Cardiology Flashcards
What criteria does NICE have for diagnosing ACS? (1+5)
Rise in troponin >99th percentile and subsequent fall +
1. Symps of ischaemia
2. New ST/T wave changes or LBBB
3. Pathological Q waves
4. Echo showing RWMA
5. Thrombus on angiogram
What risk score does NICE recommend for 6 month risk stratification and what are the levels (5 levels)
GRACE score
1. Lowest <1.5%
2. Low 1.5-3.0%
3. Intermediate 3-6%
4. High 6-9%
5 Highest >9%
Who does NICE state should have and angiogram <72 hours?
NSTEMI or unstable angina and GRACE score intermediate or higher
Which NSTEMI/unstable angina patients does NICE recommend angio < 24hours? (4)
Unstable patients, should have angio <24hours from becoming unstable
Unstable=
1. Ongoing CP despite optimum tx
2. Haemodynamic instability
3. Dynamic ECG change
4. LVF
When do NICE say an angiogram should be performed following a STEMI?
< 12 hours or <120 mins of when fibrinolysis could have been given
What drug therapy does NICE recommend if undergoing medical management only of STEMI (3)
- Aspirin
- Ticagrelor (clopidogrel or only aspirin if increased bleeding risk)
- LMWH
What drug therapy dose NICE recommend in a STEMI going to cath lab?
- Aspirin
- Prasugrel (if on anticoagulant then clopidogrel)
- UFH
What does NICE recommend for STEMI being thrombolysed?
- Aspirin
- LMWH/UFH at same time as:
- Fibronlysis
- Ticagrelor (unless increased bleeding risk, then clopidogrel)
- ECG 60-90mins later and if not improved transfer PCI
What treatment does NICE recommend for NSTEMI?
- Aspirin
- LMWH (unless cath lab)
- Ticagrelor unless high bleeding risk then clopidogrel or cath lab (prasugrel)
- GRACE risk score then decide angiogram < 72 hours or considering ischaemia testing (low risk = <3%)
What does ESC define as STEMI in men?
> 40 years old = 2mm or greater STE in 2 contiguous leads
<40 years old = 2.5mm or greater STE in 2 contiguous leads
What does ESC define as a STEMI in women?
1.5mm or greater STE in V1-3 or
1mm or greater STE in any other lead
What does ESC define as a ECG diagnosis of posterior MI?
> 0.5mm ST depression in V1-3
+
0.5mm STE V5-7
What are Scarbossa’s Criteria and which bits are the most and least sensitve?
- Concordant STE >1mm in 1 or more leads (most sensitive) (5 points)
- Concordant ST depression >1mm V1-3 (3 points)
- Discordant ST elevation >5mm (2 points)
3 or more needed
What are the signs on an ECG of RV infarct? (2)
STE VI suggest RV involvemnet
STE V4R highly specific
What part type of MI is right ventricular infarct usually a part of?
What is managed differently about RV infarct?
Inferior
Very pre-load sensitive, may need fluid and nitrates can lead to hypotension
Has dose NICE recommend for invx of stable angina if you have no known CAD?
CT coronary angiography
What dose NICE define as significant CAD on CT angiography?
> 50% stenosis in left main coronary
70% stenosis in any other artery
What does NICE recommend first line invx for stable angina if there is a hx of CAD?
Non invasive functional testing
What defines a pathological Q wave? (4)
- > 40ms (1mm) wide
- > 2mm deep
- > 25% depth QRS
- any in V1-3
What biomarkers to does recommend to rule out CCF? (2)
- BNP
- NT-proBNP
What does NICE recommend first line for acute decompensated CCF?
IV diuretics (1-2 x daily dose IV)
What does NICE recommend for CCF with
1. increased resp effot?
2. Diuretic resistent?
- NIV
- Haemofiltration
What treatments does NICE recommend commencing people on when their acute HF has been stabilised? (3)
- Beta-blocker once stable >48hours
- Ace inhib/ARB
- Spironalactone and eplerenone if decreased EF
How dose ESC recommend managed isolated RV failure? (3)
- Ionotropes and vasopressors (never vasopressor without ionotropes
- RRT
- RVAD
Causes of acute heart failure:
CHAMPIT
C - acute Coronary Syndrome
H - ypertensive emergency
A - rrhythmia
M - echanical cause
P - E
I - infections (myocarditis)
T - amponade
What does ESC say about opitates in acute heart failure?
Avoid - shown to increase intubation and length of stay
What increases the risk of sudden cardiac death in LVF and what might be used to prevent this?
- EF - decreased EF increases risk of ventricular arrhythmia
- ICD
What are the types of ICD and what can they do?
- Single chamber - 1 x defib lead in RV
- Dual chamber - right atrial pacing lead and RV lead
- Both can pace if brady and cardiovert
What leads does a CRT device have and what does it stand for?
- RV defib
- LV pacing
- Cardiac resynchronisation therapy
Describe how CRT works
As CCF progresses electrical remodeling occurs and QRS can increase. Interventricular dys-synchrony occurs and decreases cardiac contractility performance. CRT decreases this and can help with ventricular remodeling
What are the criteria for CRT? (3)
- EF < 35%
+ - QRS >150ms
or - LBBB
What does NICE recommend calculate stroke risk and bleeding risk in AF?
- CHADVASC
- ORBIT
What are the NICE recommended CHADSSVASC scores to trigger anticoagulation? (3)
1 >65 = 1 or more men, 2 or more women
2. <65 then 0 for men or 1 for women
What makes up the CHADSSVASC score? (7)`
C - HF hx (1)
H - TN hx (1)
A - age (1 - 65-74, 2 >75)
D - iabetes (1)
S - ex (female - 1, men - 0)
S - stroke/TIA/VTE hx - 2
VASC - hx (1)
What anticoagulation does NICE recommend for chronic AF ? (4)
RADE
Rixoroxaban
Apixiban
Dabigatran
Edoxaban
What are first line agents to rate control AF according to NICE? (3)
- Beta blocker
- CCB
- Digoxin if very sedentary
What does NICE recommend if 1st line treatment not managing rate for AF?
Add second agent e.g beta blocker/CCB/ digoxin
When is flecainide c/i?
IHD/structural heart disease
What is first line agent for long term rhythm control according to NICE?
Beta blocker
What medical cardioversion does NICE recommend in AF if CCF/LVF?
Amioderone
When does NICE state a ‘pill in pocket’ strategy can be used for pAF? (4)
- No hx of LVF/valvular/IHD
- Infrequent and symptomatic episodes
- SBP >100mg and HR >70bpm
- Understands when to take meds
What does NICE recommend pre and post elective DC cardioversion for AF? (2)
- 3 weeks anticoag
2.Amioderone 4 weeks before and 12 months post
In acute AF what time period does NICE state that you can’t cardiovert after?
48 hours
What rate controlling agent does NICE recommend avoiding in AF with decompensated CCF?
CCB
What does ESC define as ‘clinical AF’?
Needs to be captured on 12 lead
What drugs to ESC recommend for anticoagulation in AF? (4)
Same as NICE
D-igabatran
A - pixiban
R - ivoroxaban
E - doxaban
What risk score does ESC recommend for bleeding risk?
HASBLED
In AF, if anticoagulation is c/i what does ESC recommend?
Left atrial appendage occlusion
What rate does ESC recommend we control AF to normally and patients with symps of CCF or CRT device?
- <110bpm
- < 80bpm
What does ESC recommend first line for acute rate control in:
1. Asthma/severe COPD?
2. HFrEF?
- CCB
- B-blocker
In severe cases of AF with no response to tx what may be the next treatment options?
Increase to third line + amioderone
CRT/PPM/AV ablation
ESC recommends immediate cardioversion in AF in what group of patients?
Unstable
If patients are stable in AF and you are aiming to cardiovert, what is the first question to be asked before planning cardioversion?
Are they one OAC - if they are you can cardiovert when and how you wish
What are the two recommended options for cardioversion if AF <48hours according to ESC?
- Early cardioverson
- ‘Wait and see’ - observe for spontaneous cardioversion and cardiovert if needed before 48 hours
What does ESC recommend in patients in AF >48 hours that you wish to rhythm control?
3 weeks of OAC first or sooner if TOE exludes thrombus
What does ESC recommend with regards to anticoagulation post cardioversion? (3)
- If CHADSVASC 0 in men or 1 in females 4 weeks anticoag
- CHADSVASC > this then life long
- If AF <24 hours then optional
In which groups does NICE recommend ACEing/ARBs as first line for managing HTN? (2)
- T2DM
- <55
Which groups does NICE recommend using CCB as first line for HTN?
- > 55
- Black
Name 2 ARBs?
- Losartan
- Candasrtan
If first line management for HTN fails what does NICE recommend?
- Adding either CCB/ACEinhib or ARB/thiazide
What does NICE recommend if second line tx for HTN fails?
- CCB + ACE inhb/ARB + thiazide
Which group should avoid ACEinh and ARBs in particular?
Pregnancy
Who which HTN medication should be second line for black patients
ARB (over ACEinhib)
Or thiazide
How do you calculate rate on an ecg? (3)
- 300 divided by no. of large squares between R waves
- 1500 divided by number of small squares between R waves
- Number of R waves in rhythm strip x 6
What are prominent u waves? (2)
- > 1-2mm
- > 25% height of T wave
What are u waves?
Small deflection after the T wave
What are the causes of U - waves (5)
- Low K+
- Low Ca2+
- Low Mg2+
- Bradycardia
- Increased ICP
What are inverted u-waves specific for?
CAD - particularly in context of chest pain
What is an Osborne J wave?
Positive deflection at J point in precordial and true limb leads
What is the most specific cause of an Osborne J wave
Temp <30 degrees C
What is an AVNRT?
AV nodal re-entrant tachycardia.
Functional re-entry circuit within the AV node
‘Classic’ SVT
What helps distinguish AVNRT for orthodromic AVRT on ECG?
AVNRT -Pseudo R’ waves V1/2.
P waves either buried in QRS or partially seen in terminal part of QRS leading to pseudo R’ waves
AVRT - retrograde P waves occur later, usually notch in T wave
What is AVRT
AV re-entry tachycardia
Pre-excitation
What is orthodromic AVRT?
Antegrade pathway with AV node therefore looks very similar or AVNRT
What is antidromic AVRT?
Antegrade pathway via accessory pathway therefore widened QRS and looks like VT
How do we treat orthodromic AVRT?
Adenosine
How do we treat antidromic AVRT?
Procainamide (adenosine blocks AV node and always a chance of precipitating AF, if this was conducted via AP would lead to arrest)
What ECG changes are found in WPW? (4)
- PR <120ms
- Delta waves
- QRS >110ms
- Discordant ST/T wave changes
What is a type A WPW pattern? (3)
- Dominant R wave V1
- TWI VI-3
- Left sided
What is a type B WPW pattern? (3)
- Dominant S wave V1
- Tall R waves and TWI inversion V4-6 - pseudo LVH pattern
- Right sided
What is left anterior fascicular block? (3)
- LAD
- qR complex I, aVL
- rS complex II,III,aVF
What is left posterior fascicular block? (3)
- RAD
- rS complex I, aVL
- qR complex II,III,aVF
What is bifascicular block?
RBBB + either LAFB or LPFB
When does bifasciular block need invesitgating?
Pre-syncope/syncope
Has 1-4% progression to CHB per year
What is true trifascicular blocl
3 degree Hb + RBBB + LAFB/LAFP
What do some people describe as trifascicular block and what is its risk of becoming CHB?
- First degree HB + RBBB + LAFB/LPFB
- 1-4% - same as bifascicular block
What is an epsilon wave?
Small deflection and end of QRS complex
ARVD - 50% have epsilon waves
What is the name of the leads that are used to increase the sensitivity of epsilon waves?
Fontaine leads
What comprises the HEART score?
History - slightly suspicious 0
mildly suspicious 1
highly suspicious 2
ECG - normal 0
non-specifc repolarization disturbance 1
significant ST deviation 2
Age - < 45 0
45-64 1
> 65 2
Risk factors - none 0
1-2 risk factors 1
3 or more 2
Troponin - less than normal 0
1-3 x normal 1
> 3 x normal 2
What 3 features in electrical alterans?
- Tachycardia
- Low voltage QRS
- Consecutive normally conducted QRS that vary in height
In what condition is eletrical alterans found?
Massive pericardial effusion
What is Mobitz type I
Wenckebach
What is Mobitz type II
Intermittently non-conducted p-waves
What is Wellens syndome?
Clinical syndrome characterised by bipashic or deep T wave inversion V2-3 and a history of recent chest pain, now resolved. Strongly suggestive of critical LAD stenosis
What is Brugada sign?
Coved ST elevation >2mm in more than one of V1-3 followed by a negative T wave
Only sign that is potentially diagnostic
Aside from ECG changes, what are the clinical criteria for Brugada? (6)
One of:
1. Document VT/VF
2. FHx: SCD < 45 years
3. Coved type ECGs in family members
4. Inducible VT with programmed electrical stimulation
5. Syncope
6. Noctural agonal respiration
What features are suggestive of VT over SVT with aberrancy? (5)
- Evidence of independent atrial activity, dissociated p waves
- Fusion/capture beats
- Bizarre axis (+ve QRS in aVR)
- QRS >140ms
- Concordance of QRS complex in chest leads (either positively or negatively)
- Absence of LBBB or RBBB pattern (usually RBBB)
What drug is shown to be the most effective at managing stable VT?
Soltalol (although amioderone first line ALSG)
What does pre-excited AF look like on ECG?
Wide complex, irreg/irreg tachycardia with variable QRS morphology + fast (>200bpm)
Can look like AF with BBB (but this is slower) torsade des pointes (but without the twisting morphology)
What is the treatment for stable pre-excited AF?
IV Procainamide
What drugs should not be given in pre-excited AF?
Any AV nodal blocking drugs - VF + arrest
What is different between Torsades de Pointes and polymorphic VT?
1.ECG
2. Cause
3. Tx
- TdP ECG ‘twisting’ around isoelectric line
- Caused specifically by QT prolongation
- Magnesium
What does the Right Ventricular Outflow Tract Tachycardia (RVOT) ECG look like? (2)
- LBBB pattern
- RAD
NB QRS usually <140ms unlike VT
What part of the history can be useful in distinguishing RVOT from other causes of VT?
Usually no hx of IHD/structural heart disease + relatively young/well patients
How can RVOT be treated?
If confident of diagnosis treat as SVT (adenosine, beta blocker, calcium anatagonist)
What are the causes of broad complex tachycardia? (7)
- VT
- Polymorphic VT
- VF
- Fascicular tachycardia - RVOT
- SVT with aberrancy
- Antidromic SVT
- AF with pre-excitation
What can help differentiate RVOT and VT?
The degree of QRS widening:
QRS 110-140 in RVOT
VT it’s usually > 140
This can make it look like SVT
+ VT less likely to have LBBB morphology
What is a simple clue that suggests AF with aberrancy/pre-excitation over polymorphic VT?
Polymorphic VT not sustained and usually leads to VF and arrest
In which types of MI should we be careful/avoid GTN?
Inferior STEMI, particularly with evidence of RV infarction
Which STEMIs can lead to second and third degree HB and what percentage of these do so?
Inferior
20%
In NSTEMIs following aspirin what is the second medication that NICE say should be given immediately after?
LMWH
What are the 2 investigations most reliable for detecting infective endocarditis?
- BC - 98% have positive BC
- TOE (90%), TTE not sensitive enough
What are the ECG features of AVRD (5)
- T wave inversion in right precordial leads V1-3, in absence of RBBB (85% of patients)
- Epsilon wave (most specific)
- Localised QRS widening in V1-3 (> 110ms)
- Ventricular ectopy of LBBB morphology, with frequent PVCs
- Paroxysmal episodes of ventricular tachycardia (VT) with LBBB morphology (RVOT tachycardia)
What are Lewis leads?
Lead placements that allows better visualisation of p waves
What leads have inverted T waves normally and what is a normal variant?
- aVR and V1
- III
What are the ECG changes in the 3 types of Brugada?
Type 1 - coved STE over 2mm in V1-3 with TWI
Type 2 - over 2mm ‘saddleback’ STE, no TWI
Type 3 - morphology of either 1 or 2 but < 2mm STE
Which is the only ECG type of Brugada that is potentially diagnostic?
Type 1
What is the easiest way to tell the difference between a PPM and ICD on CXR?
ICD have thick metallic ends whereas PPM do not
