Cardiology Flashcards
When are statins used in primary prevention and at what dose?
Atorvastatin 20mg is used if Q-Risk score is over >10
When are statins used in secondary prevention and at what dose?
Atorvastatin 80mg is used in known cause of IHD Peripheral vascular disease etc
What is first line in Chronic Heart Failure?
ACEi/ARB + beta blocker
What is second line in chronic HF with a reduced ejection fraction?
Spirinolactone
What drug is used in Chronic Heart Failure 3rd line if there is a LVF of <35
Ivabridine
What is used third line in Chronic Heart Failure if there is concurrent AF?
Digoxin
What are strongly recommended in Chronic HF if they are Afro Caribbean ?
Hydralazine + Nitrates
What vaccinations are given to patients with HF
Yearly influenza
Pneumococcus every five years
What is the management of an NSTEMI if PCI isn’t indicated?
Aspirin + Ticagrelor or Clopidogrel
Fondaparinux
When is Ticragrelor used in NSTEMI?
If low bleed risk.
If not on anticoagulation
When is Clopidogrel used in NSTEMI?
If patient is at a high risk of bleeding
If a patient has a STEMI and is indicated for PCI what is the medical management?
Aspririn + Prasugrel + Fibroparinux
In STEMI when is Clopidogrel used in favour of Prasugrel?
In a high bleed risk patient
In a STEMI managed with fibrinolysis what should be given alongside it?
Antithrombin
Ticagrelor afterward
Post Fibrinolysis what investigation should be undertaken?
ECG after 60-90 minutes
If positive changes still consider PCI
What is the dosing of Adenosine used in SVT
6mg bolus -> 12mg bolus -> 18mg bolus
If you suspect a MI due to Cocaine use how do you manage this?
IV BDZ
Nitrates for the pain
What is the first line imaging in an aortic dissection?
CT angiography
If a patient with a query aortic dissection is acutely unstable what is the imaging of choice?
Trans Oesophageal Echocardiogram
What are some indications for urgent valvular repair in infective endocarditis?
Pregnant Congestive Heart Failure Overwhelming sepsis despite Abx Recurrent Emboli Abscess or Fistulae
Do you treat a >80 patient with stage one hypertension?
135-150 mmHg
No
How long after a stroke is anticoagulation prescribed and what is used first line? In the context of AF + Stroke
Wait 2 weeks. DOACs are used
Contraindicated in haemorrhagic or signs of bleeds
. A patient is found to be in AF. On subsequent investigation he is found to have valvular disease. What medication is first line?
Also applies in context of stroke.
Warfarin
Is LBBB always pathological?
Yes
MI Hypetension Aortic Sternosis, Cardiomyopathy, Digoxin toxicity
If someone has had persistent AF for over 48 hours what is their management?
Three weeks anticoagulation using DOAC before Electrocardioversion
New 1st degree heart block on the background of an Acute MI what artery is likely to have been affected?
Right Coronary Artery -
What is the criteria for surgical management of Aortic Stenosis?
Symptomatic
Gradient >40mmHg
What is the first line investigation in Acute Pericarditis - ECG is done routine.
Transoesophageal Echo
A new hypertensive presents with a Urinary Albumin : Creatine ratio of >30mg. What is their management?
ACEi - indicated in CKD with >30mg UAC
Post Electrical Cardioversion how long should someone at low risk for Stroke or TIA be on anticoagulation for?
4 weeks post cardio version
Post Electrical Cardioversion how long should someone at high risk for Stroke or TIA be on anticoagulation for?
Life long
What is used first line in Bradychardia + Shock
Atropine 500mcg
If Atropine alone isn’t increasing the heart rate what can be used?
Up to 3mg of Atropine can be used
Transcutaneous pacing
Adrenaline Infusion
What are some indications someone presenting with bradycardia may require further specialist input and transvenous pacing?
Complete Heart Block
Recent Asystole
Mobitz Type II
Ventricular tase of >3 seconds
Management of a DVT if CKD eGFR >15
DOAC
Management of a DVT if eGFR <15
Unfractionated or LMWH Heparin
When is a carotid endarterectomy undertaken in an asymptomatic patient?
If >70% of the vessel is occluded.
When is a endarterectomy undertaken in a symptomatic patient?
If >50% of the carotid artery is occluded
What medication is used in all Acute Heart Failure?
IV Furosemide and O2 if indicated
What medication for chronic HF can be continued into an acute episode?
Beta Blocker - unless <50bpm or signs of shock
ACEi
In cardiogenic shock with a systolic of <85 mmHg what is the treatment?
Ionotropes - Dobutamine
Vasopressors - Norepeniphrine - if signs of end organ damage
Mechanical Circulatory aids
If there are signs of respiratory failure what is indicated in Acute Heart Failure?
CPAP
When are nitrates used in Acute Heart Failure?
Sever hypertension
Mitral or aortic valve issues
Signs of myocardial ischaemia
When is synchronised DC cardio version and sedation used?
In SVT
When is unsynchronised DC used?
VT or VF
In someone with stable Toursade De Pointes what is the management?
IV magnesium sulphate
2g over 1 hour
Stop offending agent at correct electrolyte imbalance
In someone with unstable Toursades De Pointes what is the management?
Unsynchronised CardioVersion and IV amiodarone
What is the first stage of NSTEMI management
Aspirin + Fondaparinux + Calculate GRACE mortality score
In an NSTEMI if someone has a low GRACE mortality score what is next?
Ticagrelor
In an NSTEMI with a high GRACE score what is next ?
PCI if unstable
Stable - wait 72 hours for PCI give Prasugrel or Ticagrelor
Management of Heart Failure with preserved ejection fraction and fluid overload
ACEi
Loop diuretics
Lifestyle
Causes of high output cardiac failure
Pregnacy Pagets Anaemia AV malformation thyrotoxicosis Thymoma
Inferior ST elevation on ECG + New onset Aortic Regurgitation
Proximal Aortic dissection
What is a high GRACE score indicating PCI for NSTEMI?
> 3%
What is 1st line in secondary prevention of an MI?
ACEi
Beta Blockers
Statin
Dual Antiplatelet therapy
If someone post MI presents with a reduced LVF or ejection fraction what can be added ?
Eplerinone - aldosterone antagonist
If someone has had an ACS alone what dual antiplatelet therapy is recommended?
Ticagrelor + Aspirin
Stop Ticagrelor after 12 month
If someone underwent PCI for an ACS what dual antiplatelet is used?
Prasugrel/ Ticagrelor + Aspirin
Stop P/T after 12 months
When is the duration of dual antiplatelet therapy altered?
If at an increased CDV risk or increased haemorrhage risk
How long post MI - general advice
Sexual activities start after 4 weeks
Sildenafil after 6 months
Pericarditis vs Dresslers syndrome - MI
Pericarditis occurs days after MI
Dresslers - Autoimmune antibody mediated pericarditis like syndrome
Young male smoker with hyper cellular occlusions of lower limbs
Tortuous Corkscrew collaterals on angiography
Buergers Disease
Secondary prevention of Peripheral Vascular Disease
Clopidogrel + Atorvastatin
List congenital cyanotic cardiac abnormalities
Tetralogy of Fallow
Transposition of the great vessels
Tricuspid atresia
What is the commonest cause of cardiac cyanotic disease.
Tetralogy of fallot presents 1-2 month
Transposition of the great vessels is most common in first few days as it presents earlier
Presentation of Tetralogy of Fallot
Ejection systolic murmur
Tet Spells
Boot shaped heart on X-ray
Tetralogy of Fallot
Ventricular Septal defect
Pulmonary Stenosis - dictates severity of the disease
Left Ventricular Hypertrophy
Overriding aorta
Treatment of congenital cardiac cyanotic diseases.
Prostaglandin E1 -> surgery
Patent Ductus Arteriosus
Left subclavicular thrill, continuous machinery murmur, collapsing pulse, heaving apex beat, wide pulse pressure
What is gold standard in the assessment of a diagnosed ACS?
CT coronary angiogram is first line over exercise ECG now
List some indication for stopping Beta Blockers in HF
HR <50
or 2/3 degree heart block
What grading system is used in chronic HF?
NYHA 1 = No symptoms
NYHA 2 = Mild symptoms during exercise causing some limitation. None at rest
NYHA 3 = Moderate symptoms causing marked decrease in exercise tolerance. Comfortable at rest
NYHA 4 = Severe symptoms uncomfortable at rest.
Describe the two types of aortic dissection.
Group A = 2/3rds and occur in the ascending aorta
Group B = Descending aorta
How does the type of aortic dissection affect the management?
Group A - BP reduced to 100-120 then surgery
Group B - conservative with tight BP control and bed rest.
AAA - 3 - 4.4cm on USS
Repeat scan in 12 months
AAA 4.5 - 5.4cm on USS
Repeat in 3 months
AAA >5.5cm on USS
Refer to vascular surgery
If an aneurysm has grown by over 1cm in a year what is the management?
Referral to vascular
In a newly diagnosed LBBB what investigation should be undertaken?
High sensitivity troponin
As likely to represent a new LBBB
If someone has a CHADVAS score of 0 (M) or 1 (F) - meaning they require no anticoagulation. What investigation should they undergo?
Echocardiogram to rule out valvular disease as this is an absolute indication for anticoagulation.
Causes of dilated cardiomyopathy
Alcohol Wet Berri Berri syndrome Pregnancy Idiopathic Doxorubicin
What is a normal PR interval?
120-200ms
At what PR interval could you diagnose First degree Hear Block ?
> 200ms
Sharp stabbing chest pain ST elevation Acute pulmonary oedema Younger patient Recent URTI
Myocarditis
Resolved chest pain
Deeply inverted T waves in V2-3
Wellens syndrome
Critical stenosis of LAD
Modified DUKEs - major and minor criteria
Major - 2 +ve blood cultures, +ve serology, +ve echocardiogram, New valvular regurgitation
Minor ->38, vascular phenomena, glomerulonephritis, oslers nodes, Roth spots
List the common causes of aortic stenosis and what type of stenosis occurs in Williams ad HOCM.
> 65 - calcification
<65 - Bicuspid
Williams - supravalvular stenosis
HOCM - Subvalvular stenosis
In chronic Heart failure what can be used if ACEi/ARB cant be tolerated?
Sacubitin Valsartan
DVT WELLS score >2
DVT likely
USS in 4 hours - +ve = DOAC
- -ve = D-dimer
If USS > 4 hours - DOAC + D- Dimer
- scan -ve but D-dimer +ve = stop DOAC and USS in a week
DVT WELLS score <1 or 1
D-Dimer within 4 hours - if +ve = USS then same as WELLS >2
- if -ve = alternate diagnosis
If D-Dimer will take over 4 hours - DOAC
List BP targets for clinic and ambulatory.
Under 80 - Clinic = <140/90. Ambulatory = 135/85
Over 80 - Clinic = 150/90. Ambulatory = 145/85
How do you investigate someone for arrhythmias?
ECG + Bloods - FBC TFT
Holter monitor
External Loop Recorder
CHADVAS score
Congestive Heart Failure = 1 Hypertension = 1 Age <65 = 0 65-75 = 1 >75=2 Diabetes = 1 Stroke, TIA or VTE = 2 Gender Male = 0 Female =1 Vascular disease history = 1
Anticoagulation in AF
A third heart sound in someone under 30
can be physiological
What can be a cause of a third heart sound?
Diastolic filing of the ventricle
Dilated Cardiomyopathy
Mitral Regurgitation
Constrictive Pericarditis
Left Ventricular failure
Fourth heart sound
Atrial contraction against a stiff ventricle
Aortic stenosis
HOCM
Hypertension
Persistent ST elevation post MI with no chest pain. Usually V1-V4 + shortness of breath.
Ventricular Wall aneurysm - usually left
Requires anticoagulation
What can heart failure trigger in terms of sodium?
Dilutional Hyponatraemia
Poor perfusion of the kidneys causes activation of the renin angiotensin system. Causes increased reabsorption of sodium and water. Water more so than sodium.
Reciprocal ST depression V1-V3
Tall broad R waves
Upright T waves
Posterior STEMI
What kind of Heart Failure does HOCM present with?
Preserved ejection fraction
Intrapartum lithium use
Pan systolic ( tricuspid regurgitation)
Mid diastolic ( tricuspid stenosis)
Right atrial enlargement
Ebsteins anomaly
Fatigue
Pallor
Breathlessness
Soft ejection systolic murmur - doesn’t radiate
Anaemia
Causes a aortic flow murmur
What medication that can be used to terminate SVT is contraindicated in VT?
Verapamil - can cause cardiac arrest
Signs and symptoms of a fat embolism
Tachypnoea Tachychardia Pyrexia
Petechial Rash , subconunctival and oral petechia
Confusion and agitation
Retinal Haemorrhage
LBBB vs RBBB
WilliaM MarroW
V1. V6. V1. V6
Left Right
Late diastolic, low pitch, dyspnoea, orthopnoea
Mitral stenosis
Loud S1, opening snap, low volume pulse, malar flush, haemoptysis
If someone has asymptomatic mitral stenosis how is this managed?
Regular Echocardiogram
Acute Chest Pain management if presenting after
<12 hours ago or current with abnormal ECG - Ambulance Referral
12-72 hours ago - same day referral
>72 hours ago - ECG + troponin the decide
Cardioversion is synced too were on the ECG?
R wave
What is considered long QT?
> 430 in men
>450 in women
Causes of a prolonged QT
Medication - Amiodarone TCA SSRI Citalopram Erythromycin Haloperidol Ondansetron
Electrolytes - Hypokalaemia Hypomagnesia
Conditions - Acute MI, Hypothermia, SAH
Management of congenital Long Qt
Avoid QT prolonging drugs
Beta blockers
Implanted Cardioverter defibrillator
BP target if over 80?
<150/90
Signs linked to aortic regurgitation
Quinckes signs - pulsing fingernail bed De Mussets sign - head bobbing Early diastolic - louder on fist clenching Collapsing pulse Wide pulse pressure
Cardiac tamponade
Electrical alternans on ECG
Pulses paradoxus - inspiration causes a BP drop
Restrictive pericarditis
Kussmauls sign - Increased JVP on inspiration
Anterior MI plus complete heart block - management
External pacing
Posterior MI with new heart block - management
Atropine 500mcg
Triple AAA screening
one scan at 65
if positive then you enter screening programme
Describe and explain what pulmonary artery occlusive pressure is.
Represents preload 8-12 is normal <5 = hypovolaemia <5 + oedema = ARDS >18 = fluid overload
ST elevation
Chest Pain
No changes on Coronary Angiogram
Recent stress
Takotsubo Cardiomyopathy
Treatment is supportive
Risk factors for coarctation of the aorta
Turners
Bicuspid aortic valve
NF
Berry aneurysm
A new onset pan systolic murmur + low grade fever. What are you thinking?
Infective endocarditis
Infective endocarditis - organisms
Staph Aureus = #
Staph Epidermidis = within two months of valve replacement
Step Viridans = Poor dental hygiene + dental procedures
Strep Bovis = linked to colonic cancer
HACEK = Rarer culture negative causes
Valves affected in infective endocarditis
Mitral valve is the commonest
IVDU = Tricuspid valve
New BP >180/120 +
HF AKI End organ damage
Urgent same day referral to a specialist
BP target in type 1 diabetes mellitus
135/85
130/80 if albuminuria
If your patient is afro-carribean with hypertension not controlled by a Ca channel blocker. What medication can be used?
ARB is preferred over an ACEi
Definitive management of wolf Parkinson white syndrome
Ablation of accessory pathway
Right axis deviation = left sided pathway
Left axis deviation = right sided pathway
Brown pigment
Champagne bottle legs (lipidermatosclerosis)
Eczema
Chronic venous insufficiency
QT
Start of Q wave to the end of the T wave
PR interval
Start of P wave to the start of the QRS
Atrial Septa Defect
Pulmonary Ejection systolic murmur
Fixed split 2nd heart sound
Ejection systolic murmur louder on inspiration
Atrial Septal Defect
Diastolic murmur 2nd intercostal space right sternal border
Aortic Regurgitation
Murmurs and Breathing
rIght sided - louder on Inspiration
lEft sided - louder on Expiration
What medication is contraindicated in HOCM
ACEi as reduce preload
If cardiac tamponade has developed secondary to neoplasm what is the managment?
Percutaneous Balloon Pericardiotomy
ECG changes indicating PCI
> 2mm in 2 congruent anterior leads - V1-V6
1mm in 2 congruent inferior leads - II, III, avF, avL
LBBB
Angina management - CABG > PCI
CABG is preferred over PCI for management of angina if
>65
Diabetes
Complex 3 vessel disease
Hypokalaemia
U waves Absent or small T waves Prolonged PR Prolonged Qt ST depression
Varicose Veins Management
Majority conservatively managed - Leg elevation, weight loss, regular exercise, graduated compression stockings
Refer if - pain discomfort or significant swelling, bleeding, past or present ulceration, chronic venous insufficiency.
Varicose Veins management if referred.
Endothermal Ablation
Foam scleropathy
Surgical ligation or stripping
Contraindication to compression stockings
ABPI <0.8
When is aortic regurgitation surgically managed?
If symptomatic
or asymptomatic if LV systolic dysfunction
Management of primary heart block
Non required if asymptomatic
Beta blockers, Ca channel blockers, AV node fibrosis - all cause primary heart block
What marker is elevated in congestive heart failure?
BNP
Someone is in AF for over 48 hours and they are over 65. How are they managed?
Rate control
Beta blocker or calcium channel blocker
How do you differentiate drug induced postural hypotension from Parkinson or diabetic induced postural hypotension?
In drug induced postural hypotension it is accompanied by a reflex tachycardia as the autonomic system is still functioning. Diabetes and Parkinson’s result in autonomic dysfunction so there is no reflex tachycardia.
What is eisenmengers syndrome?
An uncorrected VSD leads to right ventricular hypertrophy. This eventually causes a right to left shunt.
Cyanosis, Clubbing, RVF, haemoptysis, embolism
Heart and lung transplant is required.
Which Mobitz type has a risk of progressing to 3rd degree heart block?
Mobitz II - PR interval is fixed and every nth P wave is dropped
- also carries risk of severe bradycardia and haemodynamic instability
Where is aortic regurgitation best heard?
Left lower sternal edge 3rd ICS
Management of superficial thrombophlebitis
USS to exclude DVT
Exclude arterial disease -> Compression stockings
NSAIDs - consider LMWH
Left circumflex ECG territory
avL I +/- V5/V6
Imaging in infective endocarditis
1st line = Transthorasic echo
Most sensitive = trans oesophageal echo
PR interval prolongation + infective endocarditis
Aortic root abscess -> surgery
Management of buergers disease
Stop smoking + nifedipine
Broad QRS
> 120ms or 0.12 seconds
Younger patient
Palpitations - heart stops then beats rapidly
Multiple episodes
No adverse affects
Supraventricular Premature Beat
What investigation should be considered in a unprovoked DVT?
CT chest abdo and pelvis - to rule out malignancy
Maintenance fluids in cardiac disease.
20-25ml/kg
1st line superficial thrombophlebitis
NSAID
