Cardiology Flashcards
1
Q
what are the causes of heart failure
A
- ischaemic heart disease
- HTN
- valvular heart disease
- Afib
- chronic lung disease
- cardiomyopathy
- previous cancer chemo drugs
- HIV
2
Q
what are the two different types of heart failure?
A
HFREF - heart failure with reduced ejection failure
HFNEF - heart failure with normal ejection failure -> elderly, HTN, afib, overweight
3
Q
what investigations are done to diagnose heart fialure?
A
- BLOODS:
- renal function
- FBC
- LFT’s hepatic congestion
- TFT’s thyroid disease
- ferritin and trasnferrin
- brain natriuretic peptide - CXR
- ECHO !!!
- Cardiac MRI
4
Q
what signs are seen on CXR of heart failure?
A
- cardiomegaly
- pleural effusions
- air bronchograms
- increased vascular pedicle
- perihilar shadowing/consolidations
- alveolar oedema
5
Q
what lifestyle modification is needed to manage heart failure?
A
- smoking cessation
- reduce alcohol consumption
- salt restriction
- fluid restriction and daily weight monitoring
6
Q
what medication is given to patients with heart failure?
A
- DIURETICS: furosemide 40-500mg OD (or bumetanide)
- ACEi
- AngII RB: valsartan/candesartan
- ANgiotensin receptor-neprilysin inhibitor
- Beta blockers: START LOW + GO SLOW -> onyl if >100mg systolic and >60 bpm HR (bisoprolol)
vasodilators, ivabradine, nitrates
7
Q
what are the two main types of pacemaker?
and what do they do?
A
CRT: cardiac resynchronisation pacemaker (used in LBBB)
ICD: implantable cardiac defibrillators (prevents sudden death in heart failure)
8
Q
what are the main symptoms of aortic stenosis?
A
angina, heart failure, syncope, decrease in exercise tolerance, dyspnoea on exertion
9
Q
what are the commenest cuases of aortic stenosis?
A
age related
congenital bicuspid valve
chronic kidney disease
previous rheumatic fever
10
Q
describe the murmur of aortic stenosis.
A
heard on the right sternal border 2nd intercostal space
ejection systolic murmur radiating to the carotid/neck
11
Q
what aortic valve area is considered mild, moderate and severe?
A
mild >1.2cm^2
moderate 1-1.2cm^2
severe <1cm^2
12
Q
what is the treatment for aortic stenosis?
A
TAVI - transcatheter aortic valve implantation (especially is older patients with significant comorbidities)
13
Q
what are teh initial symptoms of aortic regurg?
A
exertional dyspnoea and reduction in exercise tolerance
14
Q
what are the main cuases of aortic regurgitation?
A
- idiopathic dilatation of the aorta (pulling valve leaflets apart)
- congenital abnormalities of aortic valve (biscuspid valves)
- calcific degeneration
- rheumatic disease
- infective endocarditis
- marfan syndrome
15
Q
what are the main signs on examination of aortic regurgitation?
A
- murmur is best heard at the left sternal edge and is an early diastolic blowing murmur
- collapsing pulse
- De Musset’s sign (head bobbing)
16
Q
what medication is most commonly given to treat aortic regurg?
A
ACEi to reduce afterload which slows rate of left ventricular dilatation
17
Q
what is the gold standard assessment for aortic and mitral regurg?
A
echocardiogram
18
Q
is surgical intervention needed in patietns with mitral regurgitation?
A
most commonly not
patients are mostly asymptomatic and if they have chronic MR with mild-moderate disease then less likely to need surgery
19
Q
what two medical conditions have a higher rate of mitral vlave prolapse?
A
marfans syndrome and pectus excavatum
20
Q
what are teh main cuases of mitral valve regurg?
A
- marfans
- pectus excavatum
- rheumatic heart disease
- IHD
- infective endocarditis
- certain drugs
- collagen vascualr disease
21
Q
what type of murmur is mitral regurg described as?
A
pan systolic blowing murmur best heard over mitral area (5th intercostal space, left mid clavicular line) and radiates to the axilla
22
Q
what medications can be given in a patient with mitral regurg?
A
- DIURETICS
- if patient has functional or ischaemic MR then ACEi given
- if LV systolic dysfunction present then ACEi and beta blockers (bisoprolol or carvedilol) beneficial to reduce MR
23
Q
what are the predisposing cardiac conditions for infective endocarditis?
A
- mitral valve prolaps
- presence of prosthetic material (valves and patches, NOT stents)
- rheumatic heart disease
- degenerative and bicuspid aortic valve disease
- congenital heart disease
- intravascular device
24
Q
what are teh most common causative organisms for infective endocarditis?
A
- viridans group of streptococci (50%)
- staph aureus (20%) (common in IV users)
- perioperative ‘early’ IE (up to 1yr after) usually caused by staphylococci and ‘late’ IE usually caused by viridans streptococci, staph aureus and coagulase neg staphylococci
- entrococcal (10%)
- fungi (2-10%) - common in immunosupression, IV drug use, cardiac surgery, prolonged exposure to antimicrobials and IV feeding
25
what investigations need to be done in a patient suspected of having infective endocarditis?
- FBC
- ESR and CRP
- U&Es
- LFTs
- Urine dipstick and MSU for culture/microscopy
- chest xray
- ECG
- BLOOD CULTURES AND ECHO (most important !!!)
26
what presenting symptoms are common in a patient with infective endocarditis?
- unexplained fever
- bacteraemia
- systemic illness
- new murmur
- any other features of illness
27
what are teh two different types of echocardiograms dones on patients with suspected IE and which is better?
transthoracic echo (65% og vegetations detected) and transoesophageal echo (95% of vegetations detected)
28
what is the protocal for blood cultures wth a suspected IE patient?
at least three sets of blood cultures taken from different sites of several hours
if patient is stable you CAN delay ABX treatment to allow comprehensive sampling
29
what monitoring needed to be done (which investigations) of a patient with infective endocarditis/
- ECHO - weekly
- ECG - twice weekly (detect conduction disturbances)
- Blood tests - twice weekly (ESR, CRP, FBC, U&Es)
- Duration of ABX will depend on lcinical response and local microbiology guidance (6wks+)
30
when is surgery indicated in patients with infective endocarditis?
- moderate to severe cardiac failure deu to valve comprimise
- valve dehiscence
- uncontrolled infection despite appropriate antimicrobial therapy
- relapse after optimal medical therapy
- threatened or actual systemic embolism
- fungal infection or coxiella burnetii infection
- paravalvar infection
- sinus of valsalva aneurysm
- valve obstruction
31
what organ damage can a hypertensive emergency lead to?
- encephalopathy
- LV failure
- aortic dissection
- unstable angina
- renal failure
32
what is the difference between a hypertensive emergency and hypertensive urgency?
hypertensive emergency -> high BP associated with a critical event
hypertensive urgency -> high BP without a critical illness
33
what is teh immediate treatment given to patients with a hypertensive emergency?
1. sodium nitroprusside
2. labetalol
3. GTN
4. esmolol
34
during a hypertensive urgency, what diastolic blood pressure value is the aim and what oral drugs are given to achieve this?
diastolic usually >130mmHg and needs to get down to 100mmHg over 48-72 hours
- amlodipine 5-10mg OD
- diltiazem 120-300mg daily
- lisinopril 5mg OD
- ACEi and calcium antagonists
most effective:
- nifedipine 20mg MR BD + amlopdipine 10g OD for 3 days then amlopdipine 10mg OD continuation
35
what are the common symptoms in a phaeochromocytoma hypertensive emergency?
- sweating
- headache
- tachycardia
(- sustained or paroxsymal hypertension)
36
how is a diagnosis of phaeochromocytoma hypertensive emergency made?
- measurements of urinary and plasma fractionated metanephrines and catecholamines
- 24 hours urine collection is the main test
- CT or MRI of abdo confirms tumours
- MIBG (nuclear) scan can detect tumours not detected by CT or MRI
37
when phaeochromocytoma is diagnosed what should immediaelty happen?
all patients given alpha and beta blockade (phenoxybenzamine 10mg (then increased) typically used)
alpha blockade always first ! then beta blockade 2/3 dyas preoperatively
THEN resection of tumour !
38
how does a cushings hypertensive emergency present? what ivnestigations are done to confirm it?
very apparent by the typical physical apperance
- bloods reveal hyperlgycemia
- 24 hours urine cortisol excretion will be elevated
- low-dose dexamethasone suppression test
- adrenal CT
39
what signs/indications will present in a patient with primary aldosteronism in a hypertensive emergency?
LOW/normal serum K+ and high/normal Na+
FHx of premature HTN
resistant HTN
40
what investgiations need to be done to diagnose primary aldosteronism in a hypertensive emergency
an aldosterone:renin ratio should be measured in he morning
plasma renin activity is typically very low or undetectable and plasma aldosterone high
also adrenal ct !!
41
what are the 5 titles to the BASIC ECG ALGORITHM?
1. rate - tachy or brady
2. rhythm - regular, sinus arrythmia, irregular
3. Axis - LAD or RAD
4. intervals - PR, QRS, QTc
5. ST/T wave changes - elevation, depression, inversion
42
what is the heart rate which classifies brady and tachycardia?
bradycardia - <50bpm
| tachycardia - >120bpm
43
how do you calculate HR on a basic 12 lead ECG strip
look at lead II - count the amount of QRS complexes and x6 as it is a 10 sec strip
44
what are teh causes of sinus node dysfunction that is causing bradycardia?
- sinus bradycardia
- sick sinus syndrome
- sinus arrest (alone or part of vasovagal syncope)
45
what else can cuase bradycardiac (not specific sinus ndoe pathology)?
- medications
- hypothyroidism
- hypothermia
- sleep apnoea
- rheumatic fever,
- viral myocarditis
- amyloidosis
- haemochromatosis
- pericarditis
46
what types of AV nodal block are there?
- first degree
- second degree (mobitz type I and type II)
- third degree
47
what is first degree AV block?
PR interval >0.2 seconds (no dropped QRS complexes)
48
what is second degree heart block (type I and type II) ?
mobitz type I: progressive lenghtening of the PR interval followed by failure of atrial impulse to conduct to the ventricles (frequently follows inferior MI)
mobitz type II: constant PR interval followed by sudden failure of a P wave to be conducted to the ventricles (more serious invovlemnt of conudction system) - need permanent pacing if no recent cardiac event
49
what is third degree heart block?
no conduction from the atria to the ventricles and therefore AV dissociation - no relationship between P waves and QRS complexes
can be due to block above AV node (His region) or below (broad complex escape) + RBBB or LBBB
50
what are teh cuases of third degreee heart block?
- various antiarrhythmics (digoxin toxicity)
- following inferior STEMI (or anterior MI = more ominous)
- severe hyperkalaemia
51
what is the treatment of third degree heart block?
- if severe hyperkalaemia - give calcium chloride
- atropine in heamodynamically unstable patients
- give permenant pacing wihtin 24 hrs (apart from patients with recent coronary event)
52
how do you know if a patient has Left axid deviation or right axis deivation from ECG?
left axis deviation - > AVL lead most positive
| right axis deviation - > Lead III/AVF most positive
53
what is a normal PR interval?
0.12-0.2 secs (3-5 small squares)
54
what is a normal QRS duration?
<0.12 secs (3 small squares)
55
what does a short PR interval indicate?
delta wave = Wolff Parkinson White (WPW) syndrome
56
what ECG signs are indicative of LBBB and RBBB?
LBBB -> long QRS complex
| RBBB -> 'bunny rabbit ears' in lead V1 + slurring of S wave to T wave
57
what is the normal R wave progession from V1 to V6?
V1 -V2 negative QRS
V3 - amoutn of +ve = -ve in QRS
V4-V6 - positive QRS
58
what does a poor R wave progression in leads V1-V6 indicate?
- prior anteroseptal MI
- left ventricular hypertrophy (TALL R waves)
- inaccurate lead placement
- dilated cardiomyopathy
- pericardial effusion (SHORT R waves)
59
how long does the QTc interval need to be?
within 2 large squares
60
what causes a prolonged QT interval?
- MI, ischaemia
- structural heart disease, LVH
- LBBB and RBBB
- hypo K and Mg and Ca
- DKA
- drugs
61
what causes a short QT interval?
HyperCa
62
what are some complications of AF?
- cardioembolic stroke
- cardiac instability
- death
63
hwo do you diagnose AF?
- manual pulse checks recommended in presence of symptoms
- ECG to confirm irregular pulse is due to AF
- Cardiac monitoring (24 hour cardiac monitor) if paroxysmal AF suspected
- Echo if suspected structural heart disease, cardioversion /long term management needed
64
what are the symptoms of AF
- most commonyl asymptomatic
- breathlessness
- palpitations
- syncope/dizziness
- chest discomfort
- stroke
- TIA
65
what is the management of AF?
1. anticoagulation to prevent stroke
2. rate control - slow conduction at AV node to reduce ventricular conduction
3. rhythm control - controlled DC shock or with medications
CHA2DS2VaSc score - recommended to quantify risk of stroke (scores 0-2)
HAS-BLED - recommended to quantify risk of bleeding
66
name some reversible risk factors for bleeding in patientswho have AF?
- uncontrolled HTN (SBP>160mmHg)
- poor INR control
- concurrent medication (aspirin, NSAIDs)
- harmful alcohol consumption (>14 units a week)
67
what are the anticoagulation options for patients who need to be anticoagulated for AF?
DOACs - inhibit Xa factor (apixiban, rivaroxiban, edoxaban) or direct thrombin inhibition (dabigatran)
- they dont require INR monitoring as much as with warfarin
- they have lower rates of bleeding and stroke
68
what are teh types of superventricular tachycardia?
- afib
- atrial flutter
- AVRT
- AVNRT
69
what are the first line treatments for AVRT and AVNRT in heamodynamically stable patients?
- vagal manoeuvres: breath holding and valsalva manoeuvre
- carotid massage
THESE all slow conduction in the AV node and INTERRUPT the re entrant circuit
70
when SVT is not interrupted by vagal manouevres then what treatment is given?
- IV adenosine - short acting drugs blocking AV node conduction (avoid in pts with reversible airway disease)
- Calcium channel blockers - verapamil (alternative but dangerous with patients on beta blockers)
- Electrical cardioversion under general anaesthetic can be given if medications ineffective
- 2nd line drugs: flecainide, sotalol, amiodarone
71
what is the management for ventricular tachycardia?
if heamodynamically compromised then cardioversion
- beta blockers (careful if hypotensive or LV dysfunction)
- amiodarone (300mg IV over minutes, then 900mg over 24 hrs)
- lidocaine (50-100mg over 3-5 mins, repeated after 5 mins - max 300mg in one hour) §
72
what are the different types of bradycardia?
1. sinus bradycardia
2. junctional rhythm
3. heart block - 1st, 2nd (mobitz I and II) and 3rd degree
4. LBBB and RBBB (bifascicular and trifascicular block)
73
what is junctional rhythm and what would it look like on an ECG?
occurs when the sinus node is not working, so the heart relies on firing of the AV node
on ECG no p waves are present or if they are we are within QRS/T wave
narrow QRS seen as no dysfunction of Bundle of His
74
what is the difference of first and second degree heart block? ( seen on ECG )
```
first degree (wenkebach heart block) = prolonged PR interval with a dropped QRS complex
second degree (fixed heart block) = constant PR interval lenght with a random drop of QRS complexes
```
75
whats the difference between complete heart block with narrow escape and complete HB with broad escape?
complete HB = np association or relationship between the SA and AV nodes
complete HB with narrow escape = narrow QRS
with broad escape = broad QRS
76
what are cuases fo bradycardia?
- physiological/noctunrnal/medication
- sinus node
- AV node (1st, 2nd, 3rd degree HB)
- Bundle of His (wide QRS)
- conduction system disease
77
what is bifascicular and trifascicular heart block?
bifascicular heart block: RBBB or LBBB + a block of opposite sided posterior or anterior fascicle e.g RBBB + left anterior fascicle block = Left axis deviation
RBBB + left posterior fascicle block = Right axis deviation
trifascicular block: bifascicuclar heart block with first degree heart block
78
how is an NSTEMI diagnosed from a patients ECG?
ST segment depression, T wave inversion or flattenign
79
how is a STEMI diagnosed from an ECG
ST elevation in 2 or more leads from the same zone or presence of LBBB
80
how long does it take for troponin levels to raise post MI and how long do they stay raised for?
takes 3-4 hours and stay raised for up to two weeks
81
in which acute coronary syndromes is troponin raised?
NSTEMI and STEMI, not in unstable or stable angina
82
name some causes of non cardiac chest pain?
- pneumonia
- PE
- GORD (any gastrooesophageal)
- costochondritis
- pneumothorax
- psychogenic/psychosomatic e.g. panic attack
83
name some conditions that may mimic STEMI on an ECG?
1. early repolarisation cuases upsloping ST elevation, particularly in leads V1 and V2 - seen in younger, more athletic patients
2. concave ST elevation in pericarditis
3. Brugada syndrome
4. Takotsubo cardiomyopathy
84
name some secondary causes for HTN.
- cushings syndrome
- enlarged kidneys (PCK disease)
- renal bruits
- radio-femoral delay (coarctation)
85
what are important questions to ask in a history of assessment of whether a patient has angina or nto?
- precipitants of anginal attacks
- stability of symptoms (smoking history, high BP, lipids, diabetes, prior CV disease)
- risk factors
- occupation
- assessment of intensity, lenght and regularity of exercise
- basic dietary assessment
- alcohol intake
- drug history
- family history
(when diagnosing angina be aware as it is unlikely angina if the pain is conitnuous or very prolonged, unrelated to activity, brought on by breathing or associated with other symptoms such as dizziness and dysphagia)
86
what are some symptoms of HTN?
1. nil or headache
2. sweating, headache, palpitations and anxiety may point to phaechromocytoma
3. muscle weakness or tetany may point to hyperaldosteronism
87
what are the troponin levels in males and females that sugegst high liklihood of a myocardial necrosis and/or infarction?
males > 34 ng/L
females > 16 ng/L
infarction - levels five fold above the upper limit
88
what defines stage 1 stage 2 and severe hypertension?
stage 1: > and = 140/90mmHg
stage 2: > and = 160/100mmHg
severe: systolic >180mmHg or diastolic >110mmHg
89
what drug treatment can be given for stable angina?
- aspirin 70mg OD (if allergic then clopidogrel 75mg OD)
- GTN spray
- Beta blockers for symptom control and non dihydropyridine CCB (OR isosorbide mononitrate or ivabradine if either contraindicated)
- long acting nitrates and potassium channel opening drugs
- statin (+ACEi)
- possible ranolazine in chronic stable angina
90
what important signs in an examination will be present in a patient with angina?
- weight and height (high BMI)
- high BP
- presence of murmurs e.g. aortic stenosis
- evidence of hyperlipidaemia
- evidence of peripheral vascular disease and carotid bruits
91
what investgiations should be done when diagnosing a patietn with angina?
- FBC and biochemical screen including HbA1c
- full lipid profile
- resting 12 lead ECG (fro rhythm, presence of heart block, previosu MI and mycoardial hypertrophy and ischaemia)
- if liklihood of CAD 61-90% then offer invasive coronary angiography
- if liklihood of CAD 30-60% then offer functional imaging (e.g. stress MRI, echo or myoview)
- if liklihood of CAD 10-29% then offer CT calcium scoring as first line diagnostic
92
What investigations need to be done when a patient has HTN?
- testing for the presence of protein in urine for albumin: creatinine ratio and heamturia
- blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
- bloods may suggest secondary cause (low potassium, high Na: hyperaldosterism)
- examine fundi for hypertensive retinopathy
- ECG arranged
- condiser echo if suggestion of LVH, valve disease, or LVSD or diastolic dysfunction
93
what is the management for an NSTEMI?
1. IV access
2. Oxygen (aim for sata >94%)
3. analgesia (morphine and anti-emetic)
4. antithrombotic apsirin (300mg loading dose, followed by 75mg OD for life)
5. antiplatelet prasugrel - >60kg and <75y/o (or clopidogrel/tricagrelor) - inhibits ADP receptors
6. PCI (percutaneous coronary intervention)
7. full biochemical screen (including lipid profile, random glucose, HbA1c assay, FBC)
8. anti-ischaemics bisoprolol - reduce HR
9. secondary prevention ACEi (ramipril) OR AngR blocker (losartan) and statin (atorvastatin)
10. control of diabetes, HTN and smoking cessation
```
rememeber: MONA
M- morphine
O- oxygen
N- nitrates
A- aspirin
```
94
what is the managment for an NSTEMI/unstable angina?
1. pain relief (morphine and anti-emetic)
2. aspirin 300mg loading and 75mg OD
3. LMWH (enoxaparin)
4. repeat ECG
5. ticagrelor (based on grace score risk)
6. whilst waiting for inpatient angiography consider anti-anginals: nitrates, ranolazine, CCB
95
what is the risk assessment used in hypertensive patients to calculate CVD risk?
QRISK calculator
96
what other conditions may show a false positive elevation of troponin (hs-Tnl)?
- advanced renal failure
- large PE
- severe congestive cardiac failure
- myocarditis
- aortic dissection
- aortic stenosis
- hypertrophic cardiomyopathy
- malignancy
- stroke
- severe sepsis
97
when should ambulatory BP monitoring be offered?
when BP is >140/90 (stage 1)
98
what is the treatment for HTN?
non pharm:
- weight loss
- decreased salt intake
- decrease alcohol intake
- aerobic exericise
- smoking cessation
pharm: *look at NICE guidelines key
1. under 55 = ACEi/ARB, if >55 or black/caribbean then CCB
2. ACEi/ARB + CCB
3. ACEi/ARB + CCB + thiazide like duiretic
4. ACEi/ARB + CCB + thiazide like duiretic + futher diuretic/alpha blocker/beta blocker
99
what are the commonest causes of Afib?
1. HTN
2. Heart failure
3. Pneumonia
