Cardiology Flashcards
1
Q
list 3 non-modifiable risk factors of CVD
A
- older age
- family history
- being male
2
Q
list some modifiable risk factors of CVD
A
- smoking
- alcohol
- high sugar / fat, low fruit / veg diet
- low exercise
- obesity
- poor sleep
- stress
3
Q
which medical co-morbidities contribute to CVD risk?
A
- DM
- HTN
- CKD
- inflamm stuff like RA
4
Q
which conditions can atherosclerosis result in?
A
CARDIAC
- angina
- MI
NEURO
- TIA
- stroke
PVD
chronic mesenteric ischaemia
5
Q
how can modifiable risk factors of heart disease be optimised?
A
- advise on diet, exercise, weight loss
- stop smoking
- stop drinking alcohol
- optimise comorbid condition treatments (like DM)
6
Q
what is QRISK 3 score? when should a statin be started? what dose?
A
- the % risk of a patient having a stroke or MI in the next 10 years
- when risk is >10%
- atorvastatin 20mg
7
Q
who should be put on a statin?
A
- anyone with QRISK 3 score >10%
- CKD >10 years
- T1DM >10 years
8
Q
how can statins affect LFTs? when should LFTs be checked?
A
- transiently and mildly raised ALT and AST for weeks
- check LFTs at 3m and 12m
9
Q
4As of secondary prevention of CVD? (they’re all drugs)
A
- Aspirin ( + clopidogrel, for DAPT)
- Atorvastatin
- Atenolol
- ACE-i (ramipril)
10
Q
3 main side effects of statins?
A
- myopathy (raised CK)
- T2DM
- haemorrhagic stroke (rare)
11
Q
describe the pathophysiology of angina
A
- narrowed coronary arteries
- reduced blood flow to myocardium
- demand > supply
- causes tight chest pain +/- radiation to jaw / arm
12
Q
when is angina “stable”?
A
when symptoms are completely relieved by GTN
13
Q
when is angina “unstable”?
A
when symptoms come on at rest
14
Q
gold standard investigation for angina?
A
CT coronary angiogram
15
Q
what are the baseline investigations for angina? why are they each important?
A
- physical exam (?HF, heart sounds, BMI)
- ECG
- FBC (?anaemia)
- UEs (before starting ACE-i)
- LFTs (before starting a statin)
- Lipid profile
- TFTs
- HbA1C, fasting glucose (?DM)
16
Q
RAMP: management of angina?
A
- Referral to cardiology
- Advice on Dx, when to seek help etc
- Meds
- Procedural (surgical) interventions
17
Q
which drug classes are used in angina management?
A
- short acting nitrites (GTN)
- BB
- CCB
- long acting nitrites (isosorbide mononitrate)
18
Q
what are the 2 surgical interventions for angina treatment?
A
- PCI (stent)
- CABG
19
Q
who gets offered surgical interventions in angina management?
A
those with severe stenosis seen on CT coronary angiography
20
Q
which 2 surgical scars does CABG leave?
A
- midline sternotomy scar
- scar over great saphenous vein on leg
21
Q
what does the left coronary artery divide into?
A
- circumflex
- left anterior descending (LAD)
22
Q
which areas of the heart does the circumflex artery supply?
A
- LA
- posterior of LV
23
Q
which areas of the heart does the LAD artery supply?
A
- anterior of LV
- anterior of septum
24
Q
which areas of the heart does the right coronary artery (RCA) supply?
A
- RA
- RV
- inferior of LV
- posterior of septum
25
what are the 3 types of acute coronary syndrome (ACS)?
- unstable angina
- STEMI
- NSTEMI
26
what are the diagnostic criteria on ECG for a STEMI?
either of these:
- ST elevation
- new LBBB
27
if there is no ST elevation on ECG, what is the next investigation for ACS? what would this show?
- troponin blood tests
- raised trops + other ECG signs = NSTEMI
- normal trops + normal ECG = UA / other cause of chest pain
28
1st line investigation in suspected ACS?
ECG
29
ECG changes in NSTEMI?
- ST depression
- T wave inversion
- pathological Q waves
30
symptoms other than chest pain in ACS?
- N+V
- sweaty, clammy
- sense of impending doom
- SOB
- palpitations
- jaw / arm pain
31
other than ECG and troponins, which other investigations could you do in suspected ACS? what would they show?
- CXR (?pulmonary oedema)
- echocardiogram (shows damage in heart)
- CT coronary angiogram (?CAD)
32
what can be offered if someone presents \<2h following a STEMI?
primary PCI
33
what can be offered if someone presents 2-12h following a STEMI? which medications are used here?
- thrombolysis
- streptokinase, alteplase, tenecteplase
34
BATMAN: medical management of NSTEMI?
- BB
- Aspirin 300mg stat
- Ticagrelor 180mg (or clopidogrel 300mg - ^ bleeding risk)
- Morphine
- Anticoagculant (fondaparinux - LMWH) (unless high bleeding risk)
- Nitrates (GTN)
+ Ox if sats are dropping (\<95%)
35
what is the GRACE score?
6 month risk of death / repeat MI in patients who have had an NSTEMI
36
what GRACE score would qualify for PCI?
\>5%
37
complications of MI?
D – Death (cardiac arrest)
R – Rupture of the heart septum or papillary muscles
E – “Edema” (Heart Failure)
A – Arrhythmia and Aneurysm
(VF or VT; AV block ,especially after inferior MI)
( LV aneurysm; )
D – Dressler’s Syndrome
Also
- VSD
- acute mitral regurg
38
what is Dressler's syndrome? when does it occur?
- post-MI inflammation causing pericarditis
- 2-3 weeks after an MI
39
presentation of Dressler's syndrome?
- pleuritic chest pain
- fever (low grade)
- pericardial rub on auscultation
40
what are the ECG changes in Dressler's syndrome?
- global ST elevation
- T wave inversion
41
investigations for Dressler's syndrome?
- ECG
- echocardiogram
- bloods
42
echo findings in Dressler's syndrome?
shows pericardial effusion
43
what is seen on bloods in Dressler's syndrome?
raised CRP and ESR (inflamm markers)
44
management of Dressler's syndrome?
- NSAIDs (aspirin, ibuprofen)
- steroids (prednisolone)
- pericardiocentesis (removes fluid)
45
what does secondary prevention of MI involve?
6As
- Aspirin 75mg OD
- Another antiplatelet e.g. clopidogrel or ticagrelor (12m)
\*\*\*\*\*\*DAPT
- atorvastatin (80mg OD)
- ACE-i (ramipril)
- Atenolol (or another BB)
- Aldosterone antagonist (spironolactone, EPLERENONE) if HF also present
46
how does acute LVF result in oedema?
- LV cannot push all the blood out
- backlog of blood develops in L atrium, pulmonary veins and lungs
- fluid leaks out of engorged veins into lungs
- pulmonary oedema
47
causes of acute LVF?
- iatrogenic (aggressive IV fluids in someone who is frail)
- sepsis
- MI
- arrhythmias
48
how does acute LVF present?
- rapid onset SOB
- worse lying flat + better sitting up
- cough with frothy white / pink sputum
49
what signs and symptoms might be present in acute LVF which indicate the underlying cause?
- chest pain (MI)
- fever (sepsis)
- palpitations (arrhythmias)
50
what are the findings on examination in acute LVF?
- increased RR (tachypnoeic)
- reduced O2 sats
- tachycardia
- 3rd heart sound
- bibasal "wet" crackles on auscultation
- hypotension if severe (cardiogenic shock)
51
what are the additional findings if the patient with acute LVF also has right-sided heart failure?
- raised JVP
- peripheral oedema (ankles, legs, sacrum)
52
investigations for acute LVF?
- ECG (arrhythmia, MI)
- ABG (sats)
- CXR (oedema)
- FBC, UE (infection, renal function)
- BNP (CCF)
- troponin (MI)
- echocardiogram (shows LV function)
53
is BNP sensitive or specific? does this mean it is good for ruling in or ruling out HF?
- sensitive but not specific
- good for ruling OUT HF when negative but can be raised for other causes
54
other than HF, what else can cause a raised BNP?
- tachycardia
- sepsis
- PE
- renal impairment
- COPD
55
what is ejection fraction? what is a normal ejection fraction?
- proportion of blood pumped out of LV with each contraction
- \>50%
56
ABCDE: CXR findings in acute / chronic HF?
- Alveolar oedema (bat wing)
- B lines (Kerley)
- Cardiomegaly (CTR \>0.5)
- Dilated upper lobe vessels
- Effusion (pleural)
57
stop IV SODM: management of acute LVF?
- stop IV fluids
- Sit up
- Oxygenate
- Diuretics (IV furosemide 40mg)
- Monitor fluid input and output
58
presentation of chronic heart failure? (5)
* SOBOE
* cough with frothy white / pink sputum
* * - orthopnoea (SOB lying flat, ask about pillows)
* - PND
* * peripheral oedema
59
how is chronic HF diagnosed? (4)
- clinical exam
Investigations:
- NT-proBNP
- echocardiogram
- ECG
60
what are the causes of chronic HF?
- IHD
- aortic stenosis
- HTN
- AF and other arrhythmias
61
what level of NT-proBNP needs an urgent specialist referral?
\>2000 ng/L
62
ABAL: drug management of chronic HF? hint: 2 diuretics
- ACE-i (ramipril, avoid if valve disease)
- BB (bisoprolol)
- Aldosterone antagonist (spironolactone)
- Loop diuretic (furosemide)
63
other than drugs, what else is there in the management of chronic HF?
- advise and explain the condition
- specialist referral
- surgery if caused by AS or MR
- involve the HF specialist nurse
64
what is cor pulmonale?
RSHF caused by respiratory disease (e.g. COPD)
65
causes of cor pulmonale?
- COPD (commonest)
- PE
- interstitial lung disease
- CF
- primary pulmonary HTN
66
how does cor pulmonale present?
- often asymptomatic!
- SOB(OE)
- peripheral oedema
- syncope
- chest pain
67
what are the findings on examination in cor pulmonale?
- hypoxia
- cyanosis
- raised JVP
- peripheral oedema
- 3rd heart sound
- murmur (if underlying valve disease)
- hepatomegaly (hepatic vein congestion)
68
management of cor pulmonale?
- treat underlying cause
- long term O2 therapy
69
what is normal BP defined as?
\< 120/80
70
ROPE: secondary causes of hypertension?
- Renal disease
- Obesity
- Pregnancy-induced HTN / Pre-eclampsia
- Endocrine (Conns syndrome)
71
complications of HTN?
- IHD
- cerebrovascular accident (stroke / haemorrhage)
- retinopathy
- nephropathy
- HF
72
how is HTN diagnosed?
either:
- several raised clinic readings
- raised 24h ambulatory readings
73
what is classed as stage 1 HTN? clinic and ambulatory readings
- clinic: \>140/90
- ambulatory: \>135/85
74
what is classed as stage 2 HTN? clinic and ambulatory readings
- clinic: \>160/100
- ambulatory: \>150/95
75
ABCD: drugs used in HTN management?
- ACE-i (ramipril) / ARB (candesartan)
- BB (bisoprolol)
- CCB (amlodipine)
- diuretic (thiazide-like, indapamide)
76
what are 1st and 2nd medical treatments for someone \<55 years old and not Black with HTN?
- 1st: ACE-i (ARB if not tolerated)
- 2nd: ACE-i + CCB
77
what are 1st and 2nd medical treatments for someone \>55 years old or Black with HTN?
- 1st: ARB if Black
- 2nd: ACE-i/ARB + CCB
78
what are 3rd and 4th line treatments of HTN? (hint: same for everyone)
- 3rd: ACE-i/ARB + CCB + diuretics
- 4th: ACE-i/ARB + CCB + 2 diuretics
79
what kind of diuretic is spironolactone? how does it work?
- K+ sparing
- blocks aldosterone action
- causes Na+ excretion and K+ reabsorption
80
why is it important to closely monitor UEs on ACE-i and diuretics?
they can all cause hyperkalaemia
81
what is the target BP in diabetics with HTN?
\< 130/80
82
what is the target BP in \<80 year olds with HTN?
\< 140/90
83
what is the target BP in \>80 year olds with HTN?
\< 150/90
84
what is the first line drug treatment for HTN in diabetics?
- CCB for women of child-bearing age
- ACEi + CCB for Black people
- ACE-i for everyone else
85
what is the initial management of HTN (before meds)?
- investigate for causes
- investigate for end organ damage
- advise on lifestyle, salt intake and exercise
86
what causes the first heart sound (S1)?
atrioventricular (tricuspid and mitral) valves closing as the ventricles contract
87
what causes the second heart sound (S2)?
pulmonary and aortic valves closing at the end of ventricular contraction
88
what causes an S3 sound? who is this normal in?
- chordae tendinae being twanged like a guitar string lol
- young people
89
what might an S3 sound indicate in older patients?
heart failure
90
when is S4 heard? what causes it?
- before S1
- always pathological!
- hypertrophic ventricle
91
where is Erb's point? what can be heard here?
- 3rd IC space, L sternal border
- S1 and S2
92
how can you emphasise the mitral stenosis murmur?
roll the patient over onto their L side
93
how can you emphasise the aortic regurgitation murmur?
have the patient sit up, lean forward, exhale and then hold it like that
94
what does mitral stenosis result in?
L atrial hypertrophy (thickening)
95
what does aortic stenosis result in?
L ventricular hypertrophy (thickening)
96
what does mitral regurg result in?
L atrial dilatation (thinning out)
97
what does aortic regurg result in?
L ventricular dilatation (thinning out)
98
describe the pathophysiology of mitral stenosis
- narrowed mitral valve
- makes it difficult for L atrium to push blood into L ventricle
99
main 2 causes of mitral stenosis?
- rheumatic heart disease
- infective endocarditis
100
describe the mitral stenosis murmur
- mid-diastolic
- low-pitched
- rumbling (low velocity in diastole)
101
what might be palpated in mitral stenosis? what causes this?
- a tapping apex beat
- loud S1
102
which 2 conditions are associated with mitral stenosis?
- malar flush
- atrial fibrillation
103
how does mitral stenosis cause malar flush?
- blood gets blacklogged in the pulmonary system
- CO2 rises
- results in vasodilation
104
what is mitral regurgitation?
incompetent mitral valve allowing blood to leak back into the L atrium
105
describe the mitral regurg murmur. where does it radiate it?
- pansystolic
- high-pitched
- whistling (high velocity in systole)
- radiates to L axilla
106
what does mitral regurg result in?
congestive cardiac failure (is there a 3rd heart sound?)
107
causes of mitral regurg? 6
- ageing (valve weakens)
- IHD
- infective endocarditis
- rheumatic heart disease
- papillary muscle infarction
- conn tissue disorders (Ehlers-Danlos, Marfan syndrome)
108
what is the most common valve disease?
aortic stenosis
109
describe the murmur in aortic stenosis. where does it radiate to?
- ejection-systolic
- high-pitched (high velocity in systole)
- crescendo-decrescendo (diff stages of systole)
- radiates to carotids
110
other than a murmur, what are the other signs of aortic stenosis?
- slow rising pulse
- narrow pulse pressure
- exertional syncope
111
causes of aortic stenosis?
- age-related calcification
- rheumatic heart disease
112
describe the murmur in aortic regurg
- early diastolic
- soft
113
what kind of pulse is aortic regurg associated with?
collapsing pulse at carotids
114
what is an Austin-Flint murmur? which valve disease can cause this?
- early diastolic
- rumbling
- heard at the apex
- aortic regurg can cause this
115
describe the scar seen on patients who have had a mitral / aortic valve replacement
midline sternotomy scar (same as the CABG scar)
116
what is the surgical management for severe aortic stenosis? do they need to be on warfarin afterwards?
- transcatheter aortic valve implantation (TAVI)
- no, this valve is bioprosthetic
117
what is the most common complication following valve replacement?
infective endocarditis
118
which 3 gram +ve cocci can cause infective endocarditis?
- staphylococcus
- streptococcus
- enterococcus
119
explain the pathophysiology of AF
- disorganised electrical activity overriding signals from the SAN
- causes irregular atrial and ventricular contractions
120
signs on examination of AF?
- irregularly irregular pulse
- tachycardia
- HF (due to poor filling in diastole)
121
what is the major complication caused by AF? how could this happen?
- embolic (ischaemic) stroke
- blood pools in the atria and clots
- the clots can then break off and travel to the cerebral arteries
122
how might AF present?
- asymptomatic, incidental finding
- palpitations
- SOB
- dizziness / syncope
- symptoms of underlying pathology, e.g. thyrotoxicosis / sepsis signs
123
what are the 2 differentials for an irregularly irregular pulse?
- AF
- ventricular ectopic beats
124
ECG findings in AF?
- absent P waves
- narrow QRS complex tachycardia
- irregularly irregular ventricular rhythm
125
when is AF classed as "valvular"?
when the pt also has either:
- severe mitral stenosis
- a mechanical heart valve
126
when is AF classed as "non-valvular"?
when the pt also has either:
- no underlying valve disease
- a valve disease which is NOT mitral stenosis
127
SMITH: commonest causes of AF?
- Sepsis
- Mitral stenosis / regurgitation
- IHD
- Thyrotoxicosis
- HTN
others:
- DM
- obesity
- HF
- cardiomyopathies
128
what are the 3 main categories of treatment in AF?
- rate control
- rhythm control
- anticoagulation (to prevent stroke)
129
what is the aim of rate control in AF management?
to get the HR below 100bpm so the ventricles can fill properly
130
what are the drug options for rate control?
- BB (atenolol)
- CCB (diltiazem), avoid in HF
- digoxin, only in sedentary patients
131
in which groups of AF patients can rhythm control be offered?
- reversible cause
- new onset AF \<48h
- AF is causing HF
- symptomatic despite rate control
132
what is the aim of rhythm control in AF? what does it involve?
- to produce normal sinus rhythm
- cardioversion
133
what are the 2 forms of rhythm control in AF?
- pharmacological cardioversion
- electrical cardioversion
134
when is immediate cardioversion used vs delayed in AF?
- immediate is when AF \<48h onset or they are haemodynamically unstable
- otherwise it is delayed
135
drugs used acutely for pharmacological cardioversion?
- flecanide (1st line)
- amiodarone if structural heart disease
136
drugs used for long term rhythm control?
- BBs
- dronedarone
- amiodarone
137
what is paroxysmal AF?
- AF which comes and goes in episodes
- not lasting longer than 48h
138
management of paroxysmal AF? when is this drug avoided? why?
- anticoagulated if CHADVASc score is \>1
- "pill in the pocket" approach with flecanide
- avoided in atrial flutter due to risk of tachycardia
139
where is blood most likely to clot in AF?
the atrial appendage
140
without anticoagulation, what is the risk of stroke in AF?
5%
141
with anticoagulation, what is the risk of stroke in AF?
1-2%
142
what is the HASBLED score?
risk of having a bleed whilst on an anticoagulant
143
what is the target INR range in AF?
2-3
144
which foods / drinks affect INR?
- leafy green veg (contain vit K)
- cranberry juice
- alcohol
145
what is the half-life of warfarin? how is an OD reversed?
- 1-3 days
- vitamin K
146
give 3 examples of DOACs
- apixaban
- dabigatran
- rivaroxaban
147
advantages of DOACs over warfarin?
- no monitoring
- no major interactions
- better at preventing strokes
- lower risk of bleeding
148
what does CHA2DS2-VASc stand for?
- Congestive HF
- HTN
- Age \>75 (2)
- Diabetes
- Stroke / TIA Hx (2)
- Vascular disease
- Age 65-74
- Sex is female
149
at which CHA2DS2-VASc score do you consider anticoag? when do you offer it?
- 1 to consider
- \>1 to offer
150
what does HASBLED stand for?
- HTN
- Abnormal renal / liver function
- Stroke
- Bleeding
- Labile INRs on warfarin
- Elderly
- Drugs or alcohol
151
what are the four possible rhythms in cardiac arrest?
- ventricular tachycardia (VT)
- ventricular fibrillation (VF)
- pulseless electrical activity (PEA)
- asystole
152
which 2 cardiac arrest rhythms are "shockable"?
- VT
- VF
153
which 2 cardiac arrest rhythms are "non-shockable"? what does this mean?
- PEA
- asystole
- defibrillation will not work
154
management of tachycardia in an unstable patient?
- up to 3 synchronised DC shocks
- amiodarone infusion
155
pathophysiology of atrial flutter?
- re-entrant rhythm
- electrical signals stuck in self-perpetuating loop
156
what is the ECG finding in atrial flutter? what causes it?
- sawtooth appearance
- P wave after P wave with no ventricular activity in between
157
which conditions are associated with atrial flutter?
- HTN
- IHD
- cardiomyopathy
- thyrotoxicosis
158
management of atrial flutter?
- similar to AF
- rate / rhythm control
- treat any reversible underlying condition (e.g. HTN, thyrotoxicosis)
- radiofrequency ablation of re-entrant rhythm
- anticoagulate if CHA2DS2-VASc score \>1
159
what causes supraventricular tachycardia (SVT)?
electrical signal re-entering atria from the ventricles
160
is SVT narrow or broad complex?
- narrow QRS complex
- QRS \<0.12
161
what are the 3 types of SVT? how are they classified?
- AV nodal re-entrant tachycardia
- AV re-entrant tachycardia
- atrial tachycardia
- based on the re-entry point for the electrical signal
162
what is Wolff-Parkinson-White syndrome?
atrioventricular re-entrant tachycardia (a type of SVT)
163
management of stable patients with an SVT?
- continuous ECG monitoring
- valsalva manoeuvre
- carotid sinus massage
- adenosine (alt: verapamil)
- DC cardioversion
164
how does adenosine work?
- interrupts accessory pathway in SVT
- slows conduction and HR
165
what might immediately happen after adenosine administration?
- bradycardia or asystole
- should fix itself very quickly
166
what should patients be warned about before giving adenosine?
feeling of impending doom on injection
167
where is adenosine contraindicated?
- asthma or COPD
- HF
- heart block
- severe hypotension
168
definitive treatment of WPW syndrome?
radiofrequency ablation of accessory pathway
169
ECG changes seen in WPW syndrome?
- short PR interval (\<0.12)
- wide QRS complex (\>0.12)
- delta wave (upstroke on QRS complex)
170
how is catheter ablation carried out?
- catheter inserted into femoral vein under X-ray guidance
- fed through to the heart
- once abnormal area is found, radiofrequency ablation (heat) applied
171
which conditions can be cured with radiofrequency ablation?
- AF
- atrial flutter
- SVTs
- WPW syndrome
172
what is torsades de pointes?
- "twisting of tips"
- polymorphic ventricular tachycardia
- QRS complex is twisting around the baseline
173
causes of prolonged QT interval?
- long QT syndrome (inherited)
- drugs
- electrolyte imbalances
174
drug causes of prolonged QT interval?
- antipsychotics
- citalopram
- flecainide
- sotalol
- amiodarone
- macrolide antibiotics (e.g. clarithromycin)
175
electrolyte disturbance causes of prolonged QT interval?
- hypokalaemia
- hypomagnesaemia
- hypocalcaemia
176
acute management of torsades de pointes?
- correct underlying drug / electrolyte cause
- magnesium infusion
- defibrillation if VT occurs
177
long term management of long QT syndrome?
- avoid drugs which worsen it
- BBs (except sotalol)
- pacemaker / implantable defibrillator
178
what are ventricular ectopic beats? what causes these?
- premature ventricular beats
- due to random electrical discharge from outside the atria
179
how might ventricular ectopics present?
random, brief palpitations
180
ECG changes seen in ventricular ectopics?
- absent P waves
- individual random broad QRS complexes
- otherwise normal
181
what is bigeminy?
when ventricular ectopic beats occur regularly after every sinus beat
182
management of ventricular ectopics?
- check bloods for anaemia / thyroid / electrolyte disturbances
- reassure healthy people
- seek expert advice if underlying heart conditions
183
what is first degree heart block? how does it look on an ECG?
- delayed conduction through the AVN
- long PR interval \>0.20 secs (1 big square)
184
what is second degree heart block? what are the 3 types?
- some of the atrial impulses don't make it to the ventricles
- Mobitz type 1
- Mobitz type 2
- 2:1 block
185
what is the other name for Mobitz type 1 block? how does it look on an ECG?
- Wenckebach's phenomenon
- increasing PR interval until a QRS complex is dropped, then PR interval returns to normal, then repeats
186
how does Mobitz type 2 block look on ECG?
- a set ratio of P waves to QRS complexes
- e.g. 3 P waves then a QRS complex is 3:1
187
what is the main risk associated with Mobitz type 2?
asystole
188
how does 2:1 block look on ECG?
2 P waves then 1 QRS complex
189
management of heart block in an unstable patient / risk of asystole?
- atropine 500mcg IV
- 2nd line is to repeat this up to 6 times
- then noradrenalin
- transcutaneous cardiac pacing with a defibrillator
190
management of heart block where there is HIGH risk of asystole?
- temporary transvenous cardiac pacing
- permanent implantable pacemaker
191
what class of drug is atropine? common side effects?
- antimuscarinic
- dilated pupils
- urinary retention
- dry eyes
- constipation
192
risk factors for asystole?
- Mobitz type 2
- third degree (complete) heart block
- previous asystole
193
what is third degree heart block?
- complete block
- no association between P waves and QRS complexes
194
how long do the batteries in a pacemaker last?
5 years
195
indications for a pacemaker?
- symptomatic bradycardia
- Mobitz type 2 block
- third degree block
- severe HF
- HOCM
196
what is cardiac tamponade?
heart gets compressed by excess fluid in pericardium
197
main complication of cardiac tamponade?
cardiac arrest
198
causes of cardiac tamponade?
- traumatic injury to chest
- pericarditis
- cancer
- iatrogenic (post-surgery)
199
what is becks triad? where is it seen?
- hypotension
- muffled heart sounds
- distended jugular veins
- seen in cardiac tamponade
200
presentation of cardiac tamponade?
- becks triad
- tachycardia
- SOB
- chest pain
- pulsus paradoxus
201
investigation for cardiac tamponade?
bedside USS (called FAST)
202
management of cardiac tamponade?
- pericardiocentesis
- surgery to make a pericardial window
- pericardiectomy
203
what is cardiomyopathy?
any heart muscle disorder without another obvious heart deformity
204
3 main types of cardiomyopathy?
- dilated
- hypertrophic
- restrictive
205
most common cause of unexpected death in children?
hypertrophic cardiomyopathy
206
causes of cardiomyopathy?
- idiopathic (primary)
- connective tissue disorders
- endocrine
- drugs
- infection
- nutrition
- genetic (e.g. DMD)
207
which connective tissue disorders can cause cardiomyopathy?
- sarcoidosis
- SLE
208
which endocrine disorders can cause cardiomyopathy?
- DM
- thyroid disease
- acromegaly
209
drug causes of cardiomyopathy?
- chemo
- cocaine
- alcohol
210
nutritional causes of cardiomyopathy?
- obesity
- B1 def
- Ca def
- Mg def
211
commonest type of cardiomyopathy?
dilated cardiomyopathy (DCM)
212
describe the ventricles in DCM
- larger in size
- normal wall thickness
213
which demographics are more affected by cardiomyopathy?
Black men aged 20-60
214
presentation of DCM? hint: think HF
- SOBOE
- fatigue
- peripheral oedema
- raised JVP (if RV affected)
- loud S3 and S4
- arrhythmia (e.g. AF, AVNB)
215
infective causes of DCM?
- bacterial
- HIV
- coxsackie viruses
- viral myocarditis
216
investigations in DCM?
- ECG
- CXR
- echo
- cardiac muscle biopsy (rare)
217
changes seen on ECG in DCM?
- sinus tachycardia
- T-wave inversion and Q-waves (even without Hx of MI)
- ST depression
- LBBB
218
changes seen on CXR in DCM?
signs of HF (ABCDE)
219
changes seen on echo in DCM?
dilated, hypokinetic chambers
220
management of DCM?
- treat underlying cause
- start anticoag (warfarin or NOAC)
- treat any arrhythmia
- consider pacemaker if AVNB
- treat HF
- consider ICD
- consider transplant
221
in the context of cardiomyopathy treatment, what's an ICD? when is it used?
- implantable cardioverter defibrillator
- if high risk of arrhythmia
222
prognosis in DCM?
- extremely poor
- 30% survive 5 years past diagnosis
223
markers of worse prognosis in DCM?
- being peripartum
- thin ventricular wall
- ventricles markedly dilated
224
inheritance pattern for hypertrophic cardiomyopathy (HCM)?
autosomal dominant
225
what is the effect of HCM on heart function?
diastolic dysfunction +/- outflow obstruction
226
which chamber is affected in HCM?
LV
227
presentation of HCM?
- mostly asymptomatic
- SOB
- chest pain
- syncope, especially after exercise
- palpitations
- sudden death
228
what causes sudden death in HCM? hint: 2 ways
- arrhythmia
- outflow tract obstruction
229
top differential for unexplained syncope in athlete?
hypertrophic cardiomyopathy (HCM)
230
signs O/E in HCM?
- forceful apex beat
- late ejection systolic murmur, does not radiate
- abnormal rise in BP in response to exercise
- signs of AF (20%)
231
nature of murmur in HCM?
- late ejection systolic
- no radiation
- best heard at L sternal edge, 3-4th IC space
- reduced on squatting
232
diagnostic investigation for HCM? findings?
- echocardiogram
- asymmetrical septal hypertrophy \>15mm
- non-dilated LV space
- thickened LV wall
233
investigations for HCM?
- ECG
- echo
- CXR
- cardiac MRI
234
management of HCM?
- control arrhythmia, consider ablation
- anticoag if AF
- BBs
- verapamil
- avoid ACEi, ARBs, nitrites and diuretics (opp to DCM)
- ICD if high risk sudden death
- consider transplant
235
why do a lot of HF drugs need to be avoided in HCM?
they decrease chamber size by decreasing preload, making symptoms worse
236
main complication in HCM?
sudden death
237
risk factors for sudden death in HCM?
- unexplained syncope episodes
- VF / VT episodes
- abnormal rise in BP in exercise
- FHx sudden death
- age \<30
238
how can sudden death be prevented?
implantable cardioverter defibrillator (ICD)
239
describe restrictive cardiomyopathy (RCM)
reduced compliance of ventricular walls in diastolic filling
240
how can RCM be categorised?
- some are caused by invasion of myocardium
- others aren't
241
what could invade the myocardium and cause RCM?
- amyloid plaques
- sarcoidosis
- iron, in haemachromatosis
242
which chamber is most commonly affected in RCM?
LV
243
main risk factors for RCM?
- old age
- PMH: amyloidosis, sarcoidosis, haemochromatosis
244
presentation of RCM?
- signs of heart failure (incl on CXR)
- signs of RV failure maybe
- AF in 75% cases
- other arrhythmias
245
investigations for RCM?
- ECG
- CXR
- echo
246
management of RCM?
- treat underlying cause
- avoid certain drugs
- heart transplant
247
which drugs should be avoided in RCM management? why?
- diuretics, reduce preload
- digoxin, amyloidosis patients are very sensitive to this
- nitrites, can cause HTN
248
differentials for cardiomyopathy?
- IHD
- mitral / aortic valve disease
- pericarditis
- pulmonary stenosis
- VSD
249
pathophysiology of aortic dissection?
tear in tunica intima layer of aortic wall, causing blood to leak out
250
main risk factor for aortic dissection?
HTN
251
which conditions are associated with aortic dissection?
- HTN
- trauma
- bicuspid aortic valve
- syndromes (marfan's, ehlers-danlos, turner's, noonan's)
- pregnancy
- syphilis
252
presentation of aortic dissection?
- tearing, severe chest pain
- radiates to back
- weak / absent peripheral pulses
- difference in BP between arms
- limb ischamia if distal aorta affected
- paraplegia if spinal arteries affected
253
management of acute bradycardia?
- 500 micrograms of atropine IV
- repeat every 3-5 mins
- max dose 3mg
254
what is levine's sign? what does it indicate?
- curling a fist over chest
- ischaemic chest pain
255
differentials for pleuritic chest pain?
- pulmonary embolism
- aortic dissection
256
ECG changes seen in pericarditis?
- global ST elevation (saddle-shaped slope)
- PR depression
257
what are the big 5 risk factors to ask about in a cardiac history?
- Smoking
- HTN
- DM
- hypercholesterolaemia
- FH
258
signs O/E of acute heart failure?
- raised JVP
- peripheral oedema
- crackles bibasally
259
causes of aortic regurgitation?
- age-related weakening of the valve
- aortic dissection
260
features of aortic regurgitation?
- difference in BP between arms
- absence of peripheral pulses
- delayed peripheral pulses
- severe pain, not relieved by opiates
261
what might be picked up on FBC in chest pain?
- anaemia
- infection (?pneumonia)
262
which bloods get done for chest pain patients?
- FBC
- UEs
- clotting screen
- troponin
- D dimer
- cholesterol
- glucose, HbA1c
263
criteria for a primary PCI?
either 1 of the following:
- ST elevation \>2mm in 2 contiguous chest leads
- \>1mm in 2 contiguous limb leads
- new LBBB
264
adverse effect of giving morphine following MI? what should be co-prescribed?
- delays absorption of antiplatelets (e.g. clopidogrel)
- metoclopramide
265
trend in troponin after an MI?
- rises rapidly
- falls over following days
266
if initial troponins raised (positive), when should they be repeated?
in 3 hours
267
in which scenario does a negative troponin NOT rule out MI?
chest pain with onset \<6 hours ago
268
non-ACS causes of MI?
- major haemorrhage
- pneumonia
- PE
269
what is the HEART score?
a score to determine management of chest pain
270
what are the components of the HEART score?
- History
- ECG
- Age
- Risk factors
- Troponin
271
how is the HEART score interpreted?
- 0-3 = discharge
- 4-6 = observe
- 7-10 = treatment
272
RFs for infective endocarditis?
- strongest one is past episode of IE
- rheumatic valve disease
- prosthetic valves
- congenital heart disease
- IVDU
- recent piercings
273
which valve does the vegetation grow on in an IVDU with IE?
- tricuspid
- this is the first valve it hits on the way back to the heart (venous system)
274
scoring criteria used to diagnose infective endocarditis?
modified duke's criteria
275
what modified duke's criteria scores indicate infective endocarditis?
any of the following:
- pathological criteria positive
- 2 major criteria
- 1 major + 3 minor criteria
- 5 minor criteria
276
describe the pathological criteria (modified duke's) of infective endocarditis
the pathological organisms found on histology / microbiology of the biopsied valve tissue
277
give some examples of major criteria (modified duke's) in infective endocarditis
- 2 +ve blood cultures
- persistent bacteraemia on bloods
- echo showing endocardial enlargement
- new valvular regurg
278
give some examples of minor criteria (modified duke's) in infective endocarditis
- predisposing heart condition
- IVDU
- fever \>38C
- vascular phenomena
- immunological phenomena
279
what vascular phenomena are seen in infective endocarditis?
- major emboli
- splenomegaly
- clubbing
- splinter haemorrhages
- janeway lesions
- petechiae / purpura
280
what immunological phenomena are seen in infective endocarditis?
- glomerulonephritis
- osler's nodes
- roth spots
281
poor prognostic factors in infective endocarditis?
- staph aureus infection (30% mortality!)
- prosthetic valve
- culture -ve endocarditis
- low complement levels
282
initial ABx of choice for infective endocarditis?
- if native valve: amoxicillin + low-dose gentamicin (vancomycin if pen allergic)
- if prosthetic valve: vancomycin + rifampicin + low-dose gentamicin
283
indications for surgery in infective endocarditis?
- severe valvular incompetence
- aortic abscess (lengthening PR interval on ECG)
- ABx resistant infections
- HF resistant to treatment
- recurrent emboli after ABx
