ticagrelor 180mg or clopidogrel 300mg if there is a high bleeding rosk M-Morphine A- Anticoagulant: Fondaparinux N- Nitrates: GTN to relieve vasospasm
What is a GRACE score?
It assess for PCI in NSTEMI by calculating the 6 month risk of death or repeat MI
What are the complications of MI?
DREAD
D- death R- rupture E- Edema A- Arrhythmia/ aneurysm D- Dressler's syndrome
What is Dressler’s syndrome?
Occurs 2-3 weeks after MI. Caused by a localised immune response and causes pericarditis.
How does dressler’s syndrome present?
Pleuritic chest pain
Pericardial rub
Global ST elevation and T wave inversion
What are the common triggers for left ventricular failure?
Iatrogenic
Sepsis
Myocardial infarction
Arrythmias
How does acute LVF present?
rapid onset breathlessness Type 1 respiratory failure SOB Feeling unwell Increased RR and HR Reduced O2 sats 3rd heart sound Hypotension Bilateral basal crackles
How can a diagnosis of acute LVF be confirmed?
BNP or echo
What is a normal ejection fraction for ventricles?
above 50%
What does cardiomegaly look like on CXR?
The cardiothoracic ratio is >0.5
What does acute LVF look like on CXR?
Cardiomegaly
Bilateral pleural effusions
Fluid in interlobar fissures
Fluid in septal lines (kerley lines)
What is the management of acute LVF?
Pour SOD
Pour away fluids
S-sit up
O-Oxygen
D- diuretics
What are the 2 types of chronic heart failure?
Systolic and diastolic
What are the key features of heart failure?
Breathlessness worsened by exertion Cough Orthopnoea Paroxysmal nocturnal dyspnoea Peripheral oedema
How is chronic heart failure diagnosed?
Clinical presentation
BNP
Echo
ECG
How should chronic heart failure first be managed?
Refer to cardiology
Lifestyle changes
Flu and pneumococcal vaccines
ABAL: ACE-i Beta-blocker Aldosterone antagonist: spironolactone Loop diuretic (furosemide)
What is cor pulmonale?
Right sided heart failure caused by respiratory disease
What is the most common cause of cor pulmonale?
COPD
What is the presentation of cor pulmonale?
Usually asymptomatic
SOB
Peripheral oedema
Syncope
What is the management of cor pulmonale?
Treating symptoms and the underlying cause
Long term O2 therapy
What are the readings which suggest a diagnosis of hypertension?
> 140/90 in clinic or
>135/85 ambulatory
What are the causes of secondary hypertension?
ROPE: Renal disease Obesity Pregnancy/ pre-eclampsia Endocrine (Conn's syndrome)
What are the 3 stages of hypertension?
1= 140/90
2-160/100
3=180/120
Which tests should be done to assess for end organ damage in all new patients with a diagnosis of HTN?
Urine albumin: creatinine ratio Urine dipstick for blood HbA1c, renal function and lipids Fundus examination ECG
What are the potential antihypertensives which can be used?
A- ACE-i (ramipril) B- Beta-blocker (bisprolol) C- CCB (amlodipine) D- Diuretic (thiazide like, indapamide) ARB candasartan
What is the medical management of HTN?
1= A if <55 and white, C if >55 or black
2= A+C, if black ARB+C
3= A+C+D
4=A+C+D+ spironolactone, B, alpha blocker (doxazosin)
What can be used when thiazide like diuretics cause hypokalaemia in management of HTN and why?
Potassium sparing diuretics like spironolactone because it causes sodium excretion and potassium reabsorption by blocking aldosterone
What causes the first heart sound?
Closing of the AV valves
What causes the second heart sound?
Closing of the semilunar valves
What causes a third heart sound?
Rapid ventricular filling causing the chordae tendineae to twang like a guitar string
What kind of hypertrophy does mitral stenosis cause?
Left atrial hypertrophy
What kind of hypertrophy does aortic stenosis cause?
Left ventricular hypertrophy
What causes hypertrophy and what causes dilatation?
Stenosis= Hypertrophy Regurgitation= dilatation
What are the common causes of mitral stenosis?
Rheumatic heart disease
Infective endocarditis
What is heard when there is mitral stenosis
A low, rumbling mid-diastolic murmur
What are the associations of mitral stenosis?
Malar flush
Atrial fibrilation
What type of murmur is heart in mitral regurgitation?
Pan-systolic, high pitched whistling
What are the causes of mitral regurgitation
Ehlers Danlos syndrome or Marfan syndrome
What does aortic stenosis sound like?
Ejection systolic, high pitched murmur which has a crescendo-decrescendo character
What does aortic regurgitation sound like?
Early diastolic, soft murmur
What is aortic regurgitation associated with?
Corrigan’s pulse (collapsing pulse)
What are the major complications of mechanical heart valves?
Thrombus
Infective endocarditis
Haemolysis
What are the presenting features of atrial fibrilation?
Palpitations
SOB
Syncope
What are the 2 differentials for an irregularly irregular pulse?
AF
Ventricular ectopics
What is seen on an ECG of AF?
Absent P waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm
What are the most common causes of AF?
SMITH
Sepsis Mitral valve pathology Ischaemic heart disease Thyrotoxicosis Hypertension
What are the contraindications for rate control in AF?
There is a reversible cause of AF
AF is of new onset in the last 48 hours
AF is causing heart failure
What are the options for rate control in AF?
Beta blocker
CCB
Digoxin
When can rhythm control be offered in AF?
New, reversible cause of AF
New onset < 48 hours
Causing heart failure
Symptomatic
What are the 2 types of cardioversion for AF?
Immediate and delayed. If someone has delayed cardioversion they must be anticoagulated for a minimum of 3 weeks prior
What are the 2 choices of pharmacological cardioversion?
Flecanide
Amiodarone
What is the management of paroxysmal AF?
If no structural heart defect then “pill in the pocket” approach can be appropriate
If there is a defect, manage as normal
What is the mechanism of action of warfarin?
Vitamin K antagonist. Prolongs the prothrombin time
What is the target INR for someone on warfarin?
2-3
How do you reverse apixaban and rivaroxaban?
Andexanet alfa
Why are DOACs better than warfarin?
No monitoring required
No major interaction problems
What should the CHADSVASC score be to offer coagulation?
> 1
Which scoring system assesses the risk of a bleed?
HASBLED
What are the 2 shockable rhythms?
VT
VF
What are the 2 non-shockable rhythms
Asystole
Pulseless activity
How are supraventricular tachycardias managed?
Vagal maoeuvres and adenosine
What causes atrial flutter?
Re-entrant rhythm
What is seen on an ECG of atrial flutter?
atrial contraction 300bpm, ventricular contraction 150 bpm and sawtooth appearance
What is the management of atrial flutter?
Rate and rhythm control
Radiofrequency ablation
Anticoagulation
What happens in supraventricular tachycardia?
Electrical signal re-enters the atria from the ventricles causing a self perpetuating loop
What are the ECG changes seen in Wolf-Parkinson White?
Short PR
Wide QRS
Delta wave (slurred upstroke of the QRS)
What is toursades de pointes?
Polymorphic ventricular tachycardia
What is wenkebach’s phenomenon
Present in mobitz type 1 where atrial impulses become gradually weaker until they dont pass through the AV node. There is then no QRS complex and the pattern repeats
What is type 1 heart block
Delayed conduction through the AV. There is a QRS after every P but the PR interval is greater than 0.2s (1 big square)
What is mobitz type 2 block?
Failure or interruption of AV conduction. 3:1 block, 3 p waves to every 1 QRS
What is 3rd degree heart block?
Complete heart block, there is no relationship between P and QRS
How are heart blocks managed?
Pacing or atropine
What is eisenmenger syndrome?
When pulmonary pressure increases so much that a left to right shunt is reversed so that it is a right to left shunt
What is the presentation of atrial septal defects?
Dyspnoea
Stroke
Atrial fibrillation or atrial flutter
What can be heard on auscultation in atrial septal defect?
Mid-systolic, crescendo-decrescendo murmur which is loudest at the left sternal border with a fixed split second heart sound
What is the management of atrial septal defects?
Percutaneous transvenous catheter closure or open heart surgery.
Can be managed by anticoagulants if asymptomatic
How do VSDs present?
pansystolic murmur
Present late in adulthood
What are the 3 differentials for pansystolic murmur?
VSD
Mitral regurgitation
Tricuspid regurgitation
What is the management of VSD?
Transvenous catheter closure
Open heart surgery
What is coarctation of the aorta?
When there is narrowing of the aortic arch
Which condition is coarctation of the aorta particularly associated with?
Turner’s syndrome
How does coarctation of the aorta present?
Systolic murmur
Left ventricular heave
How is coarctation of the aorta managed?
Stenting
Open surgical repair
What can cause a pericardial effusion?
Transudates (low protein) Exudates (high protein) Blood pus Gas
What is cardiac tamponade?
A pericardical effusion is large enough to raise the pericardial pressure. This squeezes the heart and impacts its ability to function
What might cause a transudative pericardial effusion?
Congestive heart failure
Pulmonary HTN
What might cause an exudative pericardial effusion?
Infection Autoimmune Injury MI Cancer Medications
(basically anything inflammatory)
What is the presentation of pericardial effusion?
Chest pain SOB Feeling of fullness in the chest Orthopnoea Pulsus paradoxus Quiet heart sounds
Compression of phrenic nerve may cause hiccups, reccurrent laryngeal may cause hoarseness of voice, oesophagus may cause difficulty swallowing
How is pericardial effusion diagnosed?
Echo
Fluid analysis
What is the management of pericardial effusion?
Treating the underlying cause
Drainage of effusion
(needle pericardiocentesis or surgical drainage)
Inflammatory causes (pericarditis) can be treated with aspirin, NSAIDs, colchicine and steroids
