Cardiology Flashcards
1
Q
ST elevation in leads 1, Avl, V5 and V6 - which artery affected
A
right coronary artery (inferior territory MI)
2
Q
ST elevation in leads V1 - V4 - which artery affected
A
anterior MI - left anterior descending artery
3
Q
ST elevation in leads 2, 3 and AVF - which artery affected
A
lateral MI - left circumflex artery
4
Q
findings in hypertensive retinopathy on fundoscopy
A
- papilloedema
- cotton wool spots
- flame haemorrhages
5
Q
eye findings in infective endocarditis
A
roth spots
6
Q
2 x signs of hypercholesterolaemia on examination
A
xanthelasma
corneal arcus
7
Q
findings on chest x ray in pulmonary oedema (heart failure)
A
alveolar oedema (batwing distribution) Kerley B lines cardiomegaly Diversion (upper lobe diversion) pleural effusions fluid in fissures
^ABCDEF
8
Q
which classification system is used for heart failure
A
new york heart association
9
Q
name 3 cardiac enzymes that can indicate ischaemia / muscle damage
A
- troponin
- lactate dehydrogenase
- creatinine kinase
10
Q
what criteria is used for a diagnosis of infective endocarditis
A
Duke criteria
11
Q
name the components of duke criteria (infective endocarditis)
A
major criteria:
positive blood cultures (2 x samples)
evidence of cardiac involvement: ECG changes / new valvular regurg, new murmur, worsening of pre existing murmur
minor:
predisposing heart condition
IVDU
fever
vascular phenomena eg arterial emboli, janeway lesions, conjunctival haemorrhage
immune phenomena: oslers nodes, glomerulonephritis, roth spots
microbiological evidence
12
Q
how do you manage acute pulmonary oedema
A
- oxygen
- nitrates (in the case of heart failure)
- IV furosemide or bumetanide (loop)
13
Q
what is the most common complication of an MI
A
ventricular fibrillation (most common cause of death) and ventricular tachycardia
14
Q
which type of arrythmia is common following an inferior MI
A
AV block
15
Q
what is dresslers syndrome
A
a complication that occurs around 2-3 weeks post-MI usually due to an autoimmune reaction when the myocardium is recovering
CP: fever, pleuritic chest pain + raised ESR
16
Q
management of dresslers syndrome
A
NSAIDS
17
Q
common complication following a transmural MI
A
pericarditis
occurs in 48 hours of MI
CP: pleuritic chest pain, pericardial rub on ausciltation
18
Q
symptoms of left ventricular aneurysm post mi
A
extreme tiredness increasing SOB if clot forms can cause a stroke palpitations / new arrhythmia oedema
19
Q
how should you manage pts with a left ventricular aneurysm post MI
A
anticoagulate bc at increased risk of a clot firing off
20
Q
how long after an MI does a left ventricular free wall rupture occur
A
1-2 weeks after
21
Q
how does a left ventricular free wall rupture present
A
1-2 weeks post MI, acute heart failure secondary to a cardiac tamponade:
raised JVP, SOB, cough, frothy white / pink sputum, peripheral oedema, chest pain
syncope
pulsus paroxodus
diminished heart sounds
22
Q
what is pulsus paradoxus
A
an abnormally large decrease in stroke volume, systolic BP and pulse wave amplitude during inspiration
drop has to be over 10mmhg
23
Q
management of cardiac tamponade
A
urgent pericardiocentesis + thoracotomy
24
Q
acute heart failure 1 week post MI with a pan systolic murmur
A
ventricular septal defect caused by MI
25
acute heart failure with sharp chest pain and collapse 2 weeks post MI with pulsus paradoxus and diminished heart sounds
ventricular free wall rupture
26
signs on examination in aortic regurg
1. early diastolic murmur heart at left sternal edge 3rd intercostal
2. collapsing pulse
3.
27
slow rising pulse
aortic stenosis
28
presentation of infective endocarditis
```
high persistent fever
generally unwell - myalgia, arthraliga, malaise
palpitations - new murmur
SOB
headache
anorexia
night sweats
```
29
findings on examination of a pt with infective endocarditis
```
janeway lesions (palms)
roth spots (eyes)
osler nodes
splinter haemorrhages (nails)
petechiae / purpura
splenomegaly
new or changing murmur
```
30
what diagnostic criteria is used for infective endocarditis
modified duke criteria
31
2 major criteria in duke criteria for IE
evidence of endocardial involvement on echo or auscultates a new valve regurg or new/changing murmur
2x positive blood cultures showing a typical organism eg strep viridans or persistent bacteraemia from a less specific organism eg staph aureus.
32
4 minor criteria in duke criteria for IE
predisposing heart condition
IVDU
persistent fever over 38 degrees
vascular phenomenon: splinter haemorrhages, janeway lesions, purpura/petechiae
immunological phenomenon: osler nodes, roth spots, glomerulonephritis
33
most common causative organism for infective endocarditis
staph aureus
34
causative organisms for infective endocarditis
staph aureus
strep viridans
staph epididermis
35
most common organism for infective endocarditis after valve surgery
staph epididermis
36
most common organism for infective endocarditis in IVDU
staph aureus
37
name 5 risk factors for infective endocarditis
```
IVDU
recent prosthetic heart valvue surgery
prev IE infection
poor dental hygeine
SLE (can cause non-infective endocarditis)
congenital heart defects eg PDA
rheumatic valve disease
recent piercings / tattoo
```
38
what is the strongest risk factor for infective endocarditis
previous episode of IE
39
name 3 complications of infective endocarditis
aortic abscess
heart failure
death
40
which organism that causes infective endocarditis carries the worst prognosis
staph aureus
41
management of infective endocarditis initially (before cultures back)
amoxicillin +low dose gent if normal valve
vancomycin if pen allerg
Vancomycin + low dose gent + rifampicin if prosthetic valve
42
management of infective endocarditis with prosthetic valve + staph infection
flucloxacillin + rifampicin + low dose gent
43
management of infective endocarditis with normal valve and staph infection
Flucloxacillin + low dose gent
44
management of infective endocarditis with normal valve and strep infection
Benzylpenicillin and low dose gent
45
management of infective endocarditis with prosthetic valve and strep infection
Rifampicin, Benzylpenicillin and low dose gent
46
what antibiotic do you use in infective endocarditis for pen allergic patients
Vancomycin + low dose gentamicin
47
what antibiotic do you add in patients with a prosthetic heart valve for infective endocarditis
Rifampicin
48
what investigations would you order in a patient with suspected infective endocarditis
1. 2 x blood cultures taken 12 hours apart
2. sepsis 6
3. echo
4. ECG
5 - FBC U+E LFT CRP ESR
6. complement levels - used for prognosis
7. autoimmune antibodies if thinking sle
49
what is the most common type of cardiomyopathy
dilated
50
name the cardiomyopathies that are primarily systolic dysfunction
dilated = weakens and thins the muscles = cant contract properly bc weak = systolic dysfunction
51
name the cardiomyopathies that are primarily diastolic dysfunction
hypertrophic = muscle too big = makes the area inside the ventricles smaller = cant fill properly = diastolic problem
restrictive = a hard and stiff ventricle = doesnt move to open up to fill properly = increased ventricular pressure all the time due to it being stiff so gets backflow of blood = diastolic problem
52
which chambers become dilated in dilated cardiomyopathy
all 4 chambers become dilated, but left ventricle dialted more than the right
53
name 4 causes of a dilated cardiomyopathy
```
alcohol
coxsackie B virus
HTN
cocaine
duchenne muscular dystrophy
```
54
what is cor pulmonale
right sided heart failure caused by an increase in pulmonary vessel pressures (pulmonary hypertension)
55
name 4 causes of cor pulmonale
COPD
interstitial lung disease
cystic fibrosis
PE
56
how does cor pulmonale present
often asymptomatic to begin with
then right side heart failure symptoms: raised JVP, peripheral oedema, hepatomegaly, heart murmur, cyanosis, syncope, SOBOE
57
symptoms of right heart failure
```
peripheral oedema
ascites
raised JVP
hepatomegaly
sacral oedema
```
58
symptoms of left heart failure
```
pulmonary oedema (pink frothy sputum)
nocturnal paroxysmal dyspnoea
orthopnoea
nocturnal cough
weight loss
cool peripheries
SOB
fatigue
poor exercise tolerance
```
59
name 2 causes of high output heart failure
anaemia
| thyrotoxicosis
60
what 4 investigations would you do to diagnose heart failure and why
1. BNP
2. echo - to look at EF and look for a cause
3. ECG - to look for hypertrophies or ischaemic changes
4. bloods = U+E for any meds going to start, FBC for anaemia that may be making heart failure worse
61
what is pre load
the pressure needed to over come to pump blood into ventricles - so stretching of cardiac myocytes on filling
62
what is afterload
the pressure left in the ventricle needed to overcome to pump blood out on systole
63
how do you work out cardiac output
HR x stroke volume
64
what is ejection fraction
amount of blood pumped out of the heart with each contraction
65
what is stroke volume
amount of blood pumped out of the left ventricle in one contraction
66
what is end diastolic volume
amount of blood in the ventricles at the end of diastole
67
what is end systolic volume
amount of blood left in the ventricles at the end of systole
68
how does left ventricular hypertrophy show up on ECG
left axis deviation
| T wave inversion in leads 1, avl and v5 and v6
69
how does right ventricular hypertrophy look on ECG
right axis deviation
very tall R waves in v1-v3
T wave inversion in leads v1-v3
70
Management of chronic heart failure (essential drugs)
Ace - i
beta blocker
Aldosterone antagonist! spironolactone / epelerone
Loop diuretic - furosemide
ABAL
71
which type of anti hypertensive should be avoided in patients with valvular heart disease unless indicated by a specialist
ace inhibitors
72
what are the 3 typical anginal symptoms
heavy chest pain
on exertion
relieved by rest or GTN
73
when would you use the word atypical angina
when less than 3 of the typical symptoms arent met (so for example might be heavy chest pain thats not relieved by rest or GTN)
74
what 3 tests would you consider to investigate angina
1. ECG
2. CT coronary angiography
3. exercise ECG
4. bloods such as FBC to look for things that might be exacerbating symptoms
75
management of stable angina
1. GTN for symptom relief
2. prevention with beta blocker and aspirin
3. if not controlled with betablocker can add a calcium channel blocker eg mod release nifedipine
4. if doesn't tolerate beta blocker can switch to CCB such as verapamil or dilitazem as a monotherapy only as these types of CCB's cant be used alongside beta blockers due to the risk of complete heart block
76
initial management of ACS
1. GTN
2. 300mg aspirin
3. IV morphine if in pain
77
what is the criteria for Primary PCI in ACS
- must be within 12 hours of symptom onset
| - and must be able to be done within 120 minutes of the time when fibrinolysis could have been done
78
what drugs are used for fibrinolysis in ACS
alteplase
| streptokinase (old)
79
which antiplatelet should be given if the patient is going for PCI
prasugrel
80
which antiplatelet should be given if patient is being treated for ACS with fibrinolysis
ticagrelor
81
which antiplatelet should be given if patient is having ACS but is already on an anticoag or has an increased bleeding risk
clopidogrel
82
NSTEMI treatment
if low GRACE score then conservative with batman
if high risk then PCI within 4 days of admission
```
BATMAN
beta blockers
aspirin
ticagrelor
morphine
anticoag (fondaparinoux)
nitrates (GTN)
```
83
TTO drugs post - MI
6 x A's
Aspirin
another antiplatelet (ticagrelor, prasugrel or clopidogrel)
atenolol (or other b blocker)
antihypertensive
atorvastatin
aldosterone antagonist in pts with signs of heart failure (eplerenone)
84
what is dresslers syndrome
a complication of MI that occurs 2-3 weeks post MI.
| causes a pericarditis
85
what type of scar will a pt have if they have had a valve replacement
midline sternotomy or right sided mini sternotomy
86
name 3 complications of a valve replacement
infective endocarditis
thrombotic emboli
haemolysis (from churning through the valve) = anaemia
87
what is the INR target for patients post mechanical valve insertion
2.5 - 3.5
88
what is a TAVI
transcatheter aortic valve insertion
89
what is TAVI used for
severe aortic stenosis in patients who are too high risk for open heart surgery
90
how does a mitral valve prolapse present
usually has a weird genetic disorder
atypical chest pain
new palpitations
mid systolic click on examination
91
symptoms of dresslers syndrome
```
low grade fever
pericardial rub
chest pain (pleuritic)
2-3 weeks post - mi
can present as a pericardial tamponade
```
92
management of dresslers syndrome
NSAIDS
steroids
pericardiocentesis if pericardial effusion
93
name 3 renal causes of secondary hypertension
adult polycystic kidney disease
glomerulonephritis
renal artery stenosis
94
name 3 endocrine causes of secondary hypertension
```
conns syndrome (primary hyperaldosteronism)
phaeochromocytoma
cushings
congenital adrenal hyperplasia
acromegaly
```
95
name the 2 criteria for diagnosing hypertension
1. systolic over 140 persistently on clinic readings
| 2. average 24 hr bp >135
96
investigating the cause of hypertension
1. U+E
2. lipids
3. hba1c
97
how do you diagnose hypertension
24 hour BP monitor
98
what drug would you use to control HTN in a pregnant or breastfeeding woman
labetalol
99
what 1st line drug would you use to control hypertension in a diabetic patient
ace inhibitor / arb
100
what 1st line drug would you use to treat hypertension in an under 55 year old otherwise healthy pt
ace inhibitor / arb
101
which drug would you use 1st line to treat hypertension in a person of black ethnicity
calcium channel blocker
102
what drug would you use first line to control hypertension in a patient over the age of 55
calcium channel blocker
103
what drug would you add next in a patient already on an ace inhibitor
calcium channel blocker
104
what drug would you add next in a patient already on a CCB
ARB if black
| ace inhibitor otherwise
105
what drug would you add next in a patient already on and ace inhibitor and CCB
thiazide like diuretic eg indapamide
106
what drug would you add next in a patient already on an ace inhibitor, CCB and indapamide with a potassium <4.5
low dose spironolactone
107
which two antihypertensives should you never combine
ARB and ace inhibitor
108
what drug would you add next in a patient already on an ace inhibitor, CCB and indapamide with a potassium >4.5
either an alpha blocker eg doxazocin
| or beta blocker eg bisoprolol
109
what is resistant hypertension
when HTN is failed to be controlled by 3 + drugs
110
what investigations would you order to rule out ACS
1. ECG
2. cardiac enzymes - troponin, CK, LDH
3. pci angiography
4. look for cause eg TFT, U+E, FBC, glucose, lipids
5. echo post procedures
111
which 3 cardiac enzymes can indicate ischaemia
troponin
LDH
Creatinine kinase
112
STEMI on ECG
ST elevation
| or new LBBB
113
name 3 causes of aortic stenosis
calcification with age
rheumatic heart disease
bicuspid valve
114
what is the most common cause of aortic stenosis
calcification with age
115
presentation of symptomatic aortic stenosis
```
SOBOE
syncope on exertion
ejection systolic murmur
CCF
anginal pain
```
116
signs of aortic stenosis on examination
```
ejection systolic murmur heart loudest over aortic area (left 3rd intercostal, sternal border), radiates to carotids
heaving apex beat
slow rising pulse
narrow pulse pressure
aortic thrill
```
117
murmur heard in aortic stenosis
ejection systolic
118
what investigations would you do to diagnose aortic stenosis
1. ecg
2. echo - diagnostic
3. cxr
119
management of aortic stenosis
valve replacement
| TAVI if not fit enough for open surgery
120
what is demussets sign and what is it seen in
head bobbing along with pulse in aortic regurg
121
what is quinckes sign and what is it seen in
pulsating capillaries in nail bed - aortic regurg
122
management of aortic regurg
optimise BP
monitor with echo ev 6-12 months
definitive - valve replacement
tx underlying cause eg if caused by dissection
123
indications for surgery in aortic stenosis
aortic dilation
severe symptomatic regurg
enlarging LV
deteriorating LV function
124
what murmur is heard in mitral regurg
pan systolic
125
name 4 causes of mitral regurg
```
infective endocarditis
rheumatic heart disease
annular calcification in the elderly
dilated left ventricle eg cardiomyopathy
ruptured chordinae tendinae
```
126
symptoms of mitral regurg
SOB, palpitations, fatigue
heart failure
pansystolic murmur
can cause atrial fibrillation !!
127
investigations in mitral regurg
ECG - look for AF , LV dilatation / hypertrophy
echo - diagnostic / can look at LV function
cardiac catheterisation to confirm
128
management of mitral regurg
1. rate control if AF
2. anti coag
3. valve repair / replacement surgery
4. diuretics for heart failure symptoms
129
name the most common cause of mitral stenosis
rheumatic heart disease
130
presentation of mitral stenosis
symptoms are due to pulmonary hypertension caused by the stiff mitral valve = blood backs up into pulmonary vein..
SOB
haemoptysis
hoarse voice if pulm vessel enlargement
dysphagia if pulm vessel enlargement
mallar flush
mid diastolic rumbling murmur with loud S1
can cause AF due to strain on left atrium
131
signs of mitral regurg on examination
pansystolic murmur heard loudest over mitral area and radiates to axilla
132
what murmur is heard in mitral stenosis
mis diastolic rumbling murmur
133
describe 1st degree heart block
progressive PR prolongation but doesnt drop a QRS
134
describe 2nd degree heart block
2 types
mobitz 1 and mobitz 2
mobits 1 is where PR gets progressively longer until it drops a QRS
mobitz 2 is where a QRS will drop every couple of beats so will get a set number of P's and then a dropped QRS in ratio
135
describe 3rd degree heart block
complete heart block so no atrial signals transferred to ventricles so P waves and QRS's totally independent of eachother
136
management of bradycardia
1. IV access, o2 if required, BP monitoring
2. check for cause so electrolyte levels, digoxin levels
3. if patient has adverse signs eg unstable or shock or ischemia then give IV atropine
4. if patient has no adverse signs and low risk of asystole then just observe
5. if patient still bradycardic can give atropine every 3-5 mins whilst anaesthetist on the way, can use adrenaline and also transcutaneous pacing
137
what drugs can be used to increase heart rate in brady cardic patients
atropine
| adrenaline
138
name causes of heart block
```
fibrosis
electrolyte disturbance
drug interactions
post-MI (usually inferior MI)
aortic valve disease
hypothermia
```
139
how do you manage torsades des pointes
IV magnesium sulphate
140
name 4 causes of long QT syndrome
```
inherited
hypokalaemia
low magnesium
antipsychotics
amiodarone
macrolide antibiotics
```
141
name 3 drugs that prolong the QT
antipsychotics
macrolides
amiodarone
142
management of complete heart block
implantable pacemaker
143
management of long QT syndrome
if inherited then implantable defib
| beta blockers
144
what are the two shockable rhythm's
VT
| VF
145
two non shockable rhythms
PEA
| asystole
146
SVT management
1. continuous ECG, o2, IV access
2. vagalmanouvers
3. adenosine if SVT
4. can give another 2 x bolus if doesn't work
5. if sinus rhythm not achieved check for atrial flutter (can be un masked by adenosine) and seek expert help
6. if atrial flutter seen after adenosine start beta blocker
147
management of fast AF
1. continuous ECG, O2, IV access
2. if patient unstable cardiovert +/- amiodarone
3. if patient stable then do rate control with bisoprolol or dilitazem
4. if started less than 48 hours ago then you can opt for rhythm control with flecanide or amiodarone but if unsure when started would need to anticoagulate for at least 3 weeks before doing rhythm control
148
how does WPW show up on an ECG
1. delta wave (sloped up on QRS)
2. short PR interval
3. wide QRS
149
what is the pathway called in wolf parkinson white
bundle of kent
150
how do you manage wold parkinson white
radiofrequency abalation
151
what medications are contraindicated in WPW
rate and rhythm control because they increase the risk of developing a chaotic pattern AF, polymorphic wide QRS tahcycardias
152
what score is used to determine the need for anticoagulation in chronic AF
CHA2DS2VASC
153
what are the components of CHA2DS2VASC
```
congestive cardiac failure
hypertension
age 64-75 / over 75
diabetes
stroke / tia
vascular disease
sex female
```
154
when is flecanide contraindicated for rhythm control
structural heart disease
155
what drugs can be used for rhythm control in fast AF that started less than 48 hours ago
dc cardioversion
flecanide
amiodarone
(always give heparin before)
156
management of fast AF that started more than 48 hours ago
rate control with bisoprolol
157
when can you use digoxin for rate control in chronic AF
if a beta blocker, rate limiting calcium channel blocker have both failed
158
last option for controlling chronic AF that has failed to be controlled by beta blocker, CCB and digoxin
amiodarone
159
symptoms of AF
```
palpitations
SOB
syncope
dizziness
chest pain
```
160
name 4 causes of irregularly irregular rhythm
1. AF
2. atrial flutter with heart block
3. multifocal atrial tachycardia (common in COPD)
4. sinus arrhythmia
161
name 5 causes of a regularly irregular rhythm
```
sinus tachy
focal atrial tachy
atrial flutter
AV nodal re-entry tachy (SVT)
junctional tachy
```
162
what is focal atrial tachycardia
where some random atrial cells decide to act as a pacemaker and emit impulses
163
what is atrial flutter
where electrical impulses circle around the atria and flutters at a rate of >330 per min
AV node still manages to pass on some of these impulses and the ventricular rate will always be in multiples of 300 eg 150, 75
164
name 5 causes of pericarditis
```
viral - coxsackie B
TB
malignancy
hypothyroid
uraemia
post-MI
dresslers syndrome
connective tissue disease
```
165
most common viral organism causes pericarditis
coxsackie B
166
presentation of pericarditis
```
pleuritic chest pain
SOB
low grade fever
palpitaitons
tachycardia
tachypnoea
```
167
describe pleuritic chest pain
sharp chest pain
worse on deep inspiration
relieved by sitting forward
168
what investigations would you do in suspected pericarditis
1. ECG
2. transthoracic echo - look for effusion etc
3. exclude differentials eg MI cardiac enzymes, U+E
4. look for cause - TFT's, sputum culture, CXR,
169
ecg findings in pericarditis
global saddle shaped ST elevation
170
how do you treat pericarditis
NSAIDS to be tapered down over a couple of weeks to reduce recurrence rate
colchicine for 3 months
171
presentation of cardiac tamponade
```
becks triad - raised jvp, low BP and muffled heart sounds
pulsus paradoxus
tachy
SOB
absent Y in JVP
```
172
what is becks triad in cardiac tamponade
low bp
raised JVP
muffled heart sounds
173
management of cardiac tamponade
urgent pericardiocentesis
174
what is constrictive pericarditis
where pericardium becomes stiff from inflammation causing it to compress the heart = diastolic heart failure
175
symptoms of constrictive pericarditis
right heart failure - raised JVP, peripheral oedema, hepatomegaly
SOB
kaussmall sign
176
what is kaussmall sign
paradoxical increase in JVP with inspiration - seen in constrictive pericarditis
177
what investigations would you do to diagnose constrictive pericarditis
1. ECG
2. ECHO
3. CXR - shows pericardial calcification
178
how would you manage constrictive pericarditis
more a chronic problem so not immediately life threatening so can do pericardectomy at some point to prevent diastolic heart failure
179
what would you expect the PT and APTT to be like in a patient on warfarin
PT be prolonged because warfarin acts on extrinsic pathway
180
what would you expect the PT and APTT to be like in a patient on warfarin
PT be prolonged because warfarin acts on extrinsic pathway (play tennis outside)
