Cardiology Flashcards
What is cardiovascular disease
Chronic inflammation and activation of immune system in artery walls
Affects medium and large arteries
What do deposits of lipids in artery walls do
Stiffen (causing hypertension and putting additional strain on heart)
Stenose (reducing blood flow)
Rupture (give off thrombus that can lodge elsewhere)
What are the non-modifiable risk factors for cardiovascular disease
Older age
Family history
M>F
What are the modifiable risk factors for cardiovascular disease
Smoking
Alcohol
Poor diet (high in sugars and fats)
Low exercise
Obesity
Poor sleep
Stress
What are the co-morbidities associated with cardiovascular disease
Diabetes
Hypertension
CKD
Inflammatory conditions
Atypical antipsychotic medications
What are the end results of atherosclerosis
Angina
Myocardial infarction
Transient ischaemic attack
Stroke
Peripheral vascular disease
Chronic mesenteric ischaemia
What is the QRISK3 score
Percentage risk that a person will have a stroke or MI in the next 10 years
What should be done if a QRISK score is > 10%
Start a statin
What are the NICE statin use recommendations
Check lipids every 3 months
Check adherence before increasing dose
Check LFTs at 3 and 12 months (causes rise in ALT and AST, tolerate if up to 3 times normal)
What are the 4 As of secondary prevention of cardiovascular disease
Aspirin (plus a second antiplatelet)
Atorvastatin
Atenolol (or another beta blocker)
ACE inhibitor
What are the side effects of statins
Myopathy (check creatinine kinase if muscle pain/weakness)
T2DM
Haemorrhagic stroke
What is angina
Narrowing of coronary arteries causing reduced blood flow to myocardium
During exertion
Constricting chest pain
May radiate to arm/jaw
What are the 2 types of angina
Stable (relied by rest or GTN)
Unstable (come on at rest, considered an ACS)
What are the high risk factors for angina
Diabetes
Smoking
Hyperlipidaemia
Hypertension
Family history
What investigations are needed for angina
CT coronary angiograph (gold standard)
ECG
FBC, U&Es, LFTs, bone profile, TFTs, HbA1c
What are the appropriate investigations based on the likelihood of coronary artery disease
61-90%: invasive coronary angiography
30-60%: stress MRI, ECHO
10-29%: CT calcium scoring
Men over 70: assume likelihood >90%
Women over 70: assume likelihood 61-90%
Women at high risk and have typical symptoms: >90%
What is the medical management for stable angina that gives immediate relief
GTN
PRN, causes vasodilation.
What are the medical managements for stable angina that gives long term relief
Beta blockers
Calcium channel blockers
Second line: long acting nitrates (ivabradine, nicorandil)
What is the secondary prevention for stable angina
Aspirin (75mg OD)
Atorvastatin (80mg OD)
ACE inhibitors
Beta blockers
What is the surgical management for stable angina
Percutaneous coronary intervention (PCI) with coronary angioplasty
Coronary artery bypass graft (CABG)
What are the causes of non-cardiac chest pain
Costochondritis
GORD
PE
Pneumonia
Pneumothorax
Psychogenic/psychomotor
Which parts of the heart does the right coronary artery supply
Right atrium
Right ventricle
Inferior left ventricle
Posterior septal area
Which parts of the heart does the circumflex artery supply
Left atrium
Posterior left ventricle
Which parts of the heart does the left anterior descending artery supply
Anterior left ventricle
Anterior septal area
What are the 3 types of acute coronary syndrome
Unstable angina
STEMI
NSTEMI
What are the symptoms of acute coronary syndrome
Central, constricting chest pain
Nausea and vomiting
Sweating, clamminess
Feeling of impending doom
Shortness of breath
Palpitations
Pain radiating to jaw/arm
Symptoms continue for 20 mins at rest
What investigations are needed for acute coronary syndrome
ECG
Troponin
FBC, U&Es, LFTs, lipid profile, TFTs, HbA1c
CXR/CT coronary angiogram
What are the ECG signs of STEMI
ST elevation in 2+ leads from the same zone
New left bundle branch block
ST depression in V1-V4
What conditions can mimic STEMI on ECG
Pericarditis
Brugada syndrome
What are the ECG signs of NSTEMI
ST depression
Deep T wave inversion
Pathological Q waves
What are the ECG signs of unstable angina
ST depression
T wave inversion
How long after myocardial damage does troponin start to rise
3-4 hrs
What are some non-ACS causes of raised troponin
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
PE
What is the management for acute STEMI
Discuss with cardiac centre within 12 hours
Refer to cath lab (STEMI)
Morphine
Oxygen
Antiemetic
Aspirin, prasugrel, clopidogrel, ticagrelor
Primary percutaneous coronary intervention (PPCI)
Thrombolysis
What is the management for NSTEMI/unstable angina
Analgesia
Aspirin
LMWH
Repeat ECG
What is the GRACE score
Gives 6 month risk of death/repeat MI following an NSTEMI
What are the complications of MI
Death
Rupture of heart septum/papillary muscles
Oedema
Arrhythmias, aneurysms
Dressler’s syndrome
What is Dressler’s syndrome
2-3 days after MI
Get localised immune response
Get pericarditis
Presentation: pleuritic chest pain, low grade fever, pericardial rub
Can cause: pericardial effusion, pericardial tamponade
Diagnosis: ECG, ECHO, raised inflammatory markers
Management: NSAIDs, prednisolone, pericardiocentesis (remove fluid from around heart)
What is the secondary prevention for acute coronary syndrome
Aspirin
Another antiplatelet
Atorvastatin
ACE inhibitors
Atenolol
Aldosterone antagonist
What are the 4 types of MI
1: traditional MI, due to ACS
2: ischaemia due to increased demand/reduced oxygen
3: sudden cardiac death
4: associated with PCI/stunting/CABG
What are the causes of pulmonary oedema
Iatrogenic (aggressive fluids)
Sepsis
Myocardial infarction
Arrhythmias
How might pulmonary oedema present
Shortness of breath (exacerbated on lying flat)
Type 1 respiratory failure
Feeling unwell
Cough
What would you find on examination in pulmonary oedema
Increased respiratory rate
Reduced oxygen saturations
Tachycardia
3rd heart sound
Bibasal crackles
Cardiogenic shock
What investigations are needed for pulmonary oedema
ECG
ABG
CXR
ECHO
BNP, troponin
What is BNP
B-type natriuretic peptide
Released from ventricles when excessively stretched
Vasodilator, diuretic
Sensitive, but not specific
What is the management for pulmonary oedema
Pour SOD (stop IV fluids, sit up, oxygen, diuretics)
IV opiates (act as vasodilators)
NIV
CPAP
Inotropes (noradrenaline)
What is the NICE cutoff for hypertension
140-90 in clinic
135/85 at home
What are the secondary causes of hypertension
ROPE
Renal disease
Obesity
Pregnancy/pre-eclampsia
Endocrine (hyperaldosteronism)
How might a patient with hypertension present
Asymptomatic
Headaches
What are the complications of hypertension
Ischaemic heart disease
Cerebrovascular accident
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure
What are the 3 stages of hypertension
1: >140/90 (or >135/85 at home)
2: >160/100 (or >150/95 at home)
3: >180/110
What investigations are needed for hypertension
Urine albumin:creatinine ratio
HbA1c
Fundus examination
ECG
ECHO
What medications are used for hypertension
ABCD+
ACE inhibitors
Beta blockers
CCBs
Diuretics (thiazide-like)
ARBs (for people who do not tolerate ACE inhibitors and block population)
Who should be offered hypertension management
Stage 2 hypertensives
Stage 1 hypertensives under 80 with: Qrisk > 10%, diabetes, renal disease, cardiovascular disease, end organ damage
What are the steps of antihypertensive treatment
Step 1:
- <55 and non-black: A
- >55 or black: C
Step 2:
- A+C, A+D, C+D
- If black, give ARB rather than A
Step 3:
- A+C+D
Step 4:
- A+C+D+additional
- Diuretic, alpha blocker, beta blocker
What are the treatment targets for hypertensives < 80
< 140
<90
What are the treatment targets for hypertensives > 80
< 150
< 90
What are the treatment targets for hypertensives with diabetes/stroke/MI/CKD
< 130
< 80
What is systolic and diastolic heart failure
Systolic - impaired left ventricular contraction
Diastolic - ventricular relaxation
How might chronic heart failure present
Breathlessness
Cough
Orthopnoea (breathless on lying flat)
Paroxysmal nocturnal dyspnoea (waking at night short of breath)
Peripheral oedema
What features carry a worse prognosis for chronic heart failure
Severe fluid overload
Very high NT-pro-BNP
Severe renal impairment
Increasing age
Multiple comorbidities
What investigations are needed for chronic heart failure
FBC, U&Es, LFTs, TFTs, BNP
CXR
ECG
ECHO (confirms diagnosis), cardiac MRI
What might CXR show in chronic heart failure
Cardiomegaly
Pleural effusion
Perihilar shadowing/consolidation
Alveolar oedema
Air bronchograms
Increased width of vascular pedicles
What are the causes of chronic heart failure
Ischaemic heart disease
Valvular heart disease
Hypertension
Arrhythmias
Chronic lung disease
Cardiomyopathy
Previous chemotherapy
HIV
What is the main management for chronic heart failure
ACE inhibitors
Beta blockers
Aldosterone antagonists
Loop diuretics
Surgery (for severe stenosis/regurge)
What are the additional management strategies for chronic heart failure
Yearly flu and pneumonia vaccines
Smoking cessation
Optimise co-morbidities
Exercise
Low salt diet
Fluid restriction
Ivabradine
Nitrates
Pacemaker insertion
What is cor pulmonale
Right sided heart failure caused by respiratory disease
What is the mechanism by which cor pulmonale happens
Increased pressure in pulmonary arteries
Ineffective pumping from right ventricle
Back pressure of blood into right atrium, vena cava, systemic venous system
What are the respiratory causes of cor pulmonale
COPD
PE
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension
How might cor pulmonale present
Often asymptomatic
Shortness of breath
Peripheral oedema
Syncope
Chest pain
What might you find on examination in cor pulmonale
Hypoxia
Cyanosis
Raised JVP
Peripheral oedema
3rd heart sound
Murmur
Hepatomegaly
What is the treatment for cor pulmonale
Treat underlying cause
Long term oxygen therapy
What do S1 and S2 signify
S1: closing of tricuspid and mitral valves
S2: closing of pulmonary and aortic valves
How is mitral stenosis best heard
Lie patient on left side
How is aortic regurgitation best heard
Lean patient forward, holding exhalation
How should murmurs be described
SCRIPT
Site
Character
Radiation
Intensity
Pitch
Timing
What are the grades of murmurs
1: difficult to hear
2: quiet
3: easy to hear
4: easy to hear with a palpable thrill
5: hear with stethoscope barely touching chest
6: hear with stethoscope off chest
Give an overview of mitral stenosis
Narrow mitral valve
Difficult for left atrium to push blood to ventricle
Causes: rheumatic heart disease, infective endocarditis
Associated with: malar flush, AF
Give an overview of mitral regurgitation
Causes congestive heart failure (reduced ejection fraction)
Pan-systolic, high pitched, ‘whistling’ murmur
May have 3rd heart sound
Causes: idiopathic weakness of valve with age, ischaemic heart disease, infective endocarditis, rheumatic heart disease, connective tissue disorders
Give an overview of aortic stenosis
Most common valve disease
Ejection-systolic, high pitched murmur
Crescendo-decrescendo
Other signs: radiates to carotids, slow rising pulse, narrow pulse pressure, exertional syncope
Causes: idiopathic age-related calcification, rheumatic heart disease
Give an overview of aortic regurgitation
Early diastolic, soft murmur
Early diastolic, ‘rumbling’ murmur
Collapsing pulse
Causes: idiopathic age related weakness, connective tissue disorders
What are the shockable cardiac arrest rhythms
Ventricular tachycardia
Ventricular fibrillation
What are the non-shockable cardiac arrest rhythms
Pulseless electrical activity
Asystole
How are different types of tachycardias treated
Atrial fibrillation: rate control with beta blockers or diltiazem (CCB)
Atrial flutter: rate control with beta blockers
Supraventricular tachycardia: valsalva manoeuvre and adenosine
Ventricular tachycardias: amiodarone infusion
Give an overview of atrial flutter
Re-entrant rhythm in either atrium - self-perpetuating loop
Atria contact at around 300 bpm
Ventricles contract at around 150 bpm
Sawtooth appearance on ECG
Associated conditions: hypertension, ischaemic heart disease, cardiomyopathy, thyrotoxicosis
Treatment: rate/rhythm control (beta blockers, cardioversion), treat underling cause, radiofrequency ablation, anticoagulate
Give an overview of supraventricular tachycardias
Electrical signals re-enter atria from ventricles
Treatment: ECG monitoring, valsalva manoeuvre, carotid sinus massage, adenosine, verapamil
Long term medications: beta blockers, CCBs, flecanide, sotalol, amiodarone
Give an overview of Wolff-Parkinson-White syndrome
Extra electrical pathway connecting atria to ventricles
ECG changes: short PR, wide QRS, delta wave (slurred upstroke)
Definitive treatment: radiofrequency ablation of accessory pathway
Give an overview of torsades de pointes
A polymorphic ventricular tachycardia
QRSs twisting around baseline
Can normalise spontaneously, or progress to ventricular tachycardia
Acute management: correct underlying cause, magnesium infusion, defibrillation
Long term management: avoid meds that prolong QTc, correct electrolyte imbalance, beta blockers, pacemaker, implantable defibrillator
Give an overview of ventricular ectopics
Premature ventricular beats caused by random electrical discharge from outside atria
Random, brief palpitations
Management: general bloods, reassure
Give an overview of first degree heart blocks
Delayed AV conduction through AV node
Every p wave leads to a QRS
PR > 0.2
No specific treatment needed
If symptomatic, do cardiac monitoring
Give an overview of Mobitz 1 heart blocks
Increasing PR until QRS dropped
Repeating cycle
Can be found in young, healthy patients
No specific treatment needed
If symptomatic, look for other heart block
Give an overview of Mobitz 2 heart blocks
Missed QRS complexes
Set ratio of p waves and QRS complexes
PR interval stays constant
Risk of asystole (consider pacemaker)
Give an overview of third degree heart blocks
Complete heart block
No relationship between p waves and QRS complexes
Significant risk of asystole (need urgent permanent pacing)
Causes: digoxin toxicity, inferior MI, hyperkalaemia
What is the treatment for bradycardias/AV node blocks
Stable: observe
Unstable: atropine, noradrenaline, transcutaneous cardiac pacing
High risk of asystole: temporary transvenous cardiac pacing, permanent implantable pacemaker
What is atrial fibrillation
Uncoordinated, rapid, irregular contraction of the atria
Disorganised electrical activity overrides activity from SA node
Mostly in > 80s
Absent p waves
How might atrial fibrillation present
Often asymptomatic
Palpitations
Shortness of breath
Syncope
What can atrial fibrillation lead to
Haemodynamic instability
Acute coronary syndrome
Congestive heart failure
Cardioembolic stroke
What will be seen on ECG in atrial fibrillation
Absent p waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm
What are the common causes of atrial fibrillation
SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension
What are the NICE guidelines for rate control in atrial fibrillation
All patients with AF should have rate control as 1st line unless:
There is a reversible cause
New onset (<48 hrs)
Causing heart failure
Remain symptomatic despite measures to control
Give an overview of rate control methods for atrial fibrillation
Aim to extend diastole, to allow ventricles to fill up
Beta blockers, calcium channel blockers, digoxin
Give an overview of rhythm control methods for atrial fibrillation
Aim to return patient to sinus rhythm
Cardioversion: electrical (flecanide, amiodarone), electrical
Long term: beta blockers, dronedarone, amiodarone
What is paroxysmal atrial fibrillation
Comes and goes in episodes
Does not last > 48 hours
Can use pill in pocket approach (flecanide)
Give an overview of warfarin
Vitamin K antagonist
Prolongs prothrombin time
Target INR 2-3
Half life 2-3 days
Reversible with vitamin K
Give an overview of NOACs
Apixaban, dabigatran, rivaroxaban
Inhibit factor Xa or thrombin directly
Low bleeding risk
Renally excreted (monitor renal function annually)
Go through CHA2DS2-VASc
Assess whether patients with AF should be started on anticoagulants
Anticoagulate if score 1+
Congestive heart failure
Hypertension
Age > 75 (2)
Diabetes
Stroke/TIA (2)
Vascular disease
Age 65-74
Sex (female)
Go through HAS-BLED
Assess patient’s risk of major bleeding during anticoagulation
Hypertension
Abnormal renal/liver function
Stroke
Bleeding
Labile INR (whilst on warfarin)
Elderly
Drugs (aspirin, NSAIDs)
Alcohol abuse
Which cardiac conditions predispose to infective endocarditis
Mitral valve prolapse
Prosthetic valves
Rheumatic heart disease
Degenerative aortic valve
Bicuspid aortic valve
Congenital heart disease
Which organisms cause infective endocarditis
Staphylococcus viridans
Staphylococcus aureus
Enterococcus
What is the diagnostic criteria for infective endocarditis
2 major, 1 major + 3 minor, 5 minor
Major: positive blood cultures, endocardial involvement, positive ECHO findings, new valvular regurg, dehiscence of prosthesis
Minor: predisposing valvular/cardiac abnormality, IV drug use, pyrexia > 38, embolic phenomenon, vasculitic phenomenon, suggestive blood cultures, suggestive ECHO findings
What is the medical management for infective endocarditis
Streptococci: benzylpenicillin + gentamicin
Enterococci: amoxicillin + gentamicin
Staphylococci: flucloxacillin + gentamicin
What are the indications for surgery in infective endocarditis
Moderate-severe cardiac failure
Valve dehiscence
Uncontrolled infection despite antibiotics
Relapse after medical therapy
Acute systemic embolus
Fungal infection
Paravalvular infection
Valve obstruction
What are the indications for pacemaker insertion
Symptomatic bradycardia
Mobitz type 2 heart block
3rd degree heart block
Severe heart failure
Hypertrophic obstructive cardiomyopathy
What is a hypertensive emergency
Increased blood pressure that will cause end organ damage within a few hours
What is the difference between a hypertensive emergency and hypertensive urgency
Emergency: high BP associated with a critical event
Urgency: high BP without a critical illness
What are the aims of treatment in hypertensive emergency/urgency
Reduce BP to 110 in:
3 - 12 hours (emergency)
24 hours (urgency)
How is hypertensive emergency treated
Sodium nitroprusside
Labetalol
GTN
Esmolol
How is hypertensive urgency treated
Amlodipine
Diltiazem
Lisinopril
ACE inhibitor + calcium antagonist
Give an overview of pheochromocytoma
Triad of: episodic headaches, sweating, tachycardia
Diagnosis: measure urine and plasma fractionated metanephrines and catecholamines, 24 hr urine collection, CT/MRI pelvis (look for renal tumours)
Management: adrenal resection, control hypertension (alpha and beta blockers)
