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FRCEM SBA > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What criteria does NICE have for diagnosing ACS? (1+5)

A

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

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2
Q

What risk score does NICE recommend for 6 month risk stratification and what are the levels (5 levels)

A

GRACE score
1. Lowest <1.5%
2. Low 1.5-3.0%
3. Intermediate 3-6%
4. High 6-9%
5 Highest >9%

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3
Q

Who does NICE state should have and angiogram <72 hours?

A

NSTEMI or unstable angina and GRACE score intermediate or higher

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4
Q

Which NSTEMI/unstable angina patients does NICE recommend angio < 24hours? (4)

A

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

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5
Q

When do NICE say an angiogram should be performed following a STEMI?

A

< 12 hours or <120 mins of when fibrinolysis could have been given

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6
Q

What drug therapy does NICE recommend if undergoing medical management only of STEMI (3)

A
  1. Aspirin
  2. Ticagrelor (clopidogrel or only aspirin if increased bleeding risk)
  3. LMWH
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7
Q

What drug therapy dose NICE recommend in a STEMI going to cath lab?

A
  1. Aspirin
  2. Prasugrel (if on anticoagulant then clopidogrel)
  3. UFH
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8
Q

What does NICE recommend for STEMI being thrombolysed?

A
  1. Aspirin
  2. LMWH/UFH at same time as:
  3. Fibronlysis
  4. Ticagrelor (unless increased bleeding risk, then clopidogrel)
  5. ECG 60-90mins later and if not improved transfer PCI
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9
Q

What treatment does NICE recommend for NSTEMI?

A
  1. Aspirin
  2. LMWH (unless cath lab)
  3. Ticagrelor unless high bleeding risk then clopidogrel or cath lab (prasugrel)
  4. GRACE risk score then decide angiogram < 72 hours or considering ischaemia testing (low risk = <3%)
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10
Q

What does ESC define as STEMI in men?

A

> 40 years old = 2mm or greater STE in 2 contiguous leads
<40 years old = 2.5mm or greater STE in 2 contiguous leads

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11
Q

What does ESC define as a STEMI in women?

A

1.5mm or greater STE in V1-3 or
1mm or greater STE in any other lead

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12
Q

What does ESC define as a ECG diagnosis of posterior MI?

A

> 0.5mm ST depression in V1-3
+
0.5mm STE V5-7

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13
Q

What are Scarbossa’s Criteria and which bits are the most and least sensitve?

A
  1. Concordant STE >1mm in 1 or more leads (most sensitive) (5 points)
  2. Concordant ST depression >1mm V1-3 (3 points)
  3. Discordant ST elevation >5mm (2 points)

3 or more needed

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14
Q

What are the signs on an ECG of RV infarct? (2)

A

STE VI suggest RV involvemnet
STE V4R highly specific

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15
Q

What part type of MI is right ventricular infarct usually a part of?
What is managed differently about RV infarct?

A

Inferior
Very pre-load sensitive, may need fluid and nitrates can lead to hypotension

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16
Q

Has dose NICE recommend for invx of stable angina if you have no known CAD?

A

CT coronary angiography

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17
Q

What dose NICE define as significant CAD on CT angiography?

A

> 50% stenosis in left main coronary
70% stenosis in any other artery

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18
Q

What does NICE recommend first line invx for stable angina if there is a hx of CAD?

A

Non invasive functional testing

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19
Q

What defines a pathological Q wave? (4)

A
  1. > 40ms (1mm) wide
  2. > 2mm deep
  3. > 25% depth QRS
  4. any in V1-3
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20
Q

What biomarkers to does recommend to rule out CCF? (2)

A
  1. BNP
  2. NT-proBNP
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21
Q

What does NICE recommend first line for acute decompensated CCF?

A

IV diuretics (1-2 x daily dose IV)

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22
Q

What does NICE recommend for CCF with
1. increased resp effot?
2. Diuretic resistent?

A
  1. NIV
  2. Haemofiltration
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23
Q

What treatments does NICE recommend commencing people on when their acute HF has been stabilised? (3)

A
  1. Beta-blocker once stable >48hours
  2. Ace inhib/ARB
  3. Spironalactone and eplerenone if decreased EF
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24
Q

How dose ESC recommend managed isolated RV failure? (3)

A
  1. Ionotropes and vasopressors (never vasopressor without ionotropes
  2. RRT
  3. RVAD
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25
Q

Causes of acute heart failure:
CHAMPIT

A

C - acute Coronary Syndrome
H - ypertensive emergency
A - rrhythmia
M - echanical cause
P - E
I - infections (myocarditis)
T - amponade

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26
Q

What does ESC say about opitates in acute heart failure?

A

Avoid - shown to increase intubation and length of stay

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27
Q

What increases the risk of sudden cardiac death in LVF and what might be used to prevent this?

A
  1. EF - decreased EF increases risk of ventricular arrhythmia
  2. ICD
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28
Q

What are the types of ICD and what can they do?

A
  1. Single chamber - 1 x defib lead in RV
  2. Dual chamber - right atrial pacing lead and RV lead
  3. Both can pace if brady and cardiovert
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29
Q

What leads does a CRT device have and what does it stand for?

A
  1. RV defib
  2. LV pacing
  3. Cardiac resynchronisation therapy
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30
Q

Describe how CRT works

A

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

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31
Q

What are the criteria for CRT? (3)

A
  1. EF < 35%
    +
  2. QRS >150ms
    or
  3. LBBB
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32
Q

What does NICE recommend calculate stroke risk and bleeding risk in AF?

A
  1. CHADVASC
  2. ORBIT
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33
Q

What are the NICE recommended CHADSSVASC scores to trigger anticoagulation? (3)

A

1 >65 = 1 or more men, 2 or more women
2. <65 then 0 for men or 1 for women

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34
Q

What makes up the CHADSSVASC score? (7)`

A

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)

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35
Q

What anticoagulation does NICE recommend for chronic AF ? (4)

A

RADE

Rixoroxaban
Apixiban
Dabigatran
Edoxaban

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36
Q

What are first line agents to rate control AF according to NICE? (3)

A
  1. Beta blocker
  2. CCB
  3. Digoxin if very sedentary
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37
Q

What does NICE recommend if 1st line treatment not managing rate for AF?

A

Add second agent e.g beta blocker/CCB/ digoxin

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38
Q

When is flecainide c/i?

A

IHD/structural heart disease

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39
Q

What is first line agent for long term rhythm control according to NICE?

A

Beta blocker

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40
Q

What medical cardioversion does NICE recommend in AF if CCF/LVF?

A

Amioderone

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41
Q

When does NICE state a ‘pill in pocket’ strategy can be used for pAF? (4)

A
  1. No hx of LVF/valvular/IHD
  2. Infrequent and symptomatic episodes
  3. SBP >100mg and HR >70bpm
  4. Understands when to take meds
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42
Q

What does NICE recommend pre and post elective DC cardioversion for AF? (2)

A
  1. 3 weeks anticoag
    2.Amioderone 4 weeks before and 12 months post
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43
Q

In acute AF what time period does NICE state that you can’t cardiovert after?

A

48 hours

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44
Q

What rate controlling agent does NICE recommend avoiding in AF with decompensated CCF?

A

CCB

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45
Q

What does ESC define as ‘clinical AF’?

A

Needs to be captured on 12 lead

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46
Q

What drugs to ESC recommend for anticoagulation in AF? (4)

A

Same as NICE
D-igabatran
A - pixiban
R - ivoroxaban
E - doxaban

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47
Q

What risk score does ESC recommend for bleeding risk?

A

HASBLED

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48
Q

In AF, if anticoagulation is c/i what does ESC recommend?

A

Left atrial appendage occlusion

49
Q

What rate does ESC recommend we control AF to normally and patients with symps of CCF or CRT device?

A
  1. <110bpm
  2. < 80bpm
50
Q

What does ESC recommend first line for acute rate control in:
1. Asthma/severe COPD?
2. HFrEF?

A
  1. CCB
  2. B-blocker
51
Q

In severe cases of AF with no response to tx what may be the next treatment options?

A

Increase to third line + amioderone
CRT/PPM/AV ablation

52
Q

ESC recommends immediate cardioversion in AF in what group of patients?

A

Unstable

53
Q

If patients are stable in AF and you are aiming to cardiovert, what is the first question to be asked before planning cardioversion?

A

Are they one OAC - if they are you can cardiovert when and how you wish

54
Q

What are the two recommended options for cardioversion if AF <48hours according to ESC?

A
  1. Early cardioverson
  2. ‘Wait and see’ - observe for spontaneous cardioversion and cardiovert if needed before 48 hours
55
Q

What does ESC recommend in patients in AF >48 hours that you wish to rhythm control?

A

3 weeks of OAC first or sooner if TOE exludes thrombus

56
Q

What does ESC recommend with regards to anticoagulation post cardioversion? (3)

A
  1. If CHADSVASC 0 in men or 1 in females 4 weeks anticoag
  2. CHADSVASC > this then life long
  3. If AF <24 hours then optional
57
Q

In which groups does NICE recommend ACEing/ARBs as first line for managing HTN? (2)

A
  1. T2DM
  2. <55
58
Q

Which groups does NICE recommend using CCB as first line for HTN?

A
  1. > 55
  2. Black
59
Q

Name 2 ARBs?

A
  1. Losartan
  2. Candasrtan
60
Q

If first line management for HTN fails what does NICE recommend?

A
  1. Adding either CCB/ACEinhib or ARB/thiazide
61
Q

What does NICE recommend if second line tx for HTN fails?

A
  1. CCB + ACE inhb/ARB + thiazide
62
Q

Which group should avoid ACEinh and ARBs in particular?

A

Pregnancy

63
Q

Who which HTN medication should be second line for black patients

A

ARB (over ACEinhib)
Or thiazide

64
Q

How do you calculate rate on an ecg? (3)

A
  1. 300 divided by no. of large squares between R waves
  2. 1500 divided by number of small squares between R waves
  3. Number of R waves in rhythm strip x 6
65
Q

What are u waves?

A

Small deflection after the T wave

66
Q

What are prominent u waves? (2)

A
  1. > 1-2mm
  2. > 25% height of T wave
67
Q

What are the causes of U - waves (5)

A
  1. Low K+
  2. Low Ca2+
  3. Low Mg2+
  4. Bradycardia
  5. Increased ICP
68
Q

What are inverted u-waves specific for?

A

CAD - particularly in context of chest pain

69
Q

What is an Osborne J wave?

A

Positive deflection at J point in precordial and true limb leads

70
Q

What is the most specific cause of an Osborne J wave

A

Temp <30 degrees C

71
Q

What is an AVNRT?

A

AV nodal re-entrant tachycardia.
Functional re-entry circuit within the AV node
‘Classic’ SVT

72
Q

What helps distinguish AVNRT for orthodromic AVRT on ECG?

A

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

73
Q

What is AVRT

A

AV re-entry tachycardia
Pre-excitation

74
Q

What is orthodromic AVRT?

A

Antegrade pathway with AV node therefore looks very similar or AVNRT

75
Q

What is antidromic AVRT?

A

Antegrade pathway via accessory pathway therefore widened QRS and looks like VT

76
Q

How do we treat orthodromic AVRT?

A

Adenosine

77
Q

How do we treat antidromic AVRT?

A

Procainamide (adenosine blocks AV node and always a chance of precipitating AF, if this was conducted via AP would lead to arrest)

78
Q

What ECG changes are found in WPW? (4)

A
  1. PR <120ms
  2. Delta waves
  3. QRS >110ms
  4. Discordant ST/T wave changes
79
Q

What is a type A WPW pattern? (3)

A
  1. Dominant R wave V1
  2. TWI VI-3
  3. Left sided
80
Q

What is a type B WPW pattern? (3)

A
  1. Dominant S wave V1
  2. Tall R waves and TWI inversion V4-6 - pseudo LVH pattern
  3. Right sided
81
Q

What is left anterior fascicular block? (3)

A
  1. LAD
  2. qR complex I, aVL
  3. rS complex II,III,aVF
82
Q

What is left posterior fascicular block? (3)

A
  1. RAD
  2. rS complex I, aVL
  3. qR complex II,III,aVF
83
Q

What is bifascicular block?

A

RBBB + either LAFB or LPFB

84
Q

When does bifasciular block need invesitgating?

A

Pre-syncope/syncope
Has 1-4% progression to CHB per year

85
Q

What is true trifascicular blocl

A

3 degree Hb + RBBB + LAFB/LAFP

86
Q

What do some people describe as trifascicular block and what is its risk of becoming CHB?

A
  1. First degree HB + RBBB + LAFB/LPFB
  2. 1-4% - same as bifascicular block
87
Q

What is an epsilon wave?

A

Small deflection and end of QRS complex
ARVD - 50% have epsilon waves

88
Q

What is the name of the leads that are used to increase the sensitivity of epsilon waves?

A

Fontaine leads

89
Q

What comprises the HEART score?

A

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

90
Q

What 3 features in electrical alterans?

A
  1. Tachycardia
  2. Low voltage QRS
  3. Consecutive normally conducted QRS that vary in height
91
Q

In what condition is eletrical alterans found?

A

Massive pericardial effusion

92
Q

What is Mobitz type I

A

Wenckebach

93
Q

What is Mobitz type II

A

Intermittently non-conducted p-waves

94
Q

What is Wellens syndome?

A

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

95
Q

What is Brugada sign?

A

Coved ST elevation >2mm in more than one of V1-3 followed by a negative T wave

Only sign that is potentially diagnostic

96
Q

Aside from ECG changes, what are the clinical criteria for Brugada? (6)

A

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

97
Q

What features are suggestive of VT over SVT with aberrancy? (5)

A
  1. Evidence of independent atrial activity, dissociated p waves
  2. Fusion/capture beats
  3. Bizarre axis (+ve QRS in aVR)
  4. QRS >140ms
  5. Concordance of QRS complex in chest leads (either positively or negatively)
  6. Absence of LBBB or RBBB pattern (usually RBBB)
98
Q

What drug is shown to be the most effective at managing stable VT?

A

Soltalol (although amioderone first line ALSG)

99
Q

What does pre-excited AF look like on ECG?

A

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)

100
Q

What is the treatment for stable pre-excited AF?

A

IV Procainamide

101
Q

What drugs should not be given in pre-excited AF?

A

Any AV nodal blocking drugs - VF + arrest

102
Q

What is different between Torsades de Pointes and polymorphic VT?
1.ECG
2. Cause
3. Tx

A
  1. TdP ECG ‘twisting’ around isoelectric line
  2. Caused specifically by QT prolongation
  3. Magnesium
103
Q

What does the Right Ventricular Outflow Tract Tachycardia (RVOT) ECG look like? (2)

A
  1. LBBB pattern
  2. RAD

NB QRS usually <140ms unlike VT

104
Q

What part of the history can be useful in distinguishing RVOT from other causes of VT?

A

Usually no hx of IHD/structural heart disease + relatively young/well patients

105
Q

How can RVOT be treated?

A

If confident of diagnosis treat as SVT (adenosine, beta blocker, calcium anatagonist)

106
Q

What are the causes of broad complex tachycardia? (7)

A
  1. VT
  2. Polymorphic VT
  3. VF
  4. Fascicular tachycardia - RVOT
  5. SVT with aberrancy
  6. Antidromic SVT
  7. AF with pre-excitation
107
Q

What can help differentiate RVOT and VT?

A

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

108
Q

What is a simple clue that suggests AF with aberrancy/pre-excitation over polymorphic VT?

A

Polymorphic VT not sustained and usually leads to VF and arrest

109
Q

In which types of MI should we be careful/avoid GTN?

A

Inferior STEMI, particularly with evidence of RV infarction

110
Q

Which STEMIs can lead to second and third degree HB and what percentage of these do so?

A

Inferior
20%

111
Q

In NSTEMIs following aspirin what is the second medication that NICE say should be given immediately after?

A

LMWH

112
Q

What are the 2 investigations most reliable for detecting infective endocarditis?

A
  1. BC - 98% have positive BC
  2. TOE (90%), TTE not sensitive enough
113
Q

What are the ECG features of AVRD (5)

A
  1. T wave inversion in right precordial leads V1-3, in absence of RBBB (85% of patients)
  2. Epsilon wave (most specific)
  3. Localised QRS widening in V1-3 (> 110ms)
  4. Ventricular ectopy of LBBB morphology, with frequent PVCs
  5. Paroxysmal episodes of ventricular tachycardia (VT) with LBBB morphology (RVOT tachycardia)
114
Q

What are Lewis leads?

A

Lead placements that allows better visualisation of p waves

115
Q

What leads have inverted T waves normally and what is a normal variant?

A
  1. aVR and V1
  2. III
116
Q

What are the ECG changes in the 3 types of Brugada?

A

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

117
Q

Which is the only ECG type of Brugada that is potentially diagnostic?

A

Type 1

118
Q

What is the easiest way to tell the difference between a PPM and ICD on CXR?

A

ICD have thick metallic ends whereas PPM do not

FRCEM SBA (12 decks)

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