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Internal Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Modified Duke Criteria

A

> Major criteria
- Positive blood culture:
(Typical organism in 2 separate culture OR
Persistently +ve blood culture, eg: 3 >12 hours apart OR
Single positive blood culture for Coxiella burnetti)
- Endocardium involved:
(Positive echocardiogram OR
Abnormal activity around prosthetic valve on PET/CT or SPECT/CT OR
Paravulvular lesion on cardiac CT)

> Minor criteria

  • Predisposition (IV drug abuse)
  • Fever >38’C
  • Vascular phenomena (emboli, Janeway’s lesion)
  • Immunological phenomena (glomerulonephritis, Osler’s nodes)
  • Positive blood culture that do not meet major criteria

> How to diagnose

  • 2 major OR
  • 1 major and 3 minor OR
  • All 5 minor criteria
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2
Q

Management of infective endocarditis**

A

○ Empirical antibiotics
- Generally: ampicillin + gentamycin

○ Surgery
- Indication
□ Severe valvular regurgitation/ heart failure
□ Persistent infection/ uncontrolled sepsis
□ Fungal endocarditis
□ Very large vegetation (>10mm)

○ Monitoring of treatment response

  • FBC - total WBC
  • Inflammatory markers - CRP/ ESR
  • Blood C&S - 3 to 4 days after antibiotics
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3
Q

Complication of infective endocarditis*

A
  • Cardiac: heart failure, perivalvular abscess, pericarditis
  • Neurologic: stroke, brain abscess, meningitis
  • Renal: renal infarction or abscess (following septic embolization), glomerulonephritis (due to deposition of immunoglobulin and complement in glomerular membrane)
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4
Q

Revised Jones Criteria

A 
" JONES PEACE"
> Major
- Joints (polyarthritis)
- Heart (carditis, valve damage)
- Nodule (subcutaneous)
- Erythema marginatum (painless rash)
- Sydenham chorea (flinching movement disorder)

> Minor

  • Previous rheumatic fever
  • ECG with PR prolongation
  • Arthralgias
  • CRP and ESR elevated
  • Elevated temperature

> Diagnosis
- Evidence of recent strep infection + 2 major/ 1 major + 2 minor criteria

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5
Q

Secondary prophylaxis for rheumatic fever

A

> Penicillin V 250mg/12h PO; Alternative: erythromycin 250mg BD

  • Carditis + persistent valvular disease -> at least until age 40
  • Carditis without valvular disease -> continue for 10 years
  • No carditis -> 5 years prophylaxis (until age of 21) is sufficient
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6
Q

Framingham criteria

A

> Major criteria

  • Acute pulmonary edema
  • Cardiomegaly
  • Hepatojugular reflux
  • Neck vein distension
  • Paroxysmal nocturnal dyspnea

> Minor criteria

  • Ankle edema
  • Dyspnea on exertion
  • Hepatomegaly
  • Nocturnal cough
  • Pleural effusion
  • Tachycardia (pulse >120)

> Note
- HF present in patient with at least 2 major criteria/ 1 major + 2 minor criteria

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7
Q

New York classification of heart failure

A

I: Heart disease present, but no undue dyspnea from ordinary activity
II: Comfortable at rest; dyspnea during ordinary activity
III: Less than ordinary activity cause dyspnea, which is limiting
IV: Dyspnea present at rest; all activity cause discomfort

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8
Q

ECG features of hyperkalemia***

A
  • > 5.5 mmol/L: peaked T waves
  • > 6.5: widening of P waves, PR segment lengthening
  • > 7.0: prolonged QRS interval, bradycardia
  • > 9.0: VF, asystole
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9
Q

Treatment for hyperkalemia**

A

“Lytic cocktail”

  • 10ml of 10% calcium gluconate given over 10 minutes
  • 50ml of 50% dextrose
  • 10 unit IV Actrapid
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10
Q

Physical signs in heart failure

A

General:

  • Use of accessory muscles
  • Cyanosis
  • Hand: cold periphery, CRT >2 sec
  • Face: pallor
  • Neck: raised JVP, hepatojugular reflux
  • Back and lower limb: edema

> Cardiovascular

  • Displaced apex beat
  • Parasternal heave
  • Murmur

> Other

  • Lung crepitation
  • Hepatomegaly
  • Ascites
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11
Q

Investigation for heart failure**

A
  • FBC
  • BUSE/ Cr
  • B-type natriuretic peptide
  • Liver function test: congestive hepatomegaly
  • ABG: hypoxemia, hypercapnia, acidosis
  • ECG: exclude arrhythmia, ACS, evidence of LVH
  • CXR: ABCDE
  • Echocardiography
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12
Q

Acute management of heart failure**

A

> Stabilization

  • Supplemental O2: keep >95%
  • Diuretic: IV frusemide - reduce fluid overload
  • Vasodilators: IV nitrate - concurrent ACS
  • Inotropes: IV noradrenaline, dopamine - if SBP <100mmHg at initial presentation
  • IV morphine - reduce pulmonary venous congestion
> Treat underlying causes
> Continuous assessment
- Vital signs
- Urine output
- Weight
- Respiratory distress
- Cold/ warm periphery

> DVT prophylaxis

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13
Q

Physical sign of ACS**

A
  • Hand: tendon xanthoma
  • Face: pallor, xanthelasma
  • Chest: scars (median sternotomy, CABG)
  • CVS: apex beat, murmur, carotid bruit
  • Lower limb arterial: bypass scar, trophic changes, delayed CRT
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14
Q

Immediate management of ACS**

A

“MONAC”

  • Morphine
  • Oxygen if <90%
  • Nitrates
  • Aspirin 300mg
  • Clopidogrel 300mg
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15
Q

Definitive, subsequent and long term management for STEMI***

A

> Definitive
- Depends on time from symptoms onset: PCI/ FT (eg: IV tenecteplase)

> Subsequent

  • Admit to CCU
  • Supportive: IV opioids, O2 keep >95%, dual antiplatelet therapy, anticoagulation (for patient received fibrinolytic)
  • Drugs with positive impact on survival: ACE-I/ ARB, beta blocker, mineralocorticoid receptor antagonist, statins

> Long term

  • Smoking cessation
  • Diet modification
  • Weight control
  • Physical exercise
  • Optimize BP, glucose
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16
Q

Definitive management for NSTEMI**

A
  • Initial management at ED: ECG and cardiac troponin to establish diagnosis, urgent medication (MONAC), supportive treatment (O2 when <90%, IV morphine)
  • Risk stratify patient: TIMI/ GRACE
  • Subsequent management
  • Depends of risk group: ischemic guided strategy (risk reduction + medical treatment) vs invasive strategy (coronary angiography + PCI, CABG)
  • Start medication: dual antiplatelet, anticoagulation, beta blocker, ACE inhibitor, high intensity statin
  • Discharge
17
Q

Investigation for ACS***

A
  • ECG
  • Cardiac troponin
  • FBC, RP
  • Glucose, lipid profile
18
Q

Investigation for infective endocarditis**

A 
○ Diagnosis
- Blood C&S
	□ At least 3 sets of sample, each taken at least 30 minutes apart
- Echocardiography
	□ Vegetation
	□ Abscess
○ Support diagnosis
- FBC
	□ Leukocytosis
	□ Anemia
- Inflammatory markers
	□ Raised ESR/ CRP
- Urinalysis (UFEME)
	□ Microscopic hematuria

○ Monitor treatment response

  • Repeated blood culture
  • FBC: WCC trend
  • Inflammatory markers
19
Q

Causes of AF**

A
  • Valvular heart disease: especially MS
  • Ischemic heart disease
  • Hypertension
  • Congenital heart disease: ASD, VSD
  • Secondary causes: thyrotoxicosis, medication-induced
20
Q

CHA2DS2VA risk score

A

Assess stroke risk

  • C: Congestive HF
  • H: history of HPT
  • A: Age >=75
  • D: DM
  • S: history of Stroke
  • V: Vascular ds
  • A: Age 65-74

0: OAC for 4 weeks
1: consider OAC long term
2 or more: OAC long term

21
Q

Long term management of heart failure

A

> Non-pharmaco

  • Exercise: 30min, 5 times/ week
  • Dietary
  • Fluid restriction: 1.5L/day
  • No alcohol, smoking

> Pharmaco

  • ACE-I
  • B blocker
  • Spironolactone
  • Diuretics
22
Q

Cardiac biomarker

A
  • CK-MB: good to detect reinfarction due to presence for only 1-2 days
  • Troponin is investigation of choice due to high specificity
  • Others: CK, Myoglobin
23
Q

Management of SVT***

A

> Acute

  • Unstable -> Immediate synchronized cardioversion
  • Stable -> carotid sinus massage
  • If not terminate by vagal maneuver -> IV adenosine or CCB (eg: verapamil or diltiazem)

> Prophylaxis against recurrence

  • Beta blocker or CCB
  • Radiofrequency ablation (in hemodynamically unstable attack, pre-excitation on ECG)
24
Q

5 life threatening condition of chest pain

A
  • Acute coronary syndrome
  • Aortic dissection
  • Pulmonary embolism
  • Pneumothorax
  • Oesophageal tear
25
Q

ECG features of ACS*

A

> STEMI
□ Within hours: tall T waves, ST elevation
□ Hours to days: T wave inversion and pathological Q waves

> NSTEMI/ UA
□ ST depression
□ T wave inversion
□ Normal

26
Q

Management of AF*

A

> Immediate
○ Assessment
□ Hemodynamic status
□ Immediate ECG: look for pre-excited AF
○ Management
□ Unstable: urgent synchronized electrical cardioversion
□ Stable: rate control with IV beta blocker/ non-dihydropyridine CCB (no structural heart disease); IV amiodarone (CCF)
□ If suboptimal control/ contraindicated -> Digoxin

> Subsequent

  • Assess stroke risk: CHA2DS2VA
  • Long term rate control: beta blocker, non-dihydropyridine CCB
27
Q

ECG changes in AF*

A
  • Irregular rhythm
  • Tachycardia
  • Absence of P wave
  • Fibrillatory waves
  • Loss of isoelectric baseline
  • Narrow QRS complex
28
Q

Investigation for AF

A

> Confirm diagnosis
- 12-lead ECG

> Others

  • Serum electrolyte
  • Thyroid function test
  • Transthoracic echocardiography
29
Q

What is Dabigatran and its indication

A
  • Direct thrombin inhibitor

> Indication

  • Non-valvular AF
  • DVT
  • Pulmonary embolism
  • Postoperative DVT prophylaxis
30
Q

Target INR in AF

A

2 to 3

31
Q

Investigation for myocarditis

A

○ ECG

  • ST changes
  • T waves inversion
  • Atrial arrhythmia
  • QT prolongation

○ CRP, ESR, Troponin
- May be raised

○ Echo

  • Diastolic dysfunction
  • Reginal wall abnormalities
32
Q

Management for myocarditis

A
  • Supportive
  • Treat underlying cause
  • Treat arrhythmia and heart failure
33
Q

Definition of metabolic syndrome**

A

> Central obesity (BMI >30) plus 2 of:

  • BP >= 130/85
  • Triglyceride >=1.7mmol/L
  • HDL <= 1.03 (male)/ 1.29 (female) mmol/L
  • Fasting glucose >=5.6 mmol/L
  • Type 2 DM
34
Q

How IHD cause MR

A
  • Myocardial infarction can lead to LV dilation
  • > dilation of the MV annulus
  • > tethering of the chordae tendineae
35
Q

How to diagnosed DVT

A
  • Calculate Well’s score (determine probability)
  • If <= 1 points, DVT unlikely and perform a D dimer test
    Negative -> exclude DVT
    Positive -> ultrasound to confirm
  • In high probability patient -> whole leg ultrasound (D dimer cannot be reliably used to exclude DVT)
36
Q

Example of non-ischemic cardiomyopathy

A
  • Hypertrophic CM
  • Restrictive CM
  • Dilated CM
  • Myocarditis
37
Q

Degree of AV block

A
  • 1st: PR interval is longer than normal (>0.2 sec)
  • 2nd - MB1: PR interval progressively lengthens with each beat until the atrial impulse is not conducted and the QRS complex is dropped
  • 2nd - MB2: beats are intermittently non-conducted and QRS complex dropped, usually in repeating cycle of every 3rd (3:1 block) or 4th (4:1 block) P waves
  • 3rd: AV dissociation
38
Q

Complication of prosthetic heart valve

A

> From the valve

  • Hemolysis
  • Valve dysfunction: leaking, dehiscence, thrombosis
  • Thromboembolism
  • Endocarditis

> From treatment
- Overwarfarinization (bleeding)

39
Q

Type (+ cause, management) of heart failure

A

> Dilated cardiomyopathy

  • Cause: IHD, HPT
  • Mx: anticoagulation

> Hypertrophic CM

  • Cause: hereditary (autosomal dominant HOCM)
  • Mx: beta blocker, implantable defibrillator

> Restrictive CM

  • Cause: infiltrative ds (amyloidosis, sarcoidosis, hemochromatosis)
  • Mx: anticoagulation, heart transplant

Internal Medicine (12 decks)

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