Cardiology Flashcards
Unstable angina vs NSTEMI
UA- no ST elevation and troponin normal
NSTEMI - no ST elevation , troponin raised
What is acute coronary syndrome?
STEMI NSTEMI UA
RFs for ischemic heart disease - unmodifiable (3)
Age
Male gender
Family history
RFs for ischemic heart disease - modifiable (5)
Smoking
Diabetes, HTN , high cholesterol, obesity
Likely occluded artery in an inferior MI
What leads would you see ST elevation
Right coronary
2,3, AVF
ST elevation leads I, avL,V5 ,V6
Likely occluded artery ?
Are of infarct ?
Left circumflex
Lateral MI
Anterior/anteroseptal MI
ST elevation in what leads
Likely occluded artery
V1-V4
LAD
Anterolateral MI
ST elevation in what leads
Likely occluded artery
1, avL, V4 V5 V6
LAD or left circumflex
Features of left main coronary artery (LMCA) occlusion on ECG
What should be done?
Widespread ST depression
ST elevation in aVR
Emergency coronary angio
STEMI - management acute
MONA - IV morphine, O2, Nitrates, Aspirin 300 mg Presentation : Within 12 hr of sx onset: - 1ry PCI = gold standard If unavailable or 12 hrs - thrombolkysis ( Alteplase preferred)
Long term management of MI
- Aspirin , ACEi , statins - lifelong
- Ticragrelor or Prasugrel - 12 months OR clopidogrel
- B-blockers 12 months (atenolol, bisoprolol)
Statin 80 mg OD PO
AABC+S
NSTEMI / UA management
Give ASAP :
300mg Aspirin +
LMWH (enoxaparin, dalteparin) or Fondaparinux = SC
- no high risk of bleeding and no angio in next 24 hrs
- if angio likely in next 24 or creatinine >265 give
=unfractionated heparin - IV
Intermediate/high risk of=adverse cardio event ( predicted 6 month mortality > 3% :
angio w/in 96 hrs of admission
Intravenous glycoprotein receptor antagonist
= eptifibatide or tirofiban
Becks triad
Hypotension
Muffle heart sounds
Raised JVP
= cardiac tamponade
Cardiac tamponade
- causes
- features
Becks triad
Can develop as MI complication
Most important cause is trauma
CXR - enlarged globular heart
Dx - echo
Complications of MI
Arrest - VFIB - mcc of death after MI CHF Acute pericarditis Dressler syndrome Left ventricular aneurysm Acute mitral regurgitation VSD, MR Pericardial effusion Cardiac tamponade
What is diagnostic of cardiac tamponade
Treatment
Dx - Echocardiogram
Treatments -
Oxygen + ventilation
1-2 L IV fluids
urgent pericardiocentesis
Atrial myxoma
Features
Left atrium 75%
Benign tumour , groves on inter-atrium septum wall
10% inherited
- obstruct mitral valve = mid diastolic murmur , syncope, dyspnoea
- PE stroke clubbing and blue fingers
- AF
Echo : pedunculated heterogenous mass attached to fossa ovalis
Dx?
Atrial myxoma
Axis deviation
Check lead 1 and AVF 1 & AVF - both pointing up = normal 1 up , AVF down - left axis deviation 1 down, AVF up - right axis deviation Both down - right superior axis deviation
Causes of left axis deviation (5)
Inferior MI LVH Left anterior fascicular block or hemi-block Obese WPW
Right axis deviation causes (6)
Lateral MI RVH Left posterior fascicular block or hemiblock Thin tall children Chronic lung disease Pulmonary embolism
Causes of extreme right axis deviation
Congenital heart disease
Left ventricular aneurysm
1st degree heart block + management
PR > .2s only
No treatment as long as pt is asymptomatic
2nd degree heart block + management
- Mobitz 1 = wenkebach
Progressive prolongation of PR until a beat drops - Mobitz 2
Constant PR interval, but P wave often not followed by QRS
Permanent pacemaker
3rd degree heart block + management
No association between P and QRS
Pacemaker
Rate control in AF
B blockers - 1st line , CI in asthma
CCB - (non dihydropyridine )= diltiazem, verapamil - used in asthma
Digoxin - preferred choice if coexistent with heart failure
Unstable - cardio version
Aflutter management
Cardioversion - shock
VTach management
Conscious/ semiconscious hemodynamically stabl e
- Amiodarone
Unstable - DC cardioversion
Vfib management
- defibrillation - asynchronised shock
Symptomatic sinus bradycardia
Treatment
O2 , ABCD
Atropine .5mg IV push , can repeat until 3mg given
If no response - temporary transcutaneous pacemaker
Normal in young athletes
Sinus tachy causes
Excercise, stress, anger
Hx of infection
Treat the cause
CHF management
Symptomatic relief and reduce vol overload - diuretics
= furosemide, lascivious or bumetanide
Start w/ ACEi or BB one at a time, If sx persist and the next one
- start with ACEi if diabetic
If sx still persist - add Spironolactone
CHF on treatment , still has LL oedema
Next step
Up dose of fursemide
Or switch to bumetanide to torsemide
Consider admission for IV loop diuretics
HF + a fib management
Digoxin
Patent foramen ovale
Features
Most accurate investigation
R—>L atrium blood flow
Most individuals - not problematic , undetected
Paradoxical embolism - emb from venous to arterial side
= stroke or TIA
Transoesophageal echo with bubble contrast = gold
Pericarditis
Features
ECG
Within 48 hrs of MI
Pleuritic chest pain , worse lying flat and during inspiration +_ fever, pericardial rub
Confirm via echo
ECG - widespread saddle shaped ST elevation + upward con cavity + PR depression
Treatment pericarditis
Full dose NSAID -
=ibuprofen 100-1800mg/d; indomethacin 75-150mg/d
Aspirin
2-4g/d
=7-14 days
Dressler syndrome
Features , ECG
Pericarditis in 2-6 weeks following MI
Autoimmune reaction against antigenic proteins as myocardium recovers
Same features as pericarditis + raised ESR
Saddle shaped ST elevation +- PR depression
Treatment of Dressler’s syndrome
NSAIDs
Left ventricular aneurysm
Features
XR ECHO ECG
4-6 weeks post MI
Weakened myocardium - thin muscular layer - aneurysm formation
Left ventricle failure + persistent ST elevation
Can increase risk of stroke
ECG - persistent ST elevation + LVF
Bulge at left heart border XR
Echo - paradoxical movement of ventricular wall
VSD
Features
Treatment
1st week after MI in 1-2% patients
Pan systolic murmur + acute heart failure
Echo- diagnostic - excludes MR
Urgent surgical correction
Mitral regurgitation
Pan systolic murmur (early-mid diastolic)
2-15 days after MI
Ischemia or rupture of papillary muscles of mitral valve
Hypotension tachycardia pulmonary oedema
Echo- dx
Treatment - vasodilator therapy and surgical repair
New murmur + fever + malaise and rigours
Dx?
Initial step?
Infective endocarditis
Blood culture —> echo
RF of infective endocarditis
Previous episode of endocarditis = strongest RF
Rheumatic valve disease
Prosthetic valve
Congenital heart defects
IV drug users - typically tricuspid lesion
Causative organism of IE
Staph aureus - general
Epidermis is - after prosthetic valve surgery
Viridans (mitris and sanguidis) - poor dental hygiene or after dental procedure
Modified duke criteria - major
IE 2 major or 1 major 3 minor or 5 minor Major - 1. + blood culture 2, showing HÁČEK or known organism) or persistent bacteremia in 2 cultures >12 hrs apart or 3 or + with staph aureus or epidermidis
2.evidence of endocarditis involvement = echo +ve for IE
Modified duke criteria - minor
- Predisposing heart condition or IVDU
- Microbiological evidence that doesn’t meet major criteria
- Fever >38
- Vascular phenomena
= Jane way , petechia, purpura, splinter hgx, major emboli, splenomegaly - Immunological phenomena
- oiler node, Roth spots, glomerulonephritis
Oiler node vs janeway lesion
O - painful red nodules on hand and feet
J- non tender, small erythematous or hemorhhagic macular or nodular lesions on soles /palms
= septic microemboli
Endocarditis - initial empirical blind therapy
National valve endocarditis -
Amoxicillin + low dose gentamicin or
Vancomycin + low dose gentamicin - ig peicillin allergic or MRSA suspect or sever sepsis
Hx of prosthetic valve
Vancomycin + low dose gentamicin+ rifampin
CHA2DS2VASc score
CHF HTN Age =/>75 = 2pts DM S- prior stroke , TIA, thromboembolism = 2pts Vascular disease Age 65-74 Sex category - female
Score =/> 2 - warfarin or DOAC , men >/=1 - the same
Score to estimate risk of major bleeding inpatients on anti coagulation for atrial fibrillation
HAS BLED score
What score predicts 3 month outcome in ischaemic stroke patients receiving tPA (alteplase)
DRAGON score
What is the QRISK2 score
Determines risk of cardiovascular event in next 10 years
Pulmonary oedema
Features
Desaturation Dyspnoea Orthopnoea Auscultation = crackles /rales Tachycardia Kerley lines on CXR
Most appropriate investigation for pulmonary oedema
CXR
Investigation needed to identify cause of pulmonary oedema
Echo
Management of pulmonary oedema
MONF Morphine O2 Nitrates Furosemide O2 sat >92% or 90 in COPD 2 puffs GTN 40 mg IV furosemide - slow Diamorphine 2/5-5mg IV slowly or morphine 5-10mg IV slow
If heart failure also present : + ACEi or BB one at a time on discharge
Dissecting aortic aneurysm
Clinchers
Unequal pulses upper limb Hx of Marfan Tall long slender limbs and fingers Ehler danlos/ Turner Severe chest pain radiating to back HTN - most important RF
Dissecting aneurysm presentation
Presentation: hypotension, SOF , tachycardia, sweating
Most important risk factor dissecting aneurysm
HTN
Pathophysiology of dissecting aneurysm
Tear in tunica intima wall of aorta
- blood floes between layers of aorta - forces layers apart
Investigations for dissecting aortic aneurysm
Emergency - US or CT
TEE - 98% sensitive, 97% specific
- preferred imaging modality
CT scan w/ contrast or MRI
Stanford classification of aortic dissection
Type A - ascending aorta -2/3 of cases
B - descending aorta, distal to left subclavian , 1/3 of cases
Management of aortic dissection
Type A - surgical , control BP to 100-120 mmHg SBP in the meantime
Type B - conservative - bed rest , reduce BP , IV labetalol to prevent progression
LBBB
ECG features
Broad QRS - notched M = I avL V6(not always)
Deep inverted negative QRS - V1 usually
LAD - not always
New onset LBBB - characteristic for MI
“William” = W in V1 , M in V6
Rule turned abdominal aortic aneurysm
Most appropriate initial investigation
US
If not in options pick CT abdomen
AAA screening in the UK
Criteria
Men @ 65 years old via ultrasound
Once only
Coronary artery dominance
Artery that supplies the posterior descending artery - determines dominance
85% - Right coronary artery
15% left circumflex
Artery dominance = RCA =gives off PDA in 85% of people
ECG changes hypokalemia
U wave - an additional wave after T
Management hypokalemia
Oral or IV kcl based on severity
<2.5 - IV
Treat the cause
Paroxysmal supraventricular tachycardia
Features
Narrow complex SVT
Usually in young patients
Palpitations light headed ness,
Recurrent young
management of PSVT
Initial : Valsalva , carotid massage No improvement —> IV adenosine = 6mg rapid IV bolus if fails —> Additional 12 mg - no improvement —>Further 12 mg — no improvement —> DC cardioversion
Verapamil CCB - in asthmatics
Prevention of future PSVT episodes
B blockers
Radio-frequency ablation
Torsades de pointes
Features
Polymorphic Broad complex ventricular tachy
- beat 2 beat variations
Broad QRS, long QT, fainting episodes
Young athlete, recurrent
Treatment of torsades de pointes
IV MgSo4
HTN classification - stage 1
Clinic BP >/= 140/90 +Ambulatory BP monitor >/= 135/85 mmHg
Or
Home BP monitor - BP >/= 135/85
Stage 2 - HTN
Clinic BP >/= 160/100 mmHg +
ABPM or HBPM >/= 150/95 mmHg
Stage 3 HTN
Clinic SBP >180 mmHg
Clinic DBP >/= 110 mmHg
When you should you treat stage 1 HTN
Patient <80 yrs + any : target organ damage Established CVD Renal disease Diabetes 10 year cardiovascular risk >/= 20%
Stage 1 HTN management
Lifestyle + diet modification and follow up
Unless criteria to be treated present
What should be done for a stage 2 HTN at clinic before starting antihypertensives
Check ABPM or HBPM
Stage 2 HTN or higher + <40 YO
What should you consider
2ry causes of HTN - refer to specialist to exclude
Medical management HTN
Step 1
<55 yo + white - ACEi ARBs
>55 yo + white - CCB
Afrocarribean + any age - CCB
Step 2 - still hypertensive after step 1
ACEi + CCB
Step 3 Add diuretic = thiazides - chlorthalidone 12-25 mg OD Or indapamide 1.5mg OD modified release, or daily 2.5mg OD Bendroflumethazide NOT recommended
Step 4 - resistant HTN
<4.5 mmol/l - spironolactone 25mg OD
>4.5mmol/l - add higher dose thiazides like diuretic
If further diuretic not tolerated or CI = consider alpha or beta blocker
Refer to specialist - if they fail to respond to step 4
BP targets
- diabetics
- hypertensive w/o DM
DM - <130/80 mmHg if end organ damage otherwise <140/80 mmHg
HTN -
<80
- clinic 140/90 mmhg , A/HBPM 135/85
- 150/90 clinic , 145/85 mmhg
Treatment of HTN in a diabetic patient
Always ACEi regardless of age
If DM + afrocarribean - ACEi + CCB as 1st step
Check eGFR before you start ACEi
<30 = advanced kidney disease - avoid ACEi & ARBs
Why use ACEi in hypertensive DM
Reno-protective
Protection against diabetic retinopathy
+ve effect on glucose metabolism
Postural hypotension
Def
Dx
Drop in SBP at least 20 mmHg within 3 mins of standing
Drop in DBP at least 10 mmhg within 3 minutes of standing
Dx - monitor BP
Postural hypotension common in
Elderly people (baroreceptors decline with age) Esp in poly pharmacy and those with HTN
Antihypertensives can cause postural hypotension
1st line in AFIB
Beta blockers
If asthmatic - CCB
If associate HF - give digoxin
Also calculate chadvasc score and anticoagulants accordingly - warfarin or DOAC
Ventricular ectopic
Features
Ventricular trigeminal - 3 beat patterns
Missed skipped beat, unsustained palpitations +- SOB
Early/ broad QRS complex
Causes ventricular ectopic
IHD - MI
Cardiomyopathy
Stress Alcohol Caffeine cocaine or natural
Can be benign if there’s no underlying hearts disease
If there is may ppt vfib
What medications should NEVER be given to CKD CHD IHD patients
NSAIDS
Selective COX-2 inhibitors - celecoxib
They can worse heart failure and renal function
NSAIDs inhibit prostaglandin synthesis = decreased gfr = salt + water retention
Silent MI in diabetics is due to
Autonomic neuropathy
Pt w/. Hx of syncope + SOB + pulmonary embolism and early-mid diastolic murmur
Suspect
Think atrial myxoma
Alcohol recommendations UK
Not more than 14 units - week
Not > 3 units a day
+ 2 alcohol free days a week
Most important cause of ventricular tachycardia clinically
Hypokalemia
Aortic stenosis murmur
Features
Ejection systolic
Rt 2nd ICS - radiates to carotid
SOB on activity, angina chest pain, syncope
Pulmonary stenosis murmur
Features
Ejection systolic
Lt 2nd ICS lateral to sternum , radiates to left shoulder and infraclavicular area
Systemic cyanosis
Aortic regurgitation
Features
Early diastolic
Rt 2nd ICS lateral to sternum
Heart failure sx
Pulmonary regurgitation
Features
Early diastolic
Left 2nd ICS , lat to sternum
Rt sided HF sx
Mitral stenosis
Mid-late diastolic + opening click (loud S1) - best heard on expiration Apex 5th ICS midclavicular line Sx of HF Low volume pulse , malar flush AFIB
Tricuspid stenosis
Features
Diastolic rumble
4-5th ICS over LSB
Fluttering discomfort in neck
Mitral regurgitation
Features
Pan- systolic murmur
Apex, left 5th ICS MCL radiates to axilla
CHF sx, oedema ascites
Tricuspid regurgitation
Features
Pan systolic
4-5th ICS LSB
Sx of Rt sided CHF
What murmurs have sx of rt sided heart failure
Pulmonary regurgitation - early diastolic
Tricuspid regurgitation - pan systolic
Murmurs with HF sx
Aortic regurgitation - early diastolic
Pulmonary regurgitation - early diastolic (rt sided HF)
Mitral stenosis - mid-late diastolic w/ opening click
Mitral regurgitation - pan systolic (CHF)
Tricuspid regurgitation- pan systolic (RHF)
Pan systolic murmur
Mitral regurgitation
Tricuspid regurgitation
VSD
Diastolic murmurs
Aortic regurgitation - early
Pulmonary regurgitation - early
Mitral stenosis - mid to late + opening click
Tricuspid stenosis - rumble
Common causes of mitral stenosis
Rheumatic fever!!!!!!!!
CXR mitral stenosis
Straight left side heart border
MS - impeded LV filling - increased LA pressure - LA hypertrophy = straight left heart border
Blood goes back to lungs - pulmonary congestion , RVF
Mitral aortic murmurs best heard
Expiration
Left heart = expirations
Tricuspid + pulmonary murmurs best heard
Inspiration
Rt - insp
ECG in mitral stenosis
Signs of RVH
P mitrale
AFIB
Decreased Ejection fraction + decreased septal wall thickness
Dilated cardiomyopathy
Increased ejection fraction + increased septal wall thickness
Hypertrophic cardiomyopathy
Causes of dilated cardiomyopathy
Alcohol Pospartum HTN
Inherited - autosomal dominant
Infection - coxsackie B , HIV , parasitic, diphtheria
Hyperthyroidism
DMD
Kwashiorkor, pellagra, thiamine/selenium def
Doxorubicin
Causes of falls
Cardiac - arrhythmia
Postural hypotension
Hypoglycemia
Seizure
Cyanotic baby with ejection systolic murmur
TOF - pulmonary stenosis
Preterm baby with continuous or machinery murmur
PDA
Progressive severe cyanosis + poor feeding + pan systolic murmur
Tricuspid atresia
Acyanotic + pan systolic murmur
VSD
Diagnosis of patent ductus arteriosus
Management
Echo
Mgmt - indomethacin/ibuprofen - closes the duct
If assoc with anther congenital heart defect - prostaglandin E1 - keep open until surgically repaired
TOF features
VSD
RVH
RV outflow tract obstricipn - pulmonary stenosis - ejection systolic murmur
Overriding aorta
Management of TOF
Surgical repair
B blockers to reduce infundibular spasm = help cyanotic episodes
Familial hypercholesterolemia
Inheritance pattern
When should suspect it?
AD
- Cholesterol >7.5 (N= < 5 mmol/l)
- Family hx of MI - 1st degree relative before 60 or 2nd degree below 50
Most common valvular disease that causes syncopal attacks
Aortic stenosis
Causes of AFIB
Endocardium - endocarditis , mitral valve disease
Myocardium - cardiomyopathy
Pericardium - constructive pericarditis
HF HTN MI
Hyperthyroidism, excessive alcohol and chronic lung disease
Before prescribing amiodarone - what should be done
Amidarone = class 3 antiarrythmic - block K+ channels - inhibits depolarisation - prolongs action potential
TFT LFT UE CXR ECG
Monitoring patients taking amiodarone
TFT LFT UE CXR ECG - prior to tx
TFT LFT every 6 mo.
ECG every 12 mo
Adverse effects. Amiodarone
Hypothyroidism , hyperthyroidism Corneal deposits Pulmonary fibrosis (**most serious) / pneumonitis Liver fibrosis/ hepatitis Peripheral neuropathy, myopathy Photosensitivity Grey skin Thrombophlebitis ( so usually given via central veins) Bradycardia Prolonged qt
Corrected pulmonary stenosis in TOF can later become
Pulmonary regurgitation
Commonest valvular disease in elderly >65
Aortic stenosis
Usually asymptomatic apart from excercise intolerance
Can cause syncopal fainting
Digoxin toxicity
GT - commonest - nausea, vomiting , anorexia
Neuro - hallucination, confusion
Visual - yellow haloes , yellow - green vision, blurred vision
Arrhythmia - Bradycardia , vtach , premature contractions
Management of digoxin toxicity
Digoxin level
Digibind / digifab = digoxin immune FAB
Correct arrhythmia
Monitor K+
Sx of aspirin toxicity
Tinnitus , impaired hearing
Hyperventilation , vomiting , dehydration, fever , double vision and feeling faint
How do thiazides like diuretics work
Adverse effects
Inhibit Na absorption from beginning of proximal DCT
- block Na-Cl symporter
Postural hypotension, gout, hypokalemia and HypOnatremia
Hypercalcemia and hypocalciuria
Loop diuretic moA
Inhibit Na-K-cl cotransporter in thick ascending limb of loop of henle
Hypotension tachycardia and pulmonary post MI
Mitral regurgitation
Osborne wave in
Hypothermia
Antiplatelet guideline Acute MI PCI TIA Ischemic stroke Ischaemic stroke + AF PAD
MI - aspirin life-long , ticragrelor or clopidogrel 12 mo
PCI- aspirin life-long, prasugrel or ticragrelor 12 mo
TIA/ischemic stroke
- aspirin 300mg 2 weeks then clopidogrel 75mg lifelong
Ischemic stroke + AF
- aspirin 300mg 2 weeks then start anticoagulation warfarin/DOAC
PAD - Clopidogrel lifelong
Who should receive statin - 1ry prevention
Anyone with 10 year CVD risk >/=10%
T1DM diagnosed >10 years ago or over 40 or established neuropathy
CKD if eGFR <60
Atorvastatin 20 mg OD
If LDL does not fall by >/= 40% - up dose to 80
2ry prevention - start statins in cases of
Known IHD , cerebrovascular disease, PAD
Atorvastatin 80 mg OD
Important side effects of CCBs
Ankle swelling
Gingival hyperplasia
Most common arrhythmia in alcoholic cardiomyopathy
AFIB
Holiday heart syndrome
Acute alcohol intake causing AF or clutter
Widespread ST depression + ST elevation in aVR
Left main coronary artery occlusion
- emergency coronary angio
AFib +unstable patient
Presents >48 hrs after sx onset
No cardioversion
Give BB + LMWH
Assess chad score for long term DOAC
QRISK3 score
Risk of cardiovascular event in next 10 years
>10% + age = 84 —> start stain
Complications of mitral stenosis
Atrial fibrillation
Venous thromboembolism
Cerebral infarction
Common complication of aortic stenosis
LVH
Most common arrythmia associated with congenital long QT syndrome
Ventricular tachyarrythmia
There is also risk of vfib - some patients use long term beta blocker treatment
Investigations of Heart failure
NT-proBNP
If raised - do Echo
Management of chest pain according onset
<3 hrs of chest pain onset
Troponin - <12 - repeat after 3 hrs of chest pain onset
>30 - correlate with ecg and hx - treat as ACS
> 3hrs
<12 - ACS unlikely
30 -ECG and history - treat as ACS
