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Cardiology Flashcards

1
Q

What is the management for Unstable Angina?

A

GTN/Opiates to manage pain
Optimise medication: 75mg aspirin, 12m ticagrelor/clopi, ACE-i, B-blocker, Statin

Routine OP angiogram + echo
? revascularisation

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2
Q

What is the management for NSTEMI?

A 
B-A-T-M-A-N
B-blocker
Aspirin 300mg
Ticagrelor
Morphine if in severe pain
Anticoagulate: Fondaparinux
Nitrate

Then long-term cardioprotection

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3
Q

What is the management for a STEMI?

A 
Morphine if in pain
Oxygen if sats low
Nitrate
Aspirin 300mg 
Fondaparinux treatment dose.

PCI if <2 hours.
Thrombolysis if >2hrs.

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4
Q

Complications of MI

A 
DARTH VADER
Death
Arrhythmia
Ruptured ventricle
Tamponade 
Heart Failure

Valve disease
Aneurysm of ventricle
Dresler Syndrome
Embolism
Regurgitation
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5
Q

What is Dresler Syndrome?

A

Post- MI inflammatory immune response
Causes pericarditis 2-3w post-MI
Sx: Pleuritic CP, low grade fever and pericardial rib.
Can cause pericardial effusion or tamponade

Rx: NSAIDs +/- steroids

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6
Q

What is the GRACE score?

A

Scoring system for people post-STEMI to assess risk of death or repeat MI in 10 years.

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7
Q

What are the ACS secondary prevention medications?

A 
6 As:
Aspirin 75mg
Another antiplatelet for 12m
ACE-i
Atenolol or other B-blocker
Atorvastatin
Aldosterone antagonist in HF
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8
Q

What are the causes of chronic heart failure?

A
  1. Hypertension
  2. Myocardial ischaemia
  3. Valve disease
  4. Arrhythmias
  5. Connective tissue disorders
  6. Renal failure and subsequent chronic overload
  7. Increased pulmonary vascular resistance- cor pulmonale
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9
Q

What investigations should you do if you suspect CCF?

A
  1. Bloods:
    FBC (anaemia), U&E (renal failure/pre-meds), LFT (meds), BNP, Troponin, Glucose, TFT
  2. ECG
  3. Imagine: Echo (diagnostic) + CXR
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10
Q

What is the medical management of CCF?

A
  1. Diuretic therapy: furosemide 40mg OD
  2. ACE-I and B-blocker
  3. Spironolactone
  4. Aspirin and statin

DIGOXIN- first line if concurrent AF, second line after the above in HF without AF.

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11
Q

What are the causes of ACUTE heart failure?

A

Fluid overload (iatrogenic often)
Sepsis
Post-MI
Arrhythmias

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12
Q

How would you approach a patient presenting with acute HF?

A

A-E assessment

  • > expect tachycardia, tachypnoea, low sats, basal creps, S3 sound
  • > O2 supplementation, IV access, attach to monitoring

ECG, ABG, Bloods at bedside
CXR + Echo when available

1- Stop any IV fluids, sit upright
2-Diuretic therapy e.g. IV furosemide 40mg STAT
3- O2 supplementation
4- If still unstable: CPAP, inotropic medication, intubation

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13
Q

What are the symptoms and signs of cardiac tamponade?

A

Symptoms:
Chest pain, shortness of breath, fatigue, syncope/pre-syncope

Signs:
Muffled heart sounds, low BP, raised JVP on inspiration
Pulsus paradoxus

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14
Q

What is pulsus paradoxus?

A

Decrease in BP on inspiration, classic sign of cardiac tamponade, tension pneumothorax, severe pericarditis

Get patient to breathe in and hold it - record BP, repeat with expiration and look for a difference

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15
Q

How would you approach a patient with suspected cardiac tamponade?

A

A-E assessment
Attach to continuous monitoring, O2 if needed and get IV access
Bloods: FBC, troponin, BNP, group and save, ABG, U&E, LFT
ECG
USS/Echo is diagnostic

Once confirmed, call cardiothoracics urgently for pericardiocentesis

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16
Q

What are the main causes of hypertension?

A

R-O-P-E

Renal: CKD, renal artery stenosis, hypoperfusion
Obesity
Pregnany-induced / pre-eclampsia
Endocrine: Conn’s/primary hyperaldosteronism, pheochromocytoma, Cushing’s, hyperthyroidism

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17
Q

What are the stages of hypertension?

A

Stage 1: >140/90 in clinic or >135/85 at home
Stage 2:>160/100 in clinic or >150/90 at home
Stage 3:>180 systolic or >110 diastolic

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18
Q

How is hypertension diagnosed?

A

Take 3 BP readings in clinic and use the lowest.

If high, 24 hr ambulatory tape / home readings to rule out white coat HTN

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19
Q

What investigations are indicated in those diagnosed with hypertension?

A

Rule out end organ damage:

  • Bloods: HbA1c, U&E, lipids
  • Urine dip + albumin:creatinine ratio
  • ECG
  • Fundoscopy

Should calculate QRISK to help dictate management

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20
Q

What is QRISK?

A

A score which calculates the risk of CVD/ a cardiac event occurring in the next 10 years.

QRISK > 10: prescribe statin

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21
Q

When should medical management be used in hypertension?

A
  • All those with S2 hypertension and above (>160/100)

- Those with S1 hypertension + other CV comorbidities/end-organ damage or QRISK >10%

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22
Q

What is the treatment algorithm for hypertension?

A
  1. ACE-inhibitor / ARB
    - > If >55 or afro-caribbean, CCB first
  2. ACE-i + CCB
    - > if AC, ARB + CCB
  3. ACE-i + CCB + Thiazide diuretic
  4. If K+ <4.5 add spironolactone, if K+ >4.5 add a/b-blocker

Target BP: <140/90

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23
Q

What is malignant hypertension?

A

Severely elevated BP (S3) with new/sudden-onset target organ damage.

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24
Q

What are the symptoms of malignant hypertension?

A 
Headache
Shortness of breath
Palpitations
Anxiety
Epistaxis

In severe cases, can present with encephalopathy as a result of cerebral oedema.

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25
How do you manage malignant hypertension?
Test for end-organ damage IV labetalol / nicardipine -> need to control slowly to prevent cardiac/cerebral ischaemia
26
What are the main causes of AF?
S-M-I-T-H ``` Sepsis Mitral valve dysfunction Ischaemic heart disease Thyrotoxicosis Hypertension ```
27
What are the signs and symptoms of AF?
Symptoms: May be asymptomatic Breathlessness, palpitations, chest pain, tiredness, syncope May present with symptoms of thrombotic complication: PE, MI, stroke Signs: irregularly irregular pulse, may be tachycardic
28
How would you manage AF?
Rate control, rhythm control, anticoagulation. In new-onset (<48hr), unstable or reversible cause: DC cardioversion = first line If >48 hrs, needs 3w anticoagulation first. Rate control: B-blocker - > calcium channel blocker - > digoxin if inactive Rhythm control: cardioversion = 1st line or medical: flecainide or amiodarone Anticoagulate: CHADSVASC + HASBLED score DOAC = 1st line, warfarin 2nd
29
How would you manage paroxysmal symptomatic AF?
Flecanide pill-in-pocket therapy | Anticoagulation based on chadsvasc
30
What are the risk factors for infective endocarditis?
``` Systemic infection Indwelling lines Prosthetic valves / joints / grafts Unsterile injections- IVDU, piercings, tattoos Immunosuppression Poor dentition Acquired valve disease e.g. rheumatic ```
31
What are the most common causative organisms and affected valves in infective endocarditis?
Organisms: S. aureus in acute disease Viridans streptococci in subacute disease Valves: Mitral valve most common in general public Tricuspid valve most common in IVDUs
32
What are the symptoms associated with infective endocarditis?
General: Fever, malaise, fatigue, night sweats, tachycardia, shortness of breath, weight loss Specific: Pleuritic chest pain, cough, arthralgia, myalgia
33
What are the signs on examination associated with infective endocarditis?
Splinter haemorrhages, Janeway lesions, Osler nodes and palmar erythema Poor dentition, petechiae New murmur - usually mitral regurgitation Signs of HF and arrhythmias Signs of infective emboli
34
How is infective endocarditis diagnosed?
Duke's criteria: > 2 major criteria > 1 major + 3 minor criteria > 5 minor criteria Major: findings on blood cultures (>2 sets, 12hr apart) or on echocardiogram Minor: RFs, fever, vascular abnormality, immune phenomena (infection markers etc) ECG should also be done to assess for complications
35
How is infective endocarditis managed?
1. Infectious Diseases team input 2. SEPSIS 6 if septic 3. 2-6w IV antibiotics depending on cause - > empirical and narrow down to sensitive 4. Surgical valve replacement / repair depending on echo findings Supportive treatment: fluids, O2 etc
36
What is the difference between post-MI pericarditis and Dresler syndrome?
Post-MI occurs 1-3 days after an infarction, Dresler syndrome occurs weeks-months after.
37
What are the causes of pericarditis?
Infective: Coxsackie B virus = most common Staph / strep / fungal Toxoplasmosis ``` Non-infective: Post-MI / Dresler syndrome Rheumatological / inflammatory causes Uraemia Radiotherapy Post-operative ```
38
What are the symptoms of pericarditis?
Sharp, pleuritic chest pain - retrosternal, may radiate to neck/shoulders, improves on leaning forward Low-grade fever Tachypnoea, Dyspnoea Non-productive cough
39
What are the signs associated with pericarditis?
Pericardial rub on auscultation- heard loudest at L sternal border with patient sat leaning forward Tachycardia, tachypnoea Quiet heart sounds Low-grade fever May have signs of HF/ fluid overload if patient has constrictive disease
40
What investigations should you do in patients with suspected pericarditis? What would you expect to find?
``` Bloods: FBC- may have raised WCC (leukocytes) U&E- rule out uraemia Cultures if infective symptoms CRP/ESR- raised Troponin: may be raised CK: may be raised BNP/D-dimer as exclusive tests ``` ECG: widespread saddle-shaped STE, PR depression, may have ST depression in avR and V1. TTE: may have pericardial effusion, rule out tamponade
41
What is the management for pericarditis?
1. Supportive treatment, often self-limiting 2. NSAIDs +/- colchicine 3. If severe, associated with inflammatory syndromes or uraemia -> prednisolone 4. Surgical: pericardiectomy in constrictive disease
42
What is the inheritance pattern of HOCM?
Autosomal dominant
43
What are the symptoms associated with HOCM?
Often asymptomatic until sudden cardiac arrest May have exertion dyspnoea, angina, dizziness, syncope and palpitations ES murmur on auscultation Biphasic pulse
44
What are the diagnostic criteria for HOCM?
Non-dilated LV hypertrophy (>15mm) with no other disease which may explain it
45
What investigations should be done in HOCM?
ECG: LVH, deep Q waves, may have giant inverted T waves in precordial leads May have non-specific ST/T wave changes, P wave changes or LBBB Associated with VT, AF and atrial flutter in more acute disease TTE: Wall thickness, outflow abnormality, asymmetrically thickened septum Genetic testing and family screening Ambulatory ECG
46
What are the management options for HOCM?
Lifestyle change and counselling B-blockers and/or calcium channel blockers in symptomatic - usually verapamil or diltiazem ICD implantation
47
In what condition would you hear a third heart sound?
Heart Failure
48
What is the most common heart murmur?
Aortic Stenosis
49
What are the most common causes of mitral stenosis?
Rheumatic fever | Infective endocarditis
50
What would you expect to find on auscultation in somebody with mitral stenosis?
Mid-diastolic murmur - low pitched | Loudest at apex on expiration
51
What would you expect to find on auscultation in somebody with mitral regurgitation?
Pan-systolic, high pitched murmur May radiate to the L axilla May be associated with S3 Loudest at the apex and on expiration
52
What conditions are associated with mitral regurgitation?
``` Marfan's Ehlers Danlos syndrome Endocarditis and rheumatic heard disease IHD Age ```
53
What would you expect to find on auscultation in somebody with aortic stenosis?
Ejection systolic murmur, high pitched, loudest on inspiration May radiate to carotids Causes slow-rising pule and narrow pulse pressure
54
What is the target INR for those with prosthetic heart valves?
2.5-3.5
55
What are the major complications of valve replacements?
Thrombus formation Infective endocarditis Haemolysis and anaemia Bleeding as a result of warfarin
56
What is an alternative treatment to valve replacement in aortic stenosis?
Transcatheter aortic valve implantation
57
What are the shockable and non-shockable arrest rhythms?
Shockable: VT, VF Non-shockable: PEA, asystole
58
How do you tell a ventricular tachycardia apart from a supra ventricular?
``` Ventricular = broad complex SV = narrow complex ```
59
How do you manage atrial flutter?
1. Medical Rate control: B-blocker or cardioversion if new Anti-coagulate based on CHASVASC 2. Treat any underlying reversible cause 3. Radiofrequency ablation of re-entrant rhythms
60
How would you manage a patient with SVT?
1. Continuous ECG monitoring 2. Valsalva manoeuvre + carotid sinus massage 3. Adenosine or verapamil 4. DC cardioversion - must be synchronised, otherwise can degrade into VF
60
How would you manage a patient with SVT?
1. Continuous ECG monitoring 2. Valsalva manoeuvre + carotid sinus massage 3. Adenosine or verapamil 6mg -> 12mg -> 12 mg adenosine via large proximal cannula 4. DC cardioversion - must be synchronised, otherwise can degrade into VF Long term: rate control with B-blockers / CCB / Amiodarone, or radio-frequency ablation
61
What are the features of WPW on ECG and how is it managed?
1. Short PR interval 2. Broad QRS 3. Delta wave- slurred upstroke on QRS Management: radio-frequency ablation of abnormal rhythm
62
What is the difference between VT and Torsades de Pointes?
VT is monomorphic broad complex tachycardia | TdP is polymorphic broach complex tachycardia - appearance of twisting around the baseline
63
What are the causes of Torsades de pointes?
``` Prolonged QT interval: 1. Medication: Macrolide antibiotics (erythromycin), Lithium, antipsychotics, citalopram, amiodarone ``` 2. Electrolyte imbalance: HYPO - kalaemia, magnesaemia, calcaemia 3. Other: Hypothermia, myocardial ischaemia, raised ICP
64
How would you manage somebody with Torsades de Pointes?
1. Stop any causative medication and correct any electrolyte abnormality 2. IV magnesium + infusion = first line to stabilise myocardium 3. In case of VF/arrest -> defibrillation
65
How would you manage a patient with unstable bradycardia?
1. A-E and cardiac monitoring 2. Atropine IV 500mcg + repeat up to 6 doses 3. Other inotropes e.g. noradrenaline 4. Transcutaneous pacing using defib In long term= implantable cardiac pacemaker
66
How would you manage VT in: pulseless, unstable and stable patients?
1. Pulseless: Defibrillate, CPR, intubate and get access IV adrenaline, amiodarone Rule out 4Hs and 4Ts 2. Unstable IV amiodarone 5mg/kg, O2 DC cardioversion, sotalol External pacing 3. Stable: O2, IV amiodarone or sotalol Cardioversion with sedation External pacing Any cardioversion should be synchronised, as depending on the focus of the abnormal rhythm the shock can cause degeneration into VF.
67
What are the different causes of VF?
1. Cardiac Myocardial infarction, myopathy, Torsades de Pointes, Channelopathies, Aortic stenosis / dissection, tamponade, myocarditis, blunt trauma 2. Respiratory Tension pneumothorax, PE, pulmonary hypertension, apnoea, bronchospasm, aspiration 3. Other Sepsis, Seizure, Stroke
68
What are the 4Hs and 4Ts to rule out in non-shockable arrests?
Hypoxia Hypovolaemia Hyper / hypokalaemia Hyper / hypothermia Toxicity Tension pneumothorax Tamponade Thromboembolism- PE/MI
69
How would you manage somebody in VF?
1. Initiate CPR and attack pads to see if shockable 2. Shocks initiated every 2 minutes with good compressions in between 3. Establish airway and access (2 large bore cannula if possible) 4. IV Adrenaline 1mg every 3-5 mins (1ml 1:10,000) 5. IV amiodarone if confirmed VF
70
How do sodium levels affect ECG traces?
They don't.
71
What are the causes of hyperkalaemia?
Renal failure, acidosis, DKA, haemolysis Addisons, insufficient steroid substitution, insulin deficiency K+ substitution, K+ sparing diuretics, ACE-I, ARB, Digoxin toxicity
72
What are the signs
72
What are the signs of hyperkalaemia on ECG?
Tall, tented T waves Broad QRS Flat P waves Sine wave formation in severe
73
What are the causes of hypokalaemia?
Diarrhoea, vomiting, alcoholism, malnutrition | Hyperaldosteronism, glucose infusion, diuretics, adrenergic agonists, steroids, insulin
74
What are the signs of hypokalaemia on ECG?
Wide, flat T waves (even T wave inversion in severe) ST depression Increased P wave amplitude and PR interval length U waves Prolonged QT - predisposes to TdP
75
What are the signs of Hypercalcaemia on ECG?
Short QT Prolonged QRS Bradycardia
76
What are the signs of hypocalcaemia on ECG?
Long QT | Shortened QRS
77
Which is more dangerous cardiologically, hyper or hypomangnesaemia?
HYPOmagnesaemia - can lead to SVT, hence first line treatment is IV magnesium
78
If a patient suffers complete heart block following an MI, which vessel is most likely affected?
Right coronary

Finals Revision (23 decks)

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