Cardiology Flashcards
What are common presentations of chronic heart failure?
SOB on exertion, cough, orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema
What is paroxysmal nocturnal dyspnoea?
When patient wakes up suddenly at night with a severe attack of shortness of breath and cough
What investigations can you order to diagnose heart failure?
ECG, BNP blood test, echocardiogram, CXR
What are four common causes of heart failure?
Myocardial ischaemia, atrial fibrillation (and other arrhythmias), hypertension, valvular heart disease
What medications are used in heart failure?
ACEi, beta blocker, aldosterone antagonists, loop diuretics, entresto (neprilysin inhibitor+angiotensin receptor blocker), ivabradine, SGLT-2 inhibitor
What is stage 1 hypertension defined as?
Clinic BP 140/90 or higher
Ambulatory BP 135/85 or higher
What us stage 2 hypertension defined as?
Clinic BP 160/100 or higher
Ambulatory BP 150/95 or higher
What is severe hypertension defined as?
Clinic systolic BP >180 or clinic diastolic BP >110
A patient being investigated for hypertension is also found to have headaches, sweating, palpitations and anxiety. What could be causing the hypertension?
Phaeochromocytoma
A hypertensive patient is found to also experience muscle weakness and tetany. What could be causing their high blood pressure?
Hyperaldosteronism
What are some non-pharmacological treatments for hypertension?
Weight reduction, reduce salt intake, minimise alcohol intake, stop smoking, aerobic exercise
What are some signs of heart failure on CXR?
Cardiomegaly, pleural effusions, perihilar shadowing (bat wing sign), kerley b lines
What are the three classical symptoms of aortic stenosis?
Angina, dyspnoea, syncope
What is the most common cause of aortic stenosis?
Age related calcification and degeneration
What murmur is heard in aortic stenosis?
An ejection systolic murmur best heard over the aortic area and radiating to the carotid
What are some causes of aortic stenosis?
Age related, congenital bicuspid valve, CKD and previous rheumatic fever
What investigations is best in assessing aortic stenosis?
Echocardiogram
Which valvular disease is associated with a collapsing pulse?
Aortic regurgitation
What are some signs of aortic regurgitation?
Head bobbing, collapsing pulse, uvulal pulsation, nail bed pulsations, pistol shot femoral pulse
What are the commonest causative organisms for infective endocarditis?
Viridans streptococci, staphylococcus aureus (most common in IV drug users), coagulase negative staphylococcus and enterococci
What is cor pulmonale?
Right sided heart failure caused by pulmonary hypertension following respiratory disease
What are causes of cor pulmonale?
COPD (most common), PE, ILD, cystic fibrosis
What are clinical signs of cor pulmonale?
Cyanosis, raised JVP, peripheral oedema, third heart sound, hepatomegaly (from back pressure in hepatic vein)
What are some secondary causes of hypertension? (Rope)
Renal disease (renal artery stenosis), obesity, pregnancy/pre-eclampsia, endocrine (hyperaldosteronism, phaeochromocytoma)
If there is ST elevation seen in lead II, lead III and aVF which coronary artery is likely to be affected?
Right coronary artery
If leads V1-V2 show ST elevation which area of the heart is affected and which coronary artery is occluded?
Septal area Proximal LAD (left anterior descending)
If there is ST elevation in leads V3-V4 which area of the heart is affected and which coronary artery is occluded?
Anterior area
LAD is coronary artery occluded
If there is ST elevation seen in lead I and aVL, which area of the heart is affected and which coronary artery is likely to be occluded?
Lateral area
Left circumflex artery
What are some common cardiovascular risk factors?
Family history, smoking, alcohol excess, obesity, hypertension
What is the immediate management of myocardial infarction (MONA)?
M-morphine
O-oxygen
N-nitroglycerin
A-aspirin 300mg loading dose
What is Dressler’s syndrome?
Pericarditis that occurs secondary to myocardial infarction
What long-term medications should be prescribed following MI?
ACEi/ARB Aldosterone antagonist (if signs/symptoms of HF and reduced left ventricular EF) Aspirin Clopidogrel Beta blocker
What are some possible complications of acute myocardial infarction?
Death, rupture of septum or papillary muscle, heart failure, arrhythmia and Dressler’s syndrome
What features on a CXR are suggestive of heart failure?
Blunting of costophrenic angles from pulmonary oedema
Batwing sign from hilar enlargement
Increased cardio thoracic ratio
Kerley B lines
What are common causes of heart failure?
Arrhythmia (e.g AF), ischaemic heart disease, valvular heart disease, hypertension
What add on therapies can be used in the treatment of heart failure with reduced ejection fraction?
Dapagliflozin, ivabradine, sacubitril valsartan, digoxin
What are the indications for electrical DC cardio version?
Haemodynamically unstable (low BP, HR>150), LOC/syncope, ongoing chest pain, increasing breathlessness
What is the CHADSVASC score used for?
Assessing the risk a patient will have a TIA or stroke secondary to their atrial fibrillation
What is the HAS-BLED score used for?
Assessing a patient’s risk of major bleeding whilst on anticoagulation
Is aspirin recommended for preventing stroke in atrial fibrillation?
No it is not recommended- use DOAC or warfarin instead
What are the clinical features which can be found on examination in a patient with aortic stenosis?
Slow rising pulse, narrow pulse pressure (systolic and diastolic BP within 25mmHg of eachother), breathlessness, cyanosis, raised JVP
Auscultation: ejection systolic murmur loudest over aortic area, louder on expiration, radiates to the carotid
What are the clinical signs of aortic regurgitation?
Early diastolic rumbling murmur heard at apex.
Collapsing pulse
Uvula pulsation: Muller’s sign
Head bobbing: De Musset’s sign
Pistol shot sound heart when auscultating femoral pulse
Nail bed pulses: Quinke’s sign
Visible distension and collapse of carotid arteries: Corrigan’s sign
What are the clinical signs of mitral stenosis?
Malar flush
On auscultation: low-pitched rumbling, mid-diastolic murmur heard loudest over the apex, loudest when patient leans to left. Loud S1
What are Roth spots?
White centred retinal haemorrhages
What clinical signs would you look for in a patient presenting with possible infective endocarditis?
Splinter haemorrhages, conjunctival haemorrhages, Roth spots, osler’s nodes, Janeway lesions
What are the causes of radial-radial delay?
Subclavian artery stenosis, aortic dissection, aortic coarctation
What is Beck’s triad seen in cardiac tamponade?
Elevated venous pressure, reduced arterial pressure, reduced heart sounds
What are four differentials for a narrow complex tachycardia?
Sinus tachycardia, SVT, atrial fibrillation, atrial flutter
How will the ECG differ in SVT compared to atrial fibrillation?
The QRS complexes will be irregularly irregular in A fib but regular in SVT
What is a delta wave on ECG?
A slurred upstroke in the QRS complex
What are the different management options for a stable patient with SVT?
Valsalva manoeuvre, carotid sinus massage
If these don’t work- adenosine (if contraindicated then verapamil)
What are the ECG changes you get with STEMI?
Tented T waves (immediately), ST elevation, t wave inversion (there for weeks )and pathological Q waves (there permanently)
What is being referred to when diabetic patients do not experience typical chest pain during an ACS?
Silent MI
What is the acute treatment for a STEMI?
MONA
Percutaneous coronary intervention if within 2 hours of presentation
Thrombolysis if PCI can’t be done within 2 hours of presentation
What are some examples of thrombolytic agents?
Alteplase, streptokinase and tenecteplase
What is the acute treatment of NSTEMI? (BATMAN)
Beta blocker 300mg aspirin Ticagrelor Morphine Anticoagulant e.g LMWH Nitrates
What is GRACE-2 score?
Risk stratifying scoring system for 6-month risk of death or repeat MI after having a NSTEMI and guides treatment with PCI
What would you consider in regard to NSTEMI treatment if a patient scores moderate or high risk with GRACE-2 score?
Early PCI within 4 days
What is the acute management for unstable angina?
Beta blocker 75mg of aspirin Ticagrelor Anticoagulant (LMWH) Nitrates (e.g GTN)
What are some complications of MI? (DREAD)
Dressler’s syndrome Septal rupture Oedema (heart failure) Arrhythmia + aneurysm Death
What will ECG show with pericardial effusion?
Global ST elevation and T wave inversion
What may you see on fundoscopy of a patient with diabetic retinopathy?
Flame shaped haemorrhages
What are 5 signs of heart failure you can see on chest X-ray?
Alveolar oedema (bat wing sign) Kerley B lines Cardiomegaly Dilated upper lobe vessels Pleural effusion
What are the mainstay heart failure drugs?
Ace inhibitor
Beta blocker
Aldosterone antagonist
Loop diuretic
Ivabridine
Entresto
SGLT-2 inhibitors
What are the secondary prevention medications given to patients following MI? (6A’s)
Aspirin Anti platelet (clopidogrel) ACE inhibitor Atenolol (beta blocker) Atorvastatin Aldosterone antagonist (those with clinical HF)
What medications need to be given after PCI?
Dual anti platelet therapy
What are examples of shockable rhythms?
V tach
V fib
What are examples of non-shockable rhythms?
Asystole
Pulseless electrical activity
What are some narrow complex tachycardias?
Atrial fibrillation
atrial flutter
Supraventricular tachycardia (AVNRT, AVRT)
What are some broad complex tachycardias?
Ventricular tachycardia
Bundle branch block
Wolff-Parkinson white syndrome
How do you manage SVT?
Valsalva manoeuvre, carotid sinus massage
Adenosine, verapamil
If not resolved or unstable then DC cardio version
How manage atrial fibrillation?
Rate control- bisoprolol
Rhythm- amiodarone or flecainide
Anticoagulation with a DOAC
How would you manage atrial flutter?
Amiodarone or flecainide for rhythm control
Bisoprolol for rate control
Laser ablation of re-entrant pathway
What drug can make the saw tooth pattern of atrial flutter clearer on ECG?
Adenosine
What is the management for ventricular tachycardia?
Haemodynamically stable- amiodarone 300mg
Unstable- DC cardioversion
What are classic features of Wolff Parkinson white syndrome on ECG?
Short PR interval, delta wave/slurred upstroke
How would you manage heart block?
Stable (not at risk of asystole)- observe
Unstable/risk of asystole- atropine, if no improvement then adrenaline, transcutaneous cardiac pacing
What is the most specific ECG finding associated with acute pericarditis?
PR depression
What is the most sensitive finding of acute pericarditis on ECG?
Widespread saddle shaped ST elevation
What is first line management for acute pericarditis?
NSAIDs
What are some indications for permanent pacemaker?
Mobitz 2 and 3rd degree heart block, symptomatic bradycardia, sick sinus syndrome, heart failure, drug resistant tachyarrhythmias
Which medication should you not give with verapamil because of risk of heart block?
Beta blocker
Which valve is found between the left atrium and left ventricle?
Mitral
Which valve is found between the right atrium and right ventricle?
Tricuspid
What are the major branches of the left coronary artery?
Left anterior descending, left circumflex,
What are the 3 major branches of the right coronary artery?
SA node branch, AV node branch, posterior descending artery
Which areas of the nervous system influence the SA node to change heart rate?
Parasympathetic- via vagus nerve
Sympathetic- C1-T5 sympathetic ganglia via cardiac nervous plexuses
Which troponin are cardiac sensitive?
T and I
What drug can be used in a stress test if exercise isn’t possible, when should this drug not be given?
Dobutamine (positive ionotropic and chronotrope). Shouldn’t be given in Left bundle branch block or patients with pacemakers
Which leads correlate with the anterior wall of the right ventricle?
V1-2
Which leads correlate with the anteroseptal wall/anterior wall of left ventricle?
V3-4
Which leads correlate with the lateral wall?
Lead 1, aVL and V5-6
Which leads correlate with the inferior border of the heart?
Leads 2-3 and aVF
What are symptoms of stable angina exacerbated by?
Exercise, cold weather, emotion and eating
What is the pathophysiology of stable angina?
Coronary artery narrowing from atherosclerotic plaque, reducing oxygen delivery to myocardium.
Resulting ischaemia causes release of acidosis, release of lactate and chemokines which stimulate nerve cells producing pain sensation
What are the three clinical features of stable angina presentation?
Central chest pain, on exertion, relived by rest/nitrates
What risk calculator is used to predict patients risk of CVD in 10 year window?
QRISK
How should stable angina be managed medically?
Optimise lifestyle factors, aspirin, statin
PRN GTN spray (immediate relief of symptoms)
beta-blocker/calcium channel blocker (prevention of symptoms)
What is monitored when a patient starts statins?
LFTs
Should be done before starting- safe if less than 3 times upper limit of normal
Measured again within 3 months and at 12 months
Which drugs can increase digoxin levels?
Amiodarone, rate limiting CCBs, spirinolactone
What are symptoms of digoxin toxicity?
Lethargy, N+V, xanthopsia (yellow flashes/discolouration of vision)
What might be seen on ECG in a patient with digoxin toxicity?
Bradycardia, prolonged QT interval, AV block, ventricular ectopics, downsloping ST depression
How is digoxin toxicity managed?
Treat any associated electrolyte abnormalities, treat arrhythmias, give antibodies (severe poisoning)
What is the management of postural hypotension?
Reduce/stop culprit antihpertensives, increase fluid and salt intake, mineralocorticoid therapy is necessary
When can a new LBBB on ECG be considered normal?
Never, this is always pathological and further investigation is required
What is seen on ECG with LBBB?
Wide QRS complexes in the precordial leads, negative V1 and predominantly positive with slow upstroke to R-wave peak in lateral leads
what is the gold standard investigation for stable angina?
CT coronary angiography
how can stable angina be managed surgically?
coronary angioplasty
coronary artery bypass graft
what scars might a patient have if theyve had previous surgery for coronary disease?
midline sternotomy scar and scar on inner calf may indicate CABG
scars in the groin or at the wrist may indicate percutaneous coronary intervention
what causes the S1 and S2 heart sounds?
S1- closing of AV valves closing
S2- semilunar valves closing
what is the most common cause of mitral stenosis?
rheumatic fever
what are clinical features (symptoms and signs) seen with mitral stenosis?
dyspnoea, fatigue
tapping apex beat, loud S1, rumbling mid-diastolic murmur, malar flush, 50% patient have AF
signs of infective endocarditis if thats the cause
what is ortner syndrome?
following mitral stensosis the left atrium can dilate and compress the recurrent laryngeal nerve and oesophagus causing a hoarse voice
if suspecting mitral stenosis, what investigations should be done?
echocradiogram, ECG (may show AF or left arial dilatation), CXR (may show left dilatation)
what is the management of mitral stenosis?
anticoagulation (warfarin, DOAC if mild)
surgery: percutaneous mitral balloon valvotomy
why does malar flush occur with mitral stenosis?
back pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation
why is AF associated with mitral stenosis?
left atrium has to work harder to push blood through a stenotic valve causing strain, electrical disruption and resulting fibrillation
why does mitral stenosis cause dyspnoea?
increase pressure in left atrium leads to increased pulmonary venous pressure
what are some risk factors of mitral regurgitation?
female, previous MI, connective tissue disorders (Marfans, Ehlers-danlos), prior mitral stenosis
what are causes of mitral regurgitation?
post-MI from ischaemic damage to papillary muscles or chordae tendinae.
mitral valve prolapse
infective endocarditis, rheumatic fever
congenital
what are symptoms of mitral regurg?
often asymptomatic
symptoms occur from left ventricular failure, arrhythmias or pulmonary hypertension= fatigue, SOB, oedema
what murmur can be heard with mitral regurg?
pansystolic ‘blowing’ murmur radiating to the left axilla
where is the pulmonary valve best auscultated?
Pulmonary valve- Left second intercostal space, at the upper sternal border
where is the aortic valve best auscultated?
Aortic valve- Right second intercostal space, at the upper sternal border
where is the tricuspid valve best auscultated?
Tricuspid valve- Left fourth intercostal space, at the lower left sternal border
where is the mitral valve best auscultated?
Mitral valve- Left fifth intercostal space, just medial to mid clavicular line
what are features of a murmur that can be assessed? (SCRIPT mneumonic)
S- site
C-character (soft, blowing, crescendo…)
R- radiation
I- intensity (grade of murmur)
P- pitch (high or low and rumbling, pitch indicates velocity)
T- timing
what are the different gradings of murmurs?
1- difficult to hear
2- quiet
3- easy to hear
4- easy to hear with palpable thrill
5- audible with stethoscope barely on chest
6- audible with stethoscope off chest
what murmur is heard with aortic stenosis?
ejection-systolic, high-pitched murmur over the aortic area with a crescendo-decrescendo character radiating to the carotids
other than the murmur what signs can be seen with aortic stenosis?
slow rising pulse, narrow pulse pressure
why do patients with aortic stenosis develop exertional syncope?
they get lightheaded and dizzy during exercise as they have difficulty maintaining a good blood flow to the brain
what is the most common cause of aortic stenosis?
idiopathic age related calcification
what are the two main options for aortic valve replacement?
surgical or transcatheter (for those with high operative risk)
why may a patient with MI have bradycardia an ECG changes suggestive of heart block?
occlusion of the right coronary artery/inferior MI can lead to ischaemia of the AV node
what is the first line management of acute pericarditis?
NSAID and colchicine
how can use position a patient to emphasise certain murmurs?
Aortic regurg: lean forward and hold exhalation
Mitral stenosis: lean on left side
what are signs of tricuspid regurg?
thrill in tricuspid area
pan systolic murmur
raised JVP with giant C-V waves
pulsatile liver
peripheral oedema
