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Finals > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What is angina

A

due to Myocardial ischaemia, not infarction

tightness/squeezing/heaviness/pan in chest, neck, jaw, arms, shoulder, back

+-diaphoresis/nausea/anxiety

elderly- stomach pain

women- burning/tenderness

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2
Q

what is stable angina

A

on exertion, emotional stress, heavy meals, cold temps

predictable
coronary stenosis >70%

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3
Q

what is unstable/crescendo angina

A

large occlusion/plaque rupture
unpredictable, at rest
does not respond to GTN/meds
medical emergency

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4
Q

what is prinzmetal’s angina

A

‘spasmodic/variant’

pain at rest, suddenonset, rare

can be caused by cocaine

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5
Q

?angina ix

A
  • troponin- normal
  • ECG
  • angiography
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6
Q

what are the ischaemic changes on an ECG

A
  • could be normal
  • ST depression
  • ST depression +- T wave inversion during unstable angina attack
  • t wave inversion only relevant if in leads with upright QRS
  • pathological q waves (q waves in V1-3, >1mm /0.04s wide (one small sq), >2mm/0.08s deep (2 small square), >25% depth of QRS
  • poor R wave progression- from V1-V6, R wave should become bigger than s wave
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7
Q

Management of Angina

A
  • Sublingual glyceryl trinitrate (can be used as preventer immediately before activity)
  • rapid access chest pain clinic
  • 1st line- betablocker- bisoprolol, low dose aspirin
  • 2nd line rate limiting- add CCB (verapamil, diltiazem), amlodipine (prinzmetals)
  • 3rd line- ivabridine, nicorandil!, ranolazine
  • HTN control

lifestyle changes

surgery

  • PCI
  • coronary bypass
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8
Q

what drug is contraindicated in prinzmetal’s angina

A

betablocker

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9
Q

what secondary preventative measures can be suggested for angina

A
  • cardiac rehab
  • exercise
  • stop smoking , drinking, eating badly
    psychological support
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10
Q

sx of mi

A 
- sudden, severe crushing central chest pain
>20mins
- not relieved by nitroglycerin
- diaphoresis
- radiation to neck, jaw, L arm
- impending doom
- lightheaded, nauseous, may vomit
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11
Q

What is the pathophysiology of an NSTEMI

A
  • severe stenosis, non occlusive thrombus
  • no transmural necrosis
  • irreversible injury to myocytes
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12
Q

ECG features of NSTEMI

A

ST depression

+- T wave inversion (in leads with upright QRS)

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13
Q

pathophysiology of STEMI

A
  • complete thrombus occlusion
  • transmural necrosis
  • irreversible damage to myocytes
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14
Q

ECG features of STEMI

A
  • ST elevation

- New LBBB (broad QRS >3smalsq with QRS wave pointing down in V1/ ‘W’ QRS in V1)

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15
Q

ix for ?MI

A

ECG

Trop- 2 samples 30min- 3 hours apart with one >99th centile

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16
Q

Immediate management of MI

A

A-E

STEMI:

MONA BASH
M- morphine 5-10mh IV plus metoclopramide 10mg IV
O- low flow if sats <90%/pulm oedema
N- Nitrates- IV nitroglycerine or GTN spray
A- antiplatelets- Aspirin 300mg PO plus clopidogrel 300mg PO

B- betablocker oral if no asthma/COPD
A- ACEI within 24hours
S- Statin- artorvo 80mg
H- Heparins LMWH (delta) SC, or fondaparinux SC

PCI-

  • if available within 2hrs
  • if not- thrombolysis (alteplase)

NSTEMI:- PCI within 72hours

Consider also stool softeners to avoid straining and sedatives

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17
Q

Causes of acute aortic regurg

A
  • infective endocarditis
  • ascending aortic dissection (type A)
  • congenital
  • AS
  • Rheumatic fever
  • chest trauma
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18
Q

Causes of chronic aortic regurg

A
  • congen
  • connective tissue eg marfarn’s
  • rheumatic heart disease
  • SLE
  • HTN
  • syphilis, RA, Takayasu’s arteritis
  • appetite suppressants
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19
Q

sx of aortic regurg

A

dyspnoea
PND, orthopnoea
palpitations

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20
Q

murmur heard for aortic regurg including location

A

decrescedno early diastolic murmur (just after S2)

  • at L lower sternal boarder
  • if loudest at R sternal border- may suggest arotic root dilatation
  • best heard with pt sitting forwards on exp hold
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21
Q

other signs of aortic regurg apart from murmur

A
  • collapsing, wide pulse pressure
  • pulsatile nail bed/vulva
  • head bobbing in time of pulse
  • pulm HTN- SOB, oedema
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22
Q

ix for ?aortic regurg

A

bloods- FBC, CRP, BNP/ANP

  • ECG
  • CXR
  • echo
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23
Q

tx for aortic regurg

A
  • vasodilators (CCB: nifedipine)
  • statin
  • betablocker if in HF
  • ACEI- improves stroke volume
  • surgery- valve replacement

IE prophylaxis (amox/clinda)- not routinely offered anymore

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24
Q

causes of aortic stenosis

A
  • senile calcification
  • rheumatic disease
  • infective vegetation
  • *- SLE
  • *- post radiation
  • bileaflet valve
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25
Q

sx aortic stenosis

A

SAD- syncope, angina, dyspnoea

  • Palpitations
  • sudden death
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26
Q

murmur heard in aortic stenosis

A
  • crescendo/decrescendo ejection systolic murmrur
  • high pitched
  • heard over 2nd ICS R sternal boarder
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27
Q

signs of aortic stenosis other than murmur

A
  • LVHF- PND, orthopnea, cyanosis, cough
  • heaves
  • low vol, slow rising, narrow pulse pressure
  • carotid bruits
  • pulm HTN- oedema
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28
Q

Ix for ?aortic stenosis

A

ECG
echo
cardiac catheter to assess value gradient and LV function

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29
Q

ECG findings in aortic stenosis

A
  • p-mitrale- p waves look like M /bifid/notched (LA enlargment)
    LVH-
  • ST depression
  • t wave inversion
  • LBBB
  • left axis deviation
  • SV1 + RV6 = >35mm (ie 35/5= 7 bigger squares)
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30
Q

aortic valve stenosis grading

A

mild >1.5cm
mod 1-1.5cm
severe <1cm

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31
Q

tx aortic stenosis

A

ACEI, betablockers if mild

balloon valvuloplasty
Valve replacement

IE prophylaxis - amox (S viridans)- not currently recommended

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32
Q

What is stage 2 of atherosclerosis formation

A

Intermediate lesions

from foam cells, T lymphocytes, plts, extracellular fluid

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33
Q

What is stage one of atherosclerosis formation

A

fatty streaks

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34
Q

What is stage 3 of atherosclerosis formation

A

Impedes blood flow, sometimes ruptures, fibrous cap

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35
Q

What is stage 4 of atherosclerosis formation

A

plaque grows and recede due to digestion by inflammatory markers

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36
Q

what are cardiomyopathies

A

myocardium is structurally and functionally abnormal without coronary disease, HTN, valvular or congenital heart disease

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37
Q

What types of cardiomyopathies are there

A
  • hypertrophic
  • dilated
  • arrythmogenic
  • restrictive
  • unclassified
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38
Q

What causes myocarditis

A
  • Viruses- adeno, COVID-19, hep B/C, parvo, HSV, HIV, EBV
  • Bacteria- Staph, Strep, Lyme
  • *- Parasites- toxoplasmosis
  • Fungi- candida, aspergillus, histoplasmosis
  • *- Meds- CT, Abx, Antiepileptic, cocaine
  • *- radiation
  • *- heavy metal and CO poisoning
  • electric shock
  • autoimmune- lupus, vasculitis, sarcoidosis, IBD, MG, polymyositis
  • *- thyrotoxicosis
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39
Q

sx and signs of myocarditis

A

asx

  • chest pain
  • SOB
  • viral sx
  • fatigue

signs:

  • arrhythmias
  • oedema
  • hypotension

children: fever, syncope, dyspnoea, high RR, tachy/arrhythmias

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40
Q

ix for ?myocarditis

A

ECG

  • ST elevation or depression
  • T wave inversion
  • atrial arrhythmias
  • AV block

bloods

  • leukocytosis may be present
  • UE
  • *- CK (muscle damage)
  • trop raised
  • ESR CRP
  • LFT
  • *CXR
  • normal silhouette
  • pleural effusion
  • interstitial and alveolar oedema

Viral serology
***Endomyocardial biopsy (gold standard)
Cardiac MRI

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41
Q

Management of myocarditis

A
  • ITU- ventilation
  • mechanical support devices
  • severe with hypotension- parenteral inotropes (phosphodiesterase inhibis- milrinone; beta adrenergic rec agonists- DA, dobutamine, adrenaline)
  • anticoag if AF
  • steroids if giant cell
  • limit activity for several months
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42
Q

What is hypertrophic cardiomyopathy

A
  • usually inherited
  • LVH is stiff
  • impaired diastolic filling due to small volume chambers
  • mitral - regurg
  • can also create turbulent flow- clot risk
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43
Q

sx hypertrophic cardiomyopathy

A
  • muscle grows during growth, so sx stable in adulthood but gets worse during childhood and when elderly (thickened heart becoming stiffer)
  • asx
  • sx worse after alcohol
  • dyspnoea
  • chest pain, palpitations (arrhythmias)
  • syncope
  • sudden death- ventricular outflow obstruction
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44
Q

signs of hypertrophic cardiomyopathy

A
  • forceful apex

- pansystolic murmur at apex- mitral regurg

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45
Q

ix for ?hypertrophic cardiomyopathy

A
  • Transthoracic echocardiogram - diagnostic
  • ECG - LVH- ST changes, T wave inversion, axis deviation
  • CXR- increased heart size
  • MRI
  • cardiac catheter
  • endomyocardial biopsy to exclude other causes of LH eg amyloidosis
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46
Q

tx hypertrophic cardiomyopathy

A
  • amiodarone, beta blockers, verapamil (CCB)- improves cardiac filling
  • AF- anticoag
  • *- implantable cardioverter defib
  • cardiac ablation
  • surgical myectomy to relieve outflow LV
  • heart transplant if HF
  • genetic counselling
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47
Q

what is dilated cardiomyopathy

A

ventricular chamber enlargement and contractile dysfunction with normal LV wall thickness

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48
Q

causes of dilated cardiomyopathy

A
  • idiopahic- most common
  • genetic
  • substance misuse- alcohol, cocaine!
  • pregnancy
  • **- thyrotoxicosis
  • autoimmune- RA, SLE
  • phenothiazines
  • haemochromatosis,
  • sarcoidosis
  • **amyloidosis, glycogen storage
  • Viruses: HIV, adeno, coxsackie, cytomegalo**
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49
Q

sx and signs of dilated cardiomyopathy

A
  • asx
  • stroke
  • palpitations
  • sudden cardiac death
  • HF- oedema, PND, orthopnoea
    +- viral prodrome

signs

  • arrhythmias
  • HF (congestive)- dyspnoea, fatigue, oedema, raised JVP, PE, cardiomegaly, loud S1/S4, pink frothy sputum
  • MR- pansystolic
  • AR- early diastolic
  • fam hx
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50
Q

ix for dilated cardiomyopathy

A
  • diagnosis of exclusion
  • CXR- cardiomegaly, pulm oedema
  • ECG- LBBB, non specific ST/T wave changes
  • echo- dilation of LV cavity
  • btype natriuretic peptide
  • cardiac catheter
  • endomyocardial biopsy- to exclude myocarditis, sarcoidosis, haemochromatosis if clinical supicion
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51
Q

management of dilated cardiomyopathy

A
  • same tx for HF
  • titrate all drugs up
  1. ACEI /ARB
    1a. betablocker
  2. add low dose loop (furesomide)
  3. add mineralocorticoid/aldosterone antag (spironolactone)
  4. ivabridine
  5. sacibutril (neprilysin inhib +ARB)
  6. hydralazine + nitrate
  7. digoxin

– add anticoag, amiodarone, digoxin if relevant

cardiac resynchronisation
catheter ablation in arrhythmia/vent tachy
LV devices
transplant

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52
Q

What is arrhythmogenic cardiomyopathies

A
  • progressive fatty and fibrous replacement of ventricular myocardium
  • leads to arrhythmias
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53
Q

sx arrhythmogenic cardiomyopathies

A
  • arrhythmia- palp, syncope
  • sudden cardiac death
  • HF in 40s/50s
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54
Q

ix arrhythmogenic cardiomyopathies

A

ECG- vent arrhythmias with LBBB

  • echo, cxr, MRI
  • cardiac catheters
  • biopsy sometimes
  • genetic assessment
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55
Q

tx arrhythmogenic cardiomyopathies

A

HF tx

  • ACEI/ARB
  • betablockers
  • diuretics
  • amiodarone
  • anticoag

***- implantable cardioverter defib, pacemakers
ablation
- transplant

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56
Q

Causes of endocarditis

A

Non infective
- vegetations- plt, immune complexes, cancer cells

Infective-

  • Bacterial- Strep viridans, S.aureus, **strep bovis, **enterococci,
  • *- Fungal- candida, aspergillus, **histoplasma
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57
Q

RF for infective endocarditis

A
  • skin breaches, IVDU
  • immunosupression- diabetes, renal failure
  • abnormal valves eg stenostic/regurg, artificial
  • hypertophic cardiomyopathy
  • hx of IE
  • structural heart issues, incl if repaired eg ASD
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58
Q

sx and signs of endocarditis

A

Infective- sepsis, cough, sore throat, flu-like sx

  • chest pain
  • abscesses elsewhere
  • SOB
  • oedema

Signs

  • anaemia
  • splenomegaly
  • new murmur
  • Deposits: vasculitis, haematuria, **glomerulonephritis, ***roth spots on fundoscopy
  • splinter haemorrhages
  • Janeway lesions- soles/palms, not tender
  • osler’s nodes- fingers/toes, tender
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59
Q

ix endocarditis

A

DUKE criteria

  • CT/PET
  • echo
  • blood cultures
  • CXR, ECG, MRI
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60
Q

tx of endocarditis

A

IV/oral abx

  • amoxicillin (native valve)- or vanc plus gent
  • rifampicin plus gent (prosthetic)
  • tx arrhythmias, heart block, HF, stroke, abscess (drain)
  • surgery to remove material
  • replace valve (if causing HF, unresp to meds, fungal, vegetation >10mm, recurrent embolisation)

NB- IE prophylaxis isnt routinely offered to high risk people anymore, even when undergoing dental procedure- safety net for red flags and inform importance of good oral hygiene

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61
Q

What is rheumatic fever caused by

A

group A beta haemolytic strep/strep pyogens

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62
Q

sx rheumatic fever

A

child- sore throat , then 1m later:

  • arthritis
  • *- carditis- tachy, chest pain, SOB, oedema, fatigue, mitral/aortic regurg, pericardial rub
  • chorea- movements of face and upper limbs
  • *- SC nodules
  • fever
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63
Q

ix ?rheumatic fever

A

throat swabs
ECG
CXR
doppler echo

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64
Q

tx rheumatic fever

A
  • penicillin
  • aspirin
  • NSAIDs
  • *- diuretics/ACEI and digoxin for HF
  • chorea- diazepam
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65
Q

What are the stages of HTN

A

> 140/90 and 135/85 ambulatory]

1- >140/90
2- >160/100 (home >150/95)
3- >180 or >120
Accelerated- severe with papilloedema/retinal haemorrhage

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66
Q

ix to assess endorgan damage in HTN

A

12 lead ECG +- ECHO
UE, eGFR, urine dip
Renal USS
fundoscopy

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67
Q

other ix you would do in HTN (apart from assessing end organ damage)

A
  • blood glucose, fasting lipids

could do

  • dexamethasone supression test
  • 24hour urinary metanephrines (phaeochromocytomas)
  • renin/aldoesterone ratio (primary hyperaldoteronism)
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68
Q

causes of secondary HTN

A
  • Cushings
    • Renal artery stenosis
  • Pheochromocytoma
  • primary hyperaloderonism (Conn’s)
  • SIADH
    • renal disease (PKD, nephritic syndrmoe- IgA, post-strep, HUS, HSP, goodpasture, SLE, vasculitis, IE, Membranoproliferative glomerulonephritis)
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69
Q

Management of HTN

A

<55yo or diabetic of any age/ethnicity
- ACEI/ARB

> 55yo/Afrocarribean
- CCBs

Then:

  • ACEi/ARB + CCB
  • add thiazide-like diuretic*****
  • alpha blocker (doxasin)
  • Beta blocker- bisoprolol
  • ACEI and spironolactone (if HF sx)
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70
Q

name some ACEI

A

-pril

ramipril
lisinopri
enalapril

NB: NOT verapamil

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71
Q

name some ARBs

A

-sartan

candesartan
losartan
valsartan

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72
Q

name some CCBs

A

-pine (mostly)

amlodipine
felodipine
nifedipine
verapamil
diltiasem
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73
Q

name a thiazide-like diuretics

A
  • indapamide

- bendroflumethiazide

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74
Q

electrolyte SE of spironolactone

A

hyperkalaemia

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75
Q

cause of the dry cough in ACEI

A

bradykinin

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76
Q

Pathophysiology of LV impairment

A

cardiac disorder increases work of LV due to lack of O2 systemically

  • LV muscle remodels
  • becomes thicker and weaker, leading to dysfunction
  • can also occur following an MI
  • this is synonymous with HF
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77
Q

symptoms of LV dysfunction/HF

A
  • SOB
  • fatigue
  • oedema
  • Palpitations, chest pain
  • *- excessive urination (BP and RAAS)
  • dizziness, syncope, nausea
  • *- fatigue and weakness
  • lack of appetite
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78
Q

signs of LV dysfunction/HF

A
  • orthopnoea, paroxysmal nocturnal dyspnoea
  • tachy/bradycardia
  • displaced apex
  • S3, murmurs, arrhythmias
  • Overload: JVP raised, ascites, oedema
  • cyanosis
  • pink frothy sputum CHF
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79
Q

Ix ?LV dysfunction/HF

A
  • Natriuretic peptide tests— N-terminal prohormone brain natriuretic peptide (NT-proBNP); BNP
  • UE, TFT, LFT, lipid, HbA1C, FBC– fatigue, urination
  • urinanalysis- urination
  • peak flow and spirometry (COPD)

-transthoracic echo- exclude valve disease, assess LV function, shunts

  • ECG
  • CXR- cardiomegaly, congestion
  • exercise tests
  • cardiac catheterisation- valve disease
  • coronary angio- IHD, angina
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80
Q

why does HF cause polyuria/nocturia

A
  • reduced CO
  • reduced renal blood flow, low BP
  • RAAS system activated–
  • aldosterone increases sodium retention and water retention
  • oedema
  • at night, the pt lies down, the excessive fluid now returns to the heart
  • increased CO
  • kidneys perfused
  • urination
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81
Q

tx of HF reduced EF

A
  • lifestyle
  • offer anticoag if AF present
  • do not give adrenaline/stimulants
  • avoid CCBs and short acting dihydropyridine agents

1.
- ACEI (ramipril, lisinopril)/ARB (candesartan) AND betablockers (bisop)– 1st line for mortality/morbitiy

  • Loop diuretics- 1st line for oedema
  1. add mineralocorticoid rec antag: spironolactone, eplerenone
  2. hydralazine with nitrate
  3. amiodarone, digoxin, ivabradine, sacubitril-valsartan

Surgery-

  • valve repair
  • LV remodelling
  • pacemaker to achieve resync (CRT)
  • transplant
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82
Q

Tx of HF with PRESERVED EF

A

Specialist tx
LTOT not recommended
- loop diuretic

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83
Q

Causes of mitral regurg

A
  • vol overload–> L atrial dilation
  • calcification
  • infective endocarditis
  • mitral prolapse, papillary muscle dysfunction (post MI)
  • *- connective tissue
  • *- cardiomyopathy
  • *- appetite supressants
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84
Q

sx mitral regurg

A
  • palpitations
  • SOB/dyspnoea
  • fatigue
  • HF sx
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85
Q

murmur of mitral regurg

A
  • pansystolic at apex
  • heard best with pt rolled on L using bell
  • radiation to L axilla
  • whistling/high pitched
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86
Q

other signs of mitral regurg apart from murmur

A
  • displaced apex (hypertophic LV)
  • AF
  • soft S1, split S2 (vol overload)
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87
Q

Ix ?mitral regurg

A
  • FBC, CRP- infection, anaemia
  • ECG- AF, LVH (ST wave depression and T wave inversion), p-mitrale (L atrial hypertophy, M p wave)
  • CXR- large Left heart, pulm oedema, valve calcified
  • ECHO
  • catheterisation
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88
Q

tx mitral regurg

A
  • diuretics
  • vasodilate- ACEI, hydralazine
  • rate- betablocker, CCB (verapamil), digoxin
  • surgery - repair/replace
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89
Q

causes of mitral stenosis

A
  • rheumatic fever
  • IE
  • calcification
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90
Q

sx of mitral stenosis

A
  • progressive dyspnoea
  • pulm venous HTN– haemoptysis
  • RSHF- oedema, ascites, epistaxis, anorexia
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91
Q

murmur character of mitral stenosis

A
  • low rumbling (low velocity)
  • mid diastolic
  • heard at apex
  • heart best with pt rolling on L at 5th ICS mid clav line
92
Q

other signs of mitral stenosis

A
  • loud S1
  • short S2
  • tapping apex beat
  • malar flush(pulm system back up– increase n CO2 and vasodilation)
  • AF
93
Q

ix for ?mitral stenosis

A

ECG- AF, p-mitrale
CXR- pulm congestion. LA big
- ECHO- diagnostic

94
Q

tx for mitral stenosis

A
  • rate- beta blockers, CCB, digoxin (improves diastolic filling)
  • diuretics
  • percutaneous valvotomy
  • surgery
  • IE prophylaxis no longer recommended
95
Q

what is S1

A

mitral valve closing

96
Q

what is S2

A

aortic valve closing

97
Q

causes of pericardial effusion

A
  • pericarditis
  • myocardial rupture
  • aortic dissection
  • malignancy
  • infection
98
Q

sx pericardial effusion

A
  • SOB, dyspnoea
  • syncope
  • chest pain
  • nausea, vomiting if viral
99
Q

signs of pericardial effusion

A
  • S1/2 muffled
  • bronchial breathing at L base

Tamponade

  • hypotension
  • JVP high
  • HF
  • tachycardia
  • hypoperfusion
100
Q

ix for ?pericardial effusion

A
  • CXR- globular, big heart
  • ECG- low V QRS
  • echo- echo free zone around heart
  • pericardiocentesis
101
Q

tx of pericardial effusion

A
  • cardiac tamponade- urgent drain of effusion
  • pericardiocentesis
  • NSAIDs
  • pred
  • colchicine
  • tx cause eg infection, dissection
102
Q

Classification of pericarditis

A
  • acute (~2w)

- chronic >6w

103
Q

causes of pericarditis

A
  • idiopathic
  • viruses, bacteria, fungi
  • autoimmune (SLE, RA)
  • CT and RT
  • **- hypothyroidism
  • **- anorexia nervosa
  • **- trauma/surgery
  • **- malignancy
104
Q

sx of pericarditis

A
  • *- hiccups( phrenic nerve runs either side of pericardial sac, irritation)
  • *- cough
  • central chest pain- worse on insp, lying, improved sitting forwards
  • fever, wt loss, joint pain
  • *- sight issues
  • *- may have sx of tamponade (lightheadedness, chest pain, LoC, syncope)
105
Q

signs of pericarditis

A
  • pericardial rub
  • pericardial effusion on Ix
  • cardiac tamponade
106
Q

Ix ?pericarditis

A

ECG

  • PR depression!!!
  • ST elevation with concave/saddle shaped
  • sinus tachy if acute
  • ESR
  • trop
  • CXR- cardiomegaly
  • CT- localised inflammation
107
Q

tx pericarditis

A
  1. NSAIDs/aspirin- 2w- NOT paracetemol!
    WITH: Colchicine- take for 3m, decreases recurrence
  2. corticosteroids (pred) if poor response to aspirin/NSAIDs, sometimes given with colchicine, however, encourages recurrence so not used as much
108
Q

what is an atrial septal defect a remnant of

A

foramen ovale

109
Q

what is the function of the foramen ovale

A

To bypass lungs, valve between R and L atria, creating R to L shunt

 Blood oxygenated in placenta
🡪 umbilical vein , return to circulation in portal vein via ductus venosus
🡪 RA
🡪foramen ovale
🡪 LA
🡪LV
🡪aorta and to the body 
→ umbilical artery come off the internal iliacs 
→ placenta
110
Q

associations of atrial septal defect

A

foetal alcohol syndrome

down’s

111
Q

what way does the shunt go in atrial septal defect

112
Q

what is Eisenmenger’s

A

when the direction of a shunt shifts

the longstanding L to R shunt causes pulmonary HTN
leading to a reversal of the shunt

113
Q

symptoms of Eisenmenger’s condition

A
  • cyanosis
  • syncope
  • palpitations
  • haemoptysis- pulm HTN
  • *- recurrent infections
  • *- stroke, gout, gallstones
114
Q

signs of Eisenmenger’s

A
  • cyanosis
  • Clubbing
  • HF
  • arrhythmias
  • bleeding disorders
  • iron deficiency, high RBC count (polycythemia)
  • poor kidney function
115
Q

symptoms of atrial septal defect

A
  • acyanotic– L–> R
  • DVT, stroke, infarction of spleen, intestine, extremities (turbulence, clot enters systemic blood supply rather than lungs– paradoxical embolism)
  • palpitations
  • migraine
  • pulm HTN (SOB, fatigue)
    • Eisenmenger’s– Cyanosis
116
Q

signs of atrial septal defect

A
  • splitting of S2– due to delayed pulm valve closure due to pulm HTN and increased R heart vol
  • soft midsystolic murmur at the upper left sternal border
117
Q

tx atrial septal defect

A
  • if small- monitor child, spont closure

- surgery- close the hole, if there is L–>R shunt with overload and R heart enlargement

118
Q

why does a ventricular septal defect occur

A
  • muscular ridge that grows up and the membranous ridge that grows down, fail to fuse
  • majority are due to issues with membranous portion
119
Q

associations with ventricular septal defect

A

foetal alcohol syndrome
down’s
other cardiac deformities

120
Q

what way does the shunt go in ventricular septal defect

121
Q

signs of ventricular septal defect

A

pansytolic murmur

Eisenmenger’s- cyanosis

122
Q

symptoms of ventricular septal defect

A
  • acyanotic
  • asx if small
  • pulm HTN– SOB, easy tiring
  • poor feeding FTT
123
Q

tx of ventricular septal defect

A
  • surgical closure if sx
124
Q

what is an atrioventricular defect

A
  • hole in atrial and ventricular septums
125
Q

direction of shunt in atrioventricular septal defect

126
Q

sx of atrioventricular septal defect

A
  • asx (partial, no valve regurg)

Baby:

  • breathing issues
  • pounding heart, weak pulse
  • poor feeding, slow wt gain
  • tired
  • oedema of legs/abdo

partial- may present as child

  • palpitations
  • congestive HF- SOB, oedema
  • pulm HTN- SOB
127
Q

signs of atrioventricular septal defect

A
  • systolic ejection murmur

- holosystolic murmur due to left AV valve regurg

128
Q

ix ?atrioventricular septal defects

A
  • USS
  • ECHO
  • ECG
129
Q

tx of atrioventicular septal defect

A
  • repair at about 5yo, sooner if sig

- if complete- do at 4-6m of age

130
Q

what abnormalities are present in tetralogy of fallot

A
  • stenosis of pulmonary artery
  • hypertrophy of RV
  • ventricular septal defect
  • overriding aorta– arises from both ventricles instead of just L
131
Q

Direction of shunt in Tetraology of Fallot

A

Pulm artery not that stenosed:
- L–> R

Pulm artery v stenosed

  • R–> L as pressure in R heart is higher than the L
  • cyanosis
132
Q

sx of tetralogy of Fallot

A
  • baby with cyanosis at birth
  • clubbing ~2m old
  • FFT

Tet spells

  • cyanotic spell
  • increased O2 demand, increased CO, increased shunt- deox blood into body
  • child squats
133
Q

why does child squat to relieve a Tet spell

A
  • kinks fem arts
  • increasing systemic resistance and in LV
  • reversing the shunt to the R
  • no deox blood now going to body
134
Q

tx of tet spell

A
  • keep child calm
  • O2, Fluid
  • betablocker,
  • **- Opioids, phenylepinephrine- these increase pulm BF and therefore decrease resistance in R heart
135
Q

Ix for ?tetralogy of Fallot

A
  • prenatal ECHO

- CXR- boot shaped

136
Q

tx of tetralogy of Fallot

A

Within 1st year of life:

  • repair VSD
  • enlarge pulm artery
  • other defects then spontaneously resolve
137
Q

Staging HF

A
  1. no undue dyspnoea from acitvity
  2. comfortable at rest, dyspnoea ordinary activity
  3. limiting dyspnoea on ADLs
  4. dyspnoea at rest, all activities cause discomfort
138
Q

Monitoring of HF

A

6 monthly HF monitoring

  • functional capacity
  • fluid status
  • cardiac rhythm
  • cognition
  • nutritional status
  • review meds
  • renal function

– doo every 2w if any changes

139
Q

what does HF with preserved EF mean

A

EF >50%

  • diastolic failure, due to inability of ventricle to relax and fill normally
  • ie the % of blood pumped out of the LV is still high, but it has filled poorly
  • vent hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity
140
Q

what is HF with reduced EF

A
  • EF <40%
  • systolic failure
  • inability of the heart contracting normally
  • causes: MI, IHD, cardiomyopathy
141
Q

what does ejection fraction mean

A

the % of blood pumped out of a filled LV

142
Q

what is a tachyarrhythmia

143
Q

Name some causes of a narrow complex tachyarrhythmia

A

QRS <120ms/3 small sq

Supraventricular Tachys:

  • sinus (regular)
  • AF (irreg)
  • atrial flutter (reg or irreg)
  • wolff-parkinson- white
  • AV re-entry
144
Q

Name some causes of a broad complex tachyarrhythmia

A

Ventricular tachys:

  • monomorphic (reg)
  • vent fib
  • torsade de pointes
  • vent flutter
  • any narrow complex causes combined with a block
145
Q

what is a Supraventricular tachycardia

A
  • arise above the level of the Bundle of His
  • encompass regular atrial, irregular atrial and regular atrioventricular tachys
  • NARROW QRS
146
Q

What is a ventricular tachycardia

A
  • tachy originating from the ventricles

- BROAD QRS complex

147
Q

What is atrial flutter

A
  • SVT

- re-entrant circuit around RA

148
Q

ECG features of atrial fluuter

A
  • saw-toothed flutter waves inbetween QRSes
  • regularly irregular- ratio of flutter waves to QRSes is generally constant
  • > 150bpm
  • narrow qrs
149
Q

sx of atrial flutter

A
  • palpitation
  • light headedness, syncope
  • chest pain
  • ## SOB
150
Q

tx for atrial flutter

A
  • cardioversion if unstable
  • beta blockers or diltiazem/verapamil, digoxin for rate control if stable
  • NO rhythm control
  • LT anticoags
151
Q

What is atrial fib

A
  • loss of regular and ordered atrial contraction, so ventricle beats irregularly
  • atrial depolarisation waves are too fast (>300bpm) for the vent to contract everytime, so only random waves make their way through
152
Q

causes of atrial fib

A

MITRAL

  • mitral valve regurg/stenosis
  • IHD
  • Thyrotoxicosis
  • Raised BP
  • Alcoholism/caffeine
  • Lone/idiopathic

TOXIC-

  • electrolytes
  • Thyrotoxicosis
  • Alcohol withdrawal
  • *- dehydration
  • *- Sepsis
  • *- Haemochromatosis

STRETCH

  • acute- PE, **MI
  • Chronic- valvular (MS, MR), LVH with LA dilatation, AS

RUB

  • myocarditis
  • pericarditis
  • *- tumours
MOST COMMON
Mrs SMITH
- female
**- Sepsis
- Mitral valve
- IHD
- Thyrotoxicosis
- HTN
153
Q

sx of AF

A
  • SOB
  • palpitations
  • light headedness
154
Q

ECG features of AF

A
  • no p waves (lead II)
  • irregularly irregular
  • chaotic, fibrillatory baseline
  • random QRS complexes
  • narrow QRSes
155
Q

ix ?AF

A
  • ECG
  • trop
  • *- TFT, UE
  • echo
156
Q

tx of AF

A
  • tx underlying cause if found

Acute

  • haem unstable- electrical cardioversion
  • Rhythm- preferable if younger, stable–> flecainide, amiodarone- gve as one off or more LT
  • rate control- preference if older, stable
    1a. beta blockers
    1b. CCB (verapamil, diltiazem)
    2. digoxin

Chronic

  • just rate control initially as cardioversion and rhythm control risks embolism
  • cardiovert/rhythm control only after 3w on anticoag

ANTICOAG
CHADSVASC score:- risk of stroke before starting anticoag
- Male + >=2- DOAC
- consider DOAC if >1 - give warfarin if DOAC is CI (prosthetic heart valve, elderly, renal)
- catheter ablation

157
Q

name some doacs

A

rivaroxaban
apixaban
dabigatran

– be careful for renal disease

158
Q

CI for spironolactone

A

hyperkalaemia

renal disease

159
Q

what is the CHA2DS2VASc score

A

Cong HF- 1

HTN- 1

Age >=75yo- 2

Diabetes- 1

hx of stroke/TIA/VTE- 2

vasc disease (peripheral artery, MI, aprtic plaque)- 1

Age 65-74yo- 1

Sex- female- 1

160
Q

what is wolff- parkinson-white syndrome

A

aberrant accessory pathway (bundle of Kent)- congential remnants
- intermittent racing heart rate, sudden onset, can last up to an hour

161
Q

sx of wolff-parkinson white

A
  • sudden palpitation
  • light-headedness/dizziness, syncope
  • SOB
  • chest pain
  • sweating
  • fatigue on exertion
  • sudden death
162
Q

ecg features wolff-parkinson white

A
  • sudden onset tachy (irreg)
  • delta wave- small p wave then no clear isolelectric PR interval, QRS starts straight after p wave- loos like a swooping up to QRS
163
Q

management of wolff-parkinson white

A

Symptomatic:
1. ablation
2 amiodarone, sotalol, flecainide
do NOT use digoxin= is contraindicated in WPW

acute: - narrow QRS, regular
1. vagal maneouvres
2. IV adenosine 6mg, 12mg, 12mg
3. BB/CCB

164
Q

What is vent fib

A

ventricular tachy
broad QRS
- chaotic vent acivtity

165
Q

sx vent fib

A
  • loss of consciousness

- sudden death

166
Q

management of vent fib/ VT no pulse

A

ALS algorithm-

  • CPR until defib is charged
  • 1st shock: give 1 shock if unwitnessed arrest, !3 quick succession shocks if witnessed arrest!
  • resume CPR 2 mins
  • rhythm check
  • 2nd shock
  • CPR 2 mins
  • rhythm check
  • 3rd shock and give adrenaline 1mg and amiodarone 300mg IV - repeat , giving A + A after 3rd, 5th, 7th, 9th shocks

once stable:
- implantable cardioverter defibrillator inacse occurs again

167
Q

ecg features of vent fib

A

wide, irregular QRS
chaotic activity- irreg delfections of varying amplitude
- no ID p waves or QRSses
- rate 150-55bpm
- amplitude deacreases with duration (caorse VF– fine VF– flatline)

168
Q

What type of tachy is torsades de Points, ecg feature

A
  • polymorphic ventricular tachy

- ECG- twisting of peaks– looks like arctic monkeys album cover

169
Q

RFs for torsades de point

A
  • *- prolonged QT
  • deranged electrolyes
  • bradycardia
  • HF
  • LV hypertorphy
  • drugs- cipro, flecainide, fluclonazole, levofloxacin, sotalol
170
Q

what drugs can prolong the QT interval

A
  • Heart meds- amiodarone, ivadradine
  • *- Opioids- apomorphine, methadone

**- kinase inhib (cancers)- bosutinib, dasatinib, encoafenib, levnatinib, sorafenib

Psych

  • Mood stabiliser- Lithium
  • SSRI- citalopram, venlafaxine
  • 1st gen- chlorpromazine, haloperidol, droperidol
  • 2nd gen- risperidone
  • fluclonazole
  • abx- clarithro, erythromycin, levofloxacin
  • anti-emetics- ondansetron (serotinergic antag), domperidone (DA antag)
  • *- quinine
  • sildenafil, vardenafil
171
Q

management of torsades de point

A
  • self limiting episodes although can turn into VF
  • cardioversion if unstable and/or below hasnt worked
  • Mg infusion (2g over 10min)
    later- LT pacemaker
172
Q

Algorithm for management of tachyarrhythmias

A

Unstable

  • synchroniced DC shck
  • amiodarone 300mg IV over 10-20mins, 900mg over 24hour
Stable
- broad irregular QRS
escalate
polymorphic VT (torsades)- Mg 2g
AF with BBB- tx as AF with bb/diltiazem
pre-excited AF- amiodarone
  • broad regular QRS
    VT–amiodarone 300mg 20m, 900mg 24hr
    if hx SVT with bundle branch block- vagal/adenosine as below
  • Narrow irregular QRS
    tx as AF- BB/ diltiazem, consider amiodarone, digoxin
  • Regular narrow QRS-
    Vagal maneouvres, adenosine bolus IV 6mg, 12mg, 12mg
    – not improves - Atrial flutter– BB
    – improves– was reentry SVT
173
Q

What could a irregular broad QRS tachy be

A
  • AF with bundle branch block
  • Polymorphic VT (torsades de point)
  • pre-excited AF
  • vent fib (no pulse and unconscious)
174
Q

What could a regular broad QRS tachy be

A
  • vent tachy

- supravent tachys with bundle branch block

175
Q

What could a irregular narrow QRS tachy be

A

SVT:

  • AF
  • atrial flutter
176
Q

What could a regular narrow QRS tachy be

A

SVT:s

  • Atriovent nodal re-entrant tachy (AVNRT)- mpost common
  • atrioventricular reciprocating tachy
  • atrial tachy

atrial flutter

177
Q

What are bradyarrhythmias caused by

A
  • IHD/MI
  • drugs eg digoxin
  • cardiac surgery
178
Q

Type of Bradyarrhythmias

A
  • 1st degree
  • 2nd degree (mobitz 1/wenckebach, mobitz 2
  • 3rd degree
  • bundle branch block (L, R)
179
Q

what is 1st degree heartblock

A
  • normal pattern but PR interval >200ms (5 small sq)
  • commonly seen in inferior MI
  • often no sx
  • should be monitored
180
Q

what conditions is 1st degree heart block commonly seen in

A

inferior MI

181
Q

Symptoms of 1st degree heart block

A

usually none

182
Q

management of 1st degree heartblock

A

monitor
if high grade occurs- stop CCBs and beta blockers
UE for electrolyte imbalances

183
Q

What is second degree heartblock

A
  • more p waves than QRSes

- regular relationship between the two (can ratio them)

184
Q

type of 2nd degree heart block

A

Mobitz 1/wenckebach
- progressively prolonged PR interval until QRS dropped, starts again

Mobitz 2
- PR int. constant but every few beats QRS is dropped - sudden unpredictable drop

185
Q

what is 3rd degree heart block

A

no relationship between p waves and QRS- go at own paces, complete dissoc

QRSes- called escape beats, can be as low as 30bpm

186
Q

Management of second degree heart block

A

Mobitz 1- consider pacing

Mobitz 2- pacemaker

187
Q

sx of second degree heart block

188
Q

tx of third degree/complete heart block

A

pacemaker- risk of sudden death

189
Q

sx of complete heart block

A
  • light-headedness/dizziness
  • fatigue
  • confusion
  • chest pressure/pain
  • SOB
190
Q

What is bundle branch block

A

disease/lesion causing delay or blockage of conducting pathways

191
Q

sx of bundle branch block

A

often asx

light headedness
SOB
Syncope

192
Q

Types and causes of bundle branch block

A

LBBB- activation spreads from R-L/front to back

  • MI
  • HTN
  • myocarditis
  • cardiomyopathy

RBBB- activation spreads from L-R
- PE, MI, congen structural disease, pulm HTN, myocarditis

193
Q

ecg features of LBBB

A
  • Broad QRS (>120ms/3 small sq)
  • W in V1, M in V6 (WiLLiaM)
  • in V1, QRS is pointing down
194
Q

ECG features of RBBB

A
  • broad QRS (>120ms/3 small sq)
  • M in V1, W in V6 (MaRRoW)
  • in V1, QRS is pointing up
195
Q

what does a new LBBB suggest

196
Q

Management of Bundle branch block

A
  • control HTN
  • tx sx of HF (loop diuretics)
  • cardiac resynch therapy pacemaker- bivent
197
Q

What are ventricular ectopics

A
  • extra QRS complexes

- very common, mostly benign

198
Q

presentation of ventricular ectopic

A
  • palpitations

- feeling of heart missing a beat, or “thud”

199
Q

Management of ectopics

A
  • if many- can lead to myocardial strain (>=5% ectopics)

- catheter ablation

200
Q

Management algorithm for badycardias

A

If unstable/risk of asystole (mobitz II/complete block, ventricular pause >3s, recent asystole):

  • atropine 500mcg IV

No response to above:
- repeat atropine 500mcg until max dose of 3mg
OR
- TC pacing with opioid
OR
- adrenaline 2-10mcg/min infusion (6mg adrenaline in 500mL saline at 10-50ml/hour)
- Isoprenaline

  • consider LT pacemaker or implantable cardioverter defib
201
Q

What is cardiogenic shock

A

Circulatory failure resulting in inadequate organ perfusion

  • <90mmHg systolic or MAP <65mmHg, with evidence of hypoperfusion
  • caused by pump failure
202
Q

causes of cardiogenic shock

A
  • ACS
  • dysrhythmias
  • valve
  • tension PTX
  • tamponade
203
Q

presentation of cardiogenic shock

A
  • cold, clammy
  • tachycardic
  • low BP
  • confusion, decreased GCS
  • poor prognosis
204
Q

name the acyanotic heart defects

A

L to R shunts

  • VSD
  • ASD
  • PDA
  • AV canal/AVSD
205
Q

Name the cyanotic heart defects

A

R to L
- any acyanotic defects that have switched due to increased pulm BP (Eisenmenger’s)

The 4 T’s

  • Transposition of the great arteries
  • Tetralogy of Fallot
  • *- Truncus arteriosus
  • *- Tricuspid abnormalities
  • *- Total anomalous pulmonary venous connection
  • Tons of others
  • *(pulmonary atresia, hypoplastic L heart, coarctation of aorta)
206
Q

ecg characteristics of digoxin toxicity

A
  • *- downsloping ST depression!
  • *- inverted T waves
  • short QT interval (<2 bigger squares from begginning of Q and end of T)

arrhythmias

  • SVT
  • slow AF
  • VT
  • sinus brady
  • AV block
207
Q

what should pts be taking after PCI for STEMI

A
  • dual antiplt
  • betablocker
  • ACEI
  • statin
208
Q

what drug class worsens psoriasis

A

beta blocker

209
Q

ecg features of PE

A
  • sinus tachy
  • RBBB
  • R axis deviation
  • RV strain- t wave inversion in V1-4
    ______________
  • SI, QIII, TIII- deep S wave lead I, q wave in III, inverted T in III (classic but present in only 20% of cases, not specific)
  • AF, flutter
  • non specific ST changed (50%) incl depression
210
Q

what time of day should you take statins

A

last thing in evening

211
Q

SE of nicorandil (angina medication after CCB, BB havent worked)

A

GI ulceration:
if this occurs discontinue the medication immediately

also GI perf/haemorrhage/fistula/abscess

212
Q

what route should you ogive medications in ALS if IV access cannot be obtained?

A

Intraosseous

213
Q

a single episode of AF o warrants what

A

anticoagulation with CHA2DS2VASc and/or HASBLED/ORBIT scores done prior

CHA2DS2VASc-

  • 0 - “low” risk and may not require anticoagulation;
  • a 1 score is “low-moderate” risk and should consider antiplatelet or anticoagulation
  • score 2 or greater is “moderate-high” risk and should otherwise be an anticoagulation candidate.

DOACs are now theoretically preferred over warfarin (in exam qs), although in practice not rly lols ok - maybe due to warfarin being better on kidneys and also has reversal agent

214
Q

is statin safe in preg

A

no- stop it

215
Q

definition of orthostatic hypotension

A

3-2-1 drop

  • after 3 mins of standing!
  • drop in BP S of at least 20mmHg
  • and/or drop in BP D of at least 10
216
Q

ECG characteristics of hypokalaemia

A
  • u waves (small deflections immediately after T wave, usually in same direction as T wave)
  • QT interval prolongation (>2 big sq from beginning of Q to end of T)
217
Q

ECG characteristics of hypercalcaemia

A
  • shortened QT interval

- J waves- positive deflection immediately after QRS)

218
Q

ECG characteritics of hyperkalaemia

A
  • tall tented twaves
  • flattened p waves
  • PR prolongation >(5ss)
  • broad QRS
219
Q

ECG changes in wolff parkinson white

A
  • delta waves (slurred upstroke to QRS)- make QRS look wide at base
  • short PR interval (<3ss)
220
Q

SE warfarin

A

haemorrhage
teratogenic, ok in breast feeding
skin necrosis
purple toes

221
Q

what antianginal do pts build up a tolerance to

A

standard release isosorbide

222
Q

what cardiac conitions have a double pulse (bisferiens)

A
  • arotic regurg
  • aortic stenosis
  • HOCM
223
Q

how do you tx pda

A

indomethacin or ibuprofen
given to the neonate
inhibits prostaglandin synthesis

if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair

224
Q

what heart defect may occur within the first week of an MI

A
  • VSD

new pansystolic murmur, HF- orthopnoea, SOB

225
Q

what additional drug should be considered in a pt who needs CPR with a hx of PE

226
Q

what is ebstein’s anomaly, signs

A

congen cardiac abnormality

  • low insertion of the tricuspid valve
  • large RA and small RV
  • tricuspid incompetence
  • assoc with Li exposure in utero

signs

  • cyanosis
  • pansystolic murmur
  • RBBB- split S1 and S2

Finals (15 decks)

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