Cardiology Flashcards
How do you investigate and manage a triple A?
Above what size is an elective repair required?
Ultrasound = 1st line
CT Aortogram for ruptured AAA
Incidental finding = elective surgical repair if >5.5cm. Surgery if ruptured.
How do you investigate and manage a cerebral aneurysm?
How would Pcomm vs Acomm compression manifest?
Cerebral angiogram
Endovascular coiling, open surgical clipping
Pcomm = CN 3 palsy Acomm = bitemporal hemianopia
How do you investigate and manage an aortic dissection?
What are some complications of this?
How do you identify a dissection?
CT = 1st line
CXR may also show widened mediastinum
Fluids, O2, analgesia, antihypertensives
MI from RCA dissection, aortic regurgitation, cardiac tamoonade regional ischemia if occlusion of vessels
Acute severe chest/ abdominal pain radiating to back, Unequal BP in both arms, pulse deficit, diastolic murmur
How do you investigate and manage unstable angina
ECG - ST depression
Troponin - normal
Acute = aspirin + P2Y12 inhibitor(prasugrel, ticagrelor, clopidogrel). Consider fondaparinux
(Post stabilisation = beta blocker, GTN, dual antiplatelet therapy)
PCI if estimated 6 month mortality(GRACE) is 3% or greater
How do you investigate and manage an NSTEMI
ECG - ST depression
Troponin - ELEVATED
Management same as unstable angina if clinically stable
How do you manage a STEMI?
What are complications of this?
Initial Management = MONA= morphine, oxygen, nitrates and aspirin(300mg)
Definite management = PCI(primary angioplasty w stent).
If PCI can NOT be performed within 2 hours of presentation = FIBRINOLYSIS e.g with Alteplase
- Dresslers syndrome - triad of pericarditis, fever, pericardial effusion
- Heart block
- Cardiac tamponade - triad of hypotension(cardiogenic shock), distended neck veins, quiet heart sounds
- pulmonary oedema - airspace opacities and “bat wings” on CXR
- Acute mitral regurgitation - SOB, pink frothy sputum. Systolic murmur
What are the classic findings in aortic stenosis? How do you investigate this?
Complications?
Exertional dyspnea, chest pain, and syncope = SAD
Ejection systolic murmur radiating to the neck
Slow rising pulse, narrow pulse pressure
TransTHORACIC echo
Left Heart Failure -> Pulmonary oedema(bibasal crepitations on auscultation) !!
What are the findings in aortic regurgitation and how do you investigate this?
pulmonary oedema and hypotension (dyspneoa, orthopnea)
Early diastolic decrescendo murmur
Collapsing pulse and widened pulse pressure
TransTHORACIC echo
How do you investigate and manage gangrene?
Pain
Oedema or swelling
Diminished pedal pulses and ABPI in ischemic gangrene
Uncommonly: skin discoloration
Dry gangrene - necrosis
Wet gangrene - necrosis + infection
Gas gangrene - clostridial species colonization
What are the findings, investigations and management for acute pericarditis?
Acute sharp pleuritic chest pain
Relieved by sitting up/leaning forward, worse when lying flat.
May radiate to trapezius ridges (phrenic involvement)
Pericardial rub
RFs include viral infection, MI, autoimmune conditions
ECG - concave ST-segment elevation globally with PR depressions in leads with positive QRS
Acute: NSAIDS + PPIs + exercise restriction (+colchicine)
What are the findings, investigations and management for constrictive pericarditis?
Dyspnea
Prominent right Heart Failure signs(elevated JP, hepatomegaly, ascites, pleural effusions, exercise intolerance), Kaussmaul’s sign(increase in JVP with inspiration)- this is absent in tamponade
Pericardial knock (after S2) Radiation to chest is a key RF
CXR and CT- shows pericardial calcification
Pericardiectomy
What are the findings, investigations and management for cardiac tamponade?
Pulsus paradoxus = hallmark
Quiet heart sounds, Hypotension and elevated JVP/ distended neck veins
TransTHORACIC echo- compressed cardiac chambers, pericardial effusion may be seen
hemodynamically stable where BP>110 and pulsus paradoxus< 10 = ibuprofen/colchicine/aspirin + omeprazole
Hemodynamically unstable BP<110 PP>10, Pericardiocentesis
What are the findings, investigations and management for myocarditis?
VIRAL SYNDROME (fever, myalgias, respiratory symptoms, or gastroenteritis in the 2 to 3 weeks preceding)
+ HEART FAILURE
Chestpain
syncope
Serum CK, CK-MB and troponin will be slightly elevated
CXR - frequently reveals bilateral pulmonary infiltrates in the setting of myocarditis-induced CHF. Globular heart
Echo - global and regional left ventricular motion abnormalities and dilatation
Supportive care and heart failure therapy
If autoimmune - treat with methylprednisolone
Complication = DILATED CARDIOMYOPATHY
How do you investigate infective enfocarditis. How does it usually present?
What makes up dukes major criteria?
Echo to check for vegetations = 1st line
3 Blood cultures within 24 hours
Fever + new onset murmur
Major criteria
- at least two separate positive blood cultures
- Evidence of endocardial involvement by echocardiography (vegetation on valves, valvular abscess or new valvular regurgitation)
Minor criteria are things like fever, IVDU, predisposing cardiac lesion, embolia phenomena immunologic phenomena eg glomerulonephritis, positive blood culture not meeting above standard eg atypical organism
What are the causative organisms for infective endocarditis? What are the risk factors for acquiring them?
S.aureus is a common cause and causes acute endocarditis - seen in drug users
Streptococcus viridans- dental work RF
Staphylococcus epidermis - Prosthetic heart valves and other prosthetic surfaces e.g dialysis lines, venous lines
Enterococcus faecalis- GI and GU tract - catheter, colonoscopy
Strep bovis - bowel malignancy link
What are the findings, investigations and management for mitral stenosis?
Mid to LATE diastolic murmur preceded by an opening snap
Dyspnea, orthopnea from resulting right HF
Uncommonly:malar flush (mitral facies), irregularly irregular pulse(AF)
Transthoracic echocardiography = hockey stick-shaped mitral deformity
ECG - classic bifid p waves
Valvulotomy
*all patients require warfarin due to Afib risk
What are the findings, investigation and management for mitral regurgitation?
Sudden worsening of HF symptoms
dyspnoea, usually on exertion, palpitations, and/or decreased exercise tolerance, lower extremity edema
HOLOSYSTOLIC murmur
Tranthoracic echo
Asymptomatic chronic = ACE inhibitors + beta blockers
Symptomatic chronic = valve surgery
What are the findings in mitral valve prolapse?
MIDSYSTOLIC CLICK best heard at apex followed by late systolic MUMUMR. Murmur increases with standing valsalva and decreases with squatting (unlike most murmurs)
What are the examination findings in tricuspid regurgitation?
fatigue, Dyspnea and oedema - HF
Systolic murmur that is increased on inspiration
Right HF signs
What are the exmaination findings in tricuspid stenosis?
Prominent a-waves in the jugular venous waveform are a hallmark of tricuspid stenosis in patients who are in sinus rhythm.
diastolic(pre-systolic) murmur at the left lower sternal border
Dyspnea
How do you identify and manage cardiac arrest?
Loss of consicousness
No pulse
Absent/agonal breathing
1 of 4 rhythm disturbances
Continuous cardiac monitoring - shockable rhythm (ventricular fibrillation/pulseless ventricular tachycardia), or non-shockable rhythm (asystole/pulseless electrical activity)
shockable rhythm = CPR + defibrillation. Given adrenaline with second shock, followed with 5 cycles of CPR. if unsuccessful add on an antiarrythmic (e.g. amiodarone) if still unsuccessful/evidence of torsades de pointes add magnesium sulphate
Non-shockable rhythm = CPR + adrenaline every 3-5 minutes. If heart rate <60 bpm, can add atropine
*if cardiac arrest is secondary to hyperkalemia - give calcium gluconate
What are the signs and sypmtoms of left vs right heart failure?
How do you investigate HF?
Left heart failure signs = orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema
Right heart failure signs = raised JVP, peripheral edema, hepatomegaly
Transthoracic echo, CXR, BNP<100
How do you manage Heart failure?
Acute = sit up, O2, loop diuretic
Chronic = ACE inhibitor + Beta blocker (may add loop diuretic for symptom relief)
Define essential hypertension
How is this treated?
blood pressure (BP) ≥140/90 mmHg,
Age 55 or over OR black african/carribean = CCB
Under 55 and not black OR hypertension with T2DM = ACE or ARB
If either group above is uncontrolled with one drug, use in combination
CCB + ACE/ARB OR + thiazide like diuretic
ACE/ARB + CCB OR + thiazide like diuretic
If still uncontrolled use all 3 types of drugs
What are some causes of secondary hypertension?
What is the investigation for Primary Hyperaldosteronism? And how do you treat the different types.
How do you treat a Phaeochromocytoma?
Kidney disease - CKD, renal artery stenosis. Adult polycystic kidney disease
Disorders of adrenal gland - cushing's, phaeos. primary hyperaldosteronism (e.g conns, first best test = plasma aldosterone:renin ratio - aldosterone will be high, renin will be low, aldosterone excess causes sodium resorption and potassium excretion so hypokalemia and metabolic alkalosis).
Acromegaly
aortic coarctation
Primary hyperaldosterone causes: 1. Bilateral adrenal hyperplasia - Aldosterone production by adrenals increase when standing up. treat with spironolactone or amiloride. 2. Conns - unilateral adrenalectomy 3. Adrenal carcinoma - surgery
Phaeo = phenoxybenzamine (1st line) doxazosin, prazosin as alpha blocker. Then beta blocker then surgery
How do you treat a patient for hypertension if they have coexisting HF?
Avoid CCBS
Use ACE/ARB + beta blocker
What hypertensive drugs are used in pregnancy?
Hydralizine, labetalol, Methyldopa, nifedipine (he likes my neonate)
What are the findings in peripheral arterial disease?
How do you investigate this?
Treatment for the different types?
ABPI; ≤0.90 is diagnostic of peripheral arterial disease. <0.5 causes rest pain(critical limb ischemia)
*IN a DIABETIC patient, must confirm with duplex ultrasound
Acute limb ischemia - 5ps presentation
IV heparin, aspirin, analgesia initially
- then Embolectomy Or Thrombolysis depending on cause
Critical limb ischemia - presents as night pain, resting pain, tissue loss/ulcers.
1. revascularization, PTA or bypass
*note that intermittent claudication does not cause rest pain and is therefore not as advanced as critical limb ischemia.
Management = hypertension, diabetes, stop smoking, exercise training, can step up to vasodilators.
Leriche syndrome = stenosis of iliac arteries -> intermittent claudication of buttocks, ERECTILE DYSFUNCTION, weak femoral pulses.
What are the findings, investigation and management for DVT
Localised pain along deep venous system
Unilateral swelling, redness/discolouration
Duplex Ultrasound Imaging
Oral anticoagulants - rivaroxaban, apixaban
Pregnant women = LMWH/UFH - e.g enoxaparin
What are the findings, investigations and management for hemochromatosis
Diabetes, bronzed skin, hepatomegaly(usually associated with cirrhosis)
Fatigue, arthralgias(especially MCP joints) - most common
hypogonadism
Serum transferrin saturation >45% - confirm with genetic testing
Serum Ferritin = raised
Advanced disease = repeated phlebotomy. 2nd line = Iron chelation (deferasirox, deferoxamine). Avoid iron supplements, vitamin c, alcohol
What are tbe findings, investigations anf management for an ischemic stroke?
Unilateral weakness or paralysis in the face arm or leg
Dysphasia, ataxia, visual disturbance, sensory loss, slurred speech
Non contrast CT - hypoattenuation of brain parenchyma
Thrombolysis using tPA (Alteplase)if < 4.5 hours of symptom onset - there are contraidications to this treatment,
>4.5 hours = 300mg aspirin
Prophylaxis treatment = clopidogrel
What are the findings in TIA?
How do you manage this?
Score system for risk of stroke?
sudden-onset, focal neurological deficit that has completely resolved within 24 hours and is not due to an underlying condition
Aspirin 300mg + statin. Carotid doppler ultrasound to check for stenosis followed by CT/MR angiography if stenosis noted . surgery for severe stenosis
Use clopidogrel for prophylaxis
ABCD2 score
What would a lesion to the middle cerebral artery result in?
contralateral paralysis and sensory loss of face and upper limb
Temporal and frontal lobe involvement -> aphasia
hemineglect
What would a lesion to the anterior cerebral artery result in?
contralateral paralysis and sensory loss lower limb. Urinary incontinence
What would a lesion to Posterior cerebral artery result in?
contralateral hemianopia with macular sparing
How does intestinal ischemia present? What is the first line investigation for this?
How do you manage this?
abdominal pain out of proportion to examination - classic presentation of acute mesenteric ischemia
CT with contrast/CT AngiograM 1st line for acute and chronic mesenteric ischemia - bowel wall thickening, bowel dilation, pneumatosis intestinalis, portal venous gas, occlusion of the mesenteric vasculature, bowel wall thickening with thumbprinting sign suggestive of submucosal oedema or haemorrhage
Surgical revascularization via angioplasty and heparin
Chronic ischemia = mesenteric bypass or stenting
What are the causes symptoms and signs of hypokalemia?
Causes - diarrhoea and vomiting, diuretics, conns syndrome, excessive sweating, burns
Symptoms - lethargy, polyuria, profound muscle weakness, muscle cramps, palpitations, arrhythmia
ECG signs - U WAVES, flattened T waves, ST- segment depression, atrial and ventricular arrhythmias
What are the causes symptoms and signs of hyperkalemia?
Causes - renal failure, missed dialysis session(dialysis removes toxins like urea and potassium from the blood), Addison’s disease, ace inhibitors, ARBS, potassium supplements
Symptoms - palpitations, muscle weakness, nausea
ECG signs - TALL T WAVES, p wave flattening, PR prolongation, widened QRS complex, arrhythmia(e.g vtach, vfib)
How do you investigate and manage varicose veins?
Duplex ultrasound - increased valve closure time, indicating reflux
Simple tourniquet test, trendelenburgs
endovenous thermal ablation, foam sclerotherapy, and open surgery.
What are the findings, investigations and management for AFib?
Irregularly irregular pulse with palpitations, SOB, chest pain
New onset may present with these signs as well as stroke or HF!!!
ECG - chaotic baseline, no distinct p wave, IRREGULARLY irregular R wave
Rate control - beta blockers, CCBs, digoxin second line
Cardioversion - amiodarone, flecainide, or dc cardioversion. Anticoagulate first before DC if >48 hrs
*ALWAYS CARDIOVERT IF <48hrs presentation
Long term anticoagulants - apixaban
What are the findings, investigations, and management for atrial flutter?
Embolic events, MI, WORSENING of heart failure or pulmonary symptoms may indicate new-onset atrial flutter
Palpitations
Fatigue/lightheadedness, chest pain, dyspnea, syncope,
ECG - negatively directed saw tooth atrial deflections INFERIOR leads (2,3, aVF). Absent p waves. Positive deflections in V1. Associated ATRIOVENTRICULAR block is common
Thyroid function tests
Management same as Afib
What are the findings, investigations and management for AVNRT?
Palpitations
ECG - narrow QRS complex tachycardia, NO P WAVES!! regular rhythm
Carotid massage, vasalve maneuver = 1st line
IV Adenosine 6mg or verapamil if asthmatic patient = 2nd line. Hemodynamic compromise give DC cardioversion
Frequent symptoms - surgical ablation
What are the findings, investigation and management for WPW?
Palpitations, dizziness, SOB, chest pain, syncope
ECG - delta wave + WIDE QRS complex + Shortened PR interval.
Antiarrhythmics
What are the findings, investigation and management for Ventricular Tachycardia? Including torsades de pointes
Tachycardia, syncope, palpitations etc
ECG - Wide complex tachycardia
CK-MB, Troponin I - elevated. ischemia is a reversible cause of VT
Electrolytes - hypokalaemia and hypomagnesaemia frequently associated with torsades de pointes
Pulslessness VT = CPR
Pulse present:
- amiodarone
- IV magnesium sulphate if torsades de pointes (poylymorphic VT)
Hemodynamically unstable(low bp, chest pain, p.oedema) = DC cardioverison
Ventricular fibrillation findings and management?
Fainting/ near fainting
CPR and defibrillation. Medication to control arrhythmia
How do the different types of AV block present on an ECG?
first-degree AV block: fixed PROLONGED PR interval >0.210 seconds
second-degree AV block, type I: progressive PR interval prolongation, eventual loss of AV conduction for 1 beat. “Grouped beating” as R-R intervals are REGULARLY IRREGULAR.
second-degree AV block, type II: occasional loss of AV conduction for 1 beat. CONSTANT unchanging PR intervals
third-degree AV block: no consistent PR relationship. Constant R-R intervals are the HALLMARK. P-P interval not equal to R-R as Atria and ventricles beat independently of each other. Heart rate = 40 bpm as ventricles depolarize at this rate (atria continue at normal rate). Cannon A-waves present (Abnormally large waves in jugular venous pressure waveform)
What are the symptoms of AV block?
Chest pain, palpitations, syncope
HR <40bpm is pacemaker indication
How does a left bundle branch block manifest?
Deep S-waves in V1, further R-wave in V6 which completes ‘M’ pattern in V6
WilliaM - LBBB has a W in V1 and and M in V6
How does a right bundle branch block manifest?
RSR pattern in V1, prominent S waves in V6
MarroW - RBBB has an M in V1 and a W in V6
What is high blood pressure and how do you manage it?
BP over 140/90
Age 55 or over/ afro-carribean = CCB (b=black)
Under 55 or hypertension with T2DM= Ace inhibitor
2nd line for both groups = ACE + CCB
3rd line for bothe groups = ACE + CCB + thiazide like diuretic
how is heart failure classified according to the NYHA?
Class 1: No limitation of physical activities
Class 2: Slight limitation of physical activity in which ordinary physical activity leads to fatigue, palpitation, dyspnea, or anginal pain; the person is comfortable at rest
Class 3: Marked limitation of physical activity in which less-than-ordinary/MINOR activity results in fatigue, palpitation, dyspnea, or anginal pain; the person is comfortable at rest
Class 4: Inability to carry on any physical activity without discomfort but also symptoms of heart failure or the anginal syndrome even at REST, with increased discomfort if any physical activity is undertaken
Peripheral arterial disease
Sites of pain/claudication and corresponding occluded vessels?
Buttock = common iliac artery Thigh = common femoral artery Calf = SUPERFICIAL femoral artery Lower 1/3rd of calf = popliteal artery Foot = tibial artery
Learn his to calculate CHAdsVAsc score for a patient
