Cardiology Flashcards
What is the management for Unstable Angina?
GTN/Opiates to manage pain
Optimise medication: 75mg aspirin, 12m ticagrelor/clopi, ACE-i, B-blocker, Statin
Routine OP angiogram + echo
? revascularisation
What is the management for NSTEMI?
B-A-T-M-A-N B-blocker Aspirin 300mg Ticagrelor Morphine if in severe pain Anticoagulate: Fondaparinux Nitrate
Then long-term cardioprotection
What is the management for a STEMI?
Morphine if in pain Oxygen if sats low Nitrate Aspirin 300mg Fondaparinux treatment dose.
PCI if <2 hours.
Thrombolysis if >2hrs.
Complications of MI
DARTH VADER Death Arrhythmia Ruptured ventricle Tamponade Heart Failure
Valve disease Aneurysm of ventricle Dresler Syndrome Embolism Regurgitation
What is Dresler Syndrome?
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
What is the GRACE score?
Scoring system for people post-STEMI to assess risk of death or repeat MI in 10 years.
What are the ACS secondary prevention medications?
6 As: Aspirin 75mg Another antiplatelet for 12m ACE-i Atenolol or other B-blocker Atorvastatin Aldosterone antagonist in HF
What are the causes of chronic heart failure?
- Hypertension
- Myocardial ischaemia
- Valve disease
- Arrhythmias
- Connective tissue disorders
- Renal failure and subsequent chronic overload
- Increased pulmonary vascular resistance- cor pulmonale
What investigations should you do if you suspect CCF?
- Bloods:
FBC (anaemia), U&E (renal failure/pre-meds), LFT (meds), BNP, Troponin, Glucose, TFT - ECG
- Imagine: Echo (diagnostic) + CXR
What is the medical management of CCF?
- Diuretic therapy: furosemide 40mg OD
- ACE-I and B-blocker
- Spironolactone
- Aspirin and statin
DIGOXIN- first line if concurrent AF, second line after the above in HF without AF.
What are the causes of ACUTE heart failure?
Fluid overload (iatrogenic often)
Sepsis
Post-MI
Arrhythmias
How would you approach a patient presenting with acute HF?
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
What are the symptoms and signs of cardiac tamponade?
Symptoms:
Chest pain, shortness of breath, fatigue, syncope/pre-syncope
Signs:
Muffled heart sounds, low BP, raised JVP on inspiration
Pulsus paradoxus
What is pulsus paradoxus?
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
How would you approach a patient with suspected cardiac tamponade?
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
What are the main causes of hypertension?
R-O-P-E
Renal: CKD, renal artery stenosis, hypoperfusion
Obesity
Pregnany-induced / pre-eclampsia
Endocrine: Conn’s/primary hyperaldosteronism, pheochromocytoma, Cushing’s, hyperthyroidism
What are the stages of hypertension?
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
How is hypertension diagnosed?
Take 3 BP readings in clinic and use the lowest.
If high, 24 hr ambulatory tape / home readings to rule out white coat HTN
What investigations are indicated in those diagnosed with hypertension?
Rule out end organ damage:
- Bloods: HbA1c, U&E, lipids
- Urine dip + albumin:creatinine ratio
- ECG
- Fundoscopy
Should calculate QRISK to help dictate management
What is QRISK?
A score which calculates the risk of CVD/ a cardiac event occurring in the next 10 years.
QRISK > 10: prescribe statin
When should medical management be used in hypertension?
- All those with S2 hypertension and above (>160/100)
- Those with S1 hypertension + other CV comorbidities/end-organ damage or QRISK >10%
What is the treatment algorithm for hypertension?
- ACE-inhibitor / ARB
- > If >55 or afro-caribbean, CCB first - ACE-i + CCB
- > if AC, ARB + CCB - ACE-i + CCB + Thiazide diuretic
- If K+ <4.5 add spironolactone, if K+ >4.5 add a/b-blocker
Target BP: <140/90
What is malignant hypertension?
Severely elevated BP (S3) with new/sudden-onset target organ damage.
What are the symptoms of malignant hypertension?
Headache Shortness of breath Palpitations Anxiety Epistaxis
In severe cases, can present with encephalopathy as a result of cerebral oedema.
How do you manage malignant hypertension?
Test for end-organ damage
IV labetalol / nicardipine
-> need to control slowly to prevent cardiac/cerebral ischaemia
What are the main causes of AF?
S-M-I-T-H
Sepsis Mitral valve dysfunction Ischaemic heart disease Thyrotoxicosis Hypertension
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
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
How would you manage paroxysmal symptomatic AF?
Flecanide pill-in-pocket therapy
Anticoagulation based on chadsvasc
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
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
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
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
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
How is infective endocarditis managed?
- Infectious Diseases team input
- SEPSIS 6 if septic
- 2-6w IV antibiotics depending on cause
- > empirical and narrow down to sensitive - Surgical valve replacement / repair depending on echo findings
Supportive treatment: fluids, O2 etc
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.
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
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
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
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
What is the management for pericarditis?
- Supportive treatment, often self-limiting
- NSAIDs +/- colchicine
- If severe, associated with inflammatory syndromes or uraemia -> prednisolone
- Surgical: pericardiectomy in constrictive disease
What is the inheritance pattern of HOCM?
Autosomal dominant
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
What are the diagnostic criteria for HOCM?
Non-dilated LV hypertrophy (>15mm) with no other disease which may explain it
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
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
In what condition would you hear a third heart sound?
Heart Failure
What is the most common heart murmur?
Aortic Stenosis
What are the most common causes of mitral stenosis?
Rheumatic fever
Infective endocarditis
What would you expect to find on auscultation in somebody with mitral stenosis?
Mid-diastolic murmur - low pitched
Loudest at apex on expiration
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
What conditions are associated with mitral regurgitation?
Marfan's Ehlers Danlos syndrome Endocarditis and rheumatic heard disease IHD Age
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
What is the target INR for those with prosthetic heart valves?
2.5-3.5
What are the major complications of valve replacements?
Thrombus formation
Infective endocarditis
Haemolysis and anaemia
Bleeding as a result of warfarin
What is an alternative treatment to valve replacement in aortic stenosis?
Transcatheter aortic valve implantation
What are the shockable and non-shockable arrest rhythms?
Shockable: VT, VF
Non-shockable: PEA, asystole
How do you tell a ventricular tachycardia apart from a supra ventricular?
Ventricular = broad complex SV = narrow complex
How do you manage atrial flutter?
- Medical
Rate control: B-blocker or cardioversion if new
Anti-coagulate based on CHASVASC - Treat any underlying reversible cause
- Radiofrequency ablation of re-entrant rhythms
How would you manage a patient with SVT?
- Continuous ECG monitoring
- Valsalva manoeuvre + carotid sinus massage
- Adenosine or verapamil
- DC cardioversion - must be synchronised, otherwise can degrade into VF
How would you manage a patient with SVT?
- Continuous ECG monitoring
- Valsalva manoeuvre + carotid sinus massage
- Adenosine or verapamil
6mg -> 12mg -> 12 mg adenosine via large proximal cannula - DC cardioversion - must be synchronised, otherwise can degrade into VF
Long term: rate control with B-blockers / CCB / Amiodarone, or radio-frequency ablation
What are the features of WPW on ECG and how is it managed?
- Short PR interval
- Broad QRS
- Delta wave- slurred upstroke on QRS
Management: radio-frequency ablation of abnormal rhythm
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
What are the causes of Torsades de pointes?
Prolonged QT interval: 1. Medication: Macrolide antibiotics (erythromycin), Lithium, antipsychotics, citalopram, amiodarone
- Electrolyte imbalance:
HYPO - kalaemia, magnesaemia, calcaemia - Other:
Hypothermia, myocardial ischaemia, raised ICP
How would you manage somebody with Torsades de Pointes?
- Stop any causative medication and correct any electrolyte abnormality
- IV magnesium + infusion = first line to stabilise myocardium
- In case of VF/arrest -> defibrillation
How would you manage a patient with unstable bradycardia?
- A-E and cardiac monitoring
- Atropine IV 500mcg + repeat up to 6 doses
- Other inotropes e.g. noradrenaline
- Transcutaneous pacing using defib
In long term= implantable cardiac pacemaker
How would you manage VT in: pulseless, unstable and stable patients?
- Pulseless:
Defibrillate, CPR, intubate and get access
IV adrenaline, amiodarone
Rule out 4Hs and 4Ts - Unstable
IV amiodarone 5mg/kg, O2
DC cardioversion, sotalol
External pacing - 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.
What are the different causes of VF?
- Cardiac
Myocardial infarction, myopathy, Torsades de Pointes, Channelopathies, Aortic stenosis / dissection,
tamponade, myocarditis, blunt trauma - Respiratory
Tension pneumothorax, PE, pulmonary hypertension, apnoea, bronchospasm, aspiration - Other
Sepsis, Seizure, Stroke
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
How would you manage somebody in VF?
- Initiate CPR and attack pads to see if shockable
- Shocks initiated every 2 minutes with good compressions in between
- Establish airway and access (2 large bore cannula if possible)
- IV Adrenaline 1mg every 3-5 mins (1ml 1:10,000)
- IV amiodarone if confirmed VF
How do sodium levels affect ECG traces?
They don’t.
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
What are the signs
What are the signs of hyperkalaemia on ECG?
Tall, tented T waves
Broad QRS
Flat P waves
Sine wave formation in severe
What are the causes of hypokalaemia?
Diarrhoea, vomiting, alcoholism, malnutrition
Hyperaldosteronism, glucose infusion, diuretics, adrenergic agonists, steroids, insulin
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
What are the signs of Hypercalcaemia on ECG?
Short QT
Prolonged QRS
Bradycardia
What are the signs of hypocalcaemia on ECG?
Long QT
Shortened QRS
Which is more dangerous cardiologically, hyper or hypomangnesaemia?
HYPOmagnesaemia - can lead to SVT, hence first line treatment is IV magnesium
If a patient suffers complete heart block following an MI, which vessel is most likely affected?
Right coronary
