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Cardiology Flashcards

1
Q

What is cardiovascular disease

A

Chronic inflammation and activation of immune system in artery walls

Affects medium and large arteries

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2
Q

What do deposits of lipids in artery walls do

A

Stiffen (causing hypertension and putting additional strain on heart)

Stenose (reducing blood flow)

Rupture (give off thrombus that can lodge elsewhere)

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3
Q

What are the non-modifiable risk factors for cardiovascular disease

A

Older age

Family history

M>F

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4
Q

What are the modifiable risk factors for cardiovascular disease

A

Smoking

Alcohol

Poor diet (high in sugars and fats)

Low exercise

Obesity

Poor sleep

Stress

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5
Q

What are the co-morbidities associated with cardiovascular disease

A

Diabetes

Hypertension

CKD

Inflammatory conditions

Atypical antipsychotic medications

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6
Q

What are the end results of atherosclerosis

A

Angina

Myocardial infarction

Transient ischaemic attack

Stroke

Peripheral vascular disease

Chronic mesenteric ischaemia

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7
Q

What is the QRISK3 score

A

Percentage risk that a person will have a stroke or MI in the next 10 years

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8
Q

What should be done if a QRISK score is > 10%

A

Start a statin

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9
Q

What are the NICE statin use recommendations

A

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)

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10
Q

What are the 4 As of secondary prevention of cardiovascular disease

A

Aspirin (plus a second antiplatelet)

Atorvastatin

Atenolol (or another beta blocker)

ACE inhibitor

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11
Q

What are the side effects of statins

A

Myopathy (check creatinine kinase if muscle pain/weakness)

T2DM

Haemorrhagic stroke

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12
Q

What is angina

A

Narrowing of coronary arteries causing reduced blood flow to myocardium

During exertion

Constricting chest pain

May radiate to arm/jaw

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13
Q

What are the 2 types of angina

A

Stable (relied by rest or GTN)

Unstable (come on at rest, considered an ACS)

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14
Q

What are the high risk factors for angina

A

Diabetes

Smoking

Hyperlipidaemia

Hypertension

Family history

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15
Q

What investigations are needed for angina

A

CT coronary angiograph (gold standard)

ECG

FBC, U&Es, LFTs, bone profile, TFTs, HbA1c

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16
Q

What are the appropriate investigations based on the likelihood of coronary artery disease

A

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%

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17
Q

What is the medical management for stable angina that gives immediate relief

A

GTN

PRN, causes vasodilation.

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18
Q

What are the medical managements for stable angina that gives long term relief

A

Beta blockers

Calcium channel blockers

Second line: long acting nitrates (ivabradine, nicorandil)

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19
Q

What is the secondary prevention for stable angina

A

Aspirin (75mg OD)

Atorvastatin (80mg OD)

ACE inhibitors

Beta blockers

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20
Q

What is the surgical management for stable angina

A

Percutaneous coronary intervention (PCI) with coronary angioplasty

Coronary artery bypass graft (CABG)

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21
Q

What are the causes of non-cardiac chest pain

A

Costochondritis

GORD

PE

Pneumonia

Pneumothorax

Psychogenic/psychomotor

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22
Q

Which parts of the heart does the right coronary artery supply

A

Right atrium

Right ventricle

Inferior left ventricle

Posterior septal area

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23
Q

Which parts of the heart does the circumflex artery supply

A

Left atrium

Posterior left ventricle

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24
Q

Which parts of the heart does the left anterior descending artery supply

A

Anterior left ventricle

Anterior septal area

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25
What are the 3 types of acute coronary syndrome
Unstable angina STEMI NSTEMI
26
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
27
What investigations are needed for acute coronary syndrome
ECG Troponin FBC, U&Es, LFTs, lipid profile, TFTs, HbA1c CXR/CT coronary angiogram
28
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
29
What conditions can mimic STEMI on ECG
Pericarditis Brugada syndrome
30
What are the ECG signs of NSTEMI
ST depression Deep T wave inversion Pathological Q waves
31
What are the ECG signs of unstable angina
ST depression T wave inversion
32
How long after myocardial damage does troponin start to rise
3-4 hrs
33
What are some non-ACS causes of raised troponin
Chronic renal failure Sepsis Myocarditis Aortic dissection PE
34
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
35
What is the management for NSTEMI/unstable angina
Analgesia Aspirin LMWH Repeat ECG
36
What is the GRACE score
Gives 6 month risk of death/repeat MI following an NSTEMI
37
What are the complications of MI
Death Rupture of heart septum/papillary muscles Oedema Arrhythmias, aneurysms Dressler's syndrome
38
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)
39
What is the secondary prevention for acute coronary syndrome
Aspirin Another antiplatelet Atorvastatin ACE inhibitors Atenolol Aldosterone antagonist
40
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
41
What are the causes of pulmonary oedema
Iatrogenic (aggressive fluids) Sepsis Myocardial infarction Arrhythmias
42
How might pulmonary oedema present
Shortness of breath (exacerbated on lying flat) Type 1 respiratory failure Feeling unwell Cough
43
What would you find on examination in pulmonary oedema
Increased respiratory rate Reduced oxygen saturations Tachycardia 3rd heart sound Bibasal crackles Cardiogenic shock
44
What investigations are needed for pulmonary oedema
ECG ABG CXR ECHO BNP, troponin
45
What is BNP
B-type natriuretic peptide Released from ventricles when excessively stretched Vasodilator, diuretic Sensitive, but not specific
46
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)
47
What is the NICE cutoff for hypertension
140-90 in clinic 135/85 at home
48
What are the secondary causes of hypertension
ROPE Renal disease Obesity Pregnancy/pre-eclampsia Endocrine (hyperaldosteronism)
49
How might a patient with hypertension present
Asymptomatic Headaches
50
What are the complications of hypertension
Ischaemic heart disease Cerebrovascular accident Hypertensive retinopathy Hypertensive nephropathy Heart failure
51
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
52
What investigations are needed for hypertension
Urine albumin:creatinine ratio HbA1c Fundus examination ECG ECHO
53
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)
54
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
55
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
56
What are the treatment targets for hypertensives < 80
< 140 <90
57
What are the treatment targets for hypertensives > 80
< 150 < 90
58
What are the treatment targets for hypertensives with diabetes/stroke/MI/CKD
< 130 < 80
59
What is systolic and diastolic heart failure
Systolic - impaired left ventricular contraction Diastolic - ventricular relaxation
60
How might chronic heart failure present
Breathlessness Cough Orthopnoea (breathless on lying flat) Paroxysmal nocturnal dyspnoea (waking at night short of breath) Peripheral oedema
61
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
62
What investigations are needed for chronic heart failure
FBC, U&Es, LFTs, TFTs, BNP CXR ECG ECHO (confirms diagnosis), cardiac MRI
63
What might CXR show in chronic heart failure
Cardiomegaly Pleural effusion Perihilar shadowing/consolidation Alveolar oedema Air bronchograms Increased width of vascular pedicles
64
What are the causes of chronic heart failure
Ischaemic heart disease Valvular heart disease Hypertension Arrhythmias Chronic lung disease Cardiomyopathy Previous chemotherapy HIV
65
What is the main management for chronic heart failure
ACE inhibitors Beta blockers Aldosterone antagonists Loop diuretics Surgery (for severe stenosis/regurge)
66
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
67
What is cor pulmonale
Right sided heart failure caused by respiratory disease
68
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
69
What are the respiratory causes of cor pulmonale
COPD PE Interstitial lung disease Cystic fibrosis Primary pulmonary hypertension
70
How might cor pulmonale present
Often asymptomatic Shortness of breath Peripheral oedema Syncope Chest pain
71
What might you find on examination in cor pulmonale
Hypoxia Cyanosis Raised JVP Peripheral oedema 3rd heart sound Murmur Hepatomegaly
72
What is the treatment for cor pulmonale
Treat underlying cause Long term oxygen therapy
73
What do S1 and S2 signify
S1: closing of tricuspid and mitral valves S2: closing of pulmonary and aortic valves
74
How is mitral stenosis best heard
Lie patient on left side
75
How is aortic regurgitation best heard
Lean patient forward, holding exhalation
76
How should murmurs be described
SCRIPT Site Character Radiation Intensity Pitch Timing
77
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
78
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
79
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
80
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
81
Give an overview of aortic regurgitation
Early diastolic, soft murmur Early diastolic, 'rumbling' murmur Collapsing pulse Causes: idiopathic age related weakness, connective tissue disorders
82
What are the shockable cardiac arrest rhythms
Ventricular tachycardia Ventricular fibrillation
83
What are the non-shockable cardiac arrest rhythms
Pulseless electrical activity Asystole
84
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
85
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
86
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
87
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
88
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
89
Give an overview of ventricular ectopics
Premature ventricular beats caused by random electrical discharge from outside atria Random, brief palpitations Management: general bloods, reassure
90
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
91
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
92
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)
93
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
94
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
95
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
96
How might atrial fibrillation present
Often asymptomatic Palpitations Shortness of breath Syncope
97
What can atrial fibrillation lead to
Haemodynamic instability Acute coronary syndrome Congestive heart failure Cardioembolic stroke
98
What will be seen on ECG in atrial fibrillation
Absent p waves Narrow QRS complex tachycardia Irregularly irregular ventricular rhythm
99
What are the common causes of atrial fibrillation
SMITH Sepsis Mitral valve pathology Ischaemic heart disease Thyrotoxicosis Hypertension
100
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
101
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
102
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
103
What is paroxysmal atrial fibrillation
Comes and goes in episodes Does not last > 48 hours Can use pill in pocket approach (flecanide)
104
Give an overview of warfarin
Vitamin K antagonist Prolongs prothrombin time Target INR 2-3 Half life 2-3 days Reversible with vitamin K
105
Give an overview of NOACs
Apixaban, dabigatran, rivaroxaban Inhibit factor Xa or thrombin directly Low bleeding risk Renally excreted (monitor renal function annually)
106
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)
107
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
108
Which cardiac conditions predispose to infective endocarditis
Mitral valve prolapse Prosthetic valves Rheumatic heart disease Degenerative aortic valve Bicuspid aortic valve Congenital heart disease
109
Which organisms cause infective endocarditis
Staphylococcus viridans Staphylococcus aureus Enterococcus
110
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
111
What is the medical management for infective endocarditis
Streptococci: benzylpenicillin + gentamicin Enterococci: amoxicillin + gentamicin Staphylococci: flucloxacillin + gentamicin
112
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
113
What are the indications for pacemaker insertion
Symptomatic bradycardia Mobitz type 2 heart block 3rd degree heart block Severe heart failure Hypertrophic obstructive cardiomyopathy
114
What is a hypertensive emergency
Increased blood pressure that will cause end organ damage within a few hours
115
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
116
What are the aims of treatment in hypertensive emergency/urgency
Reduce BP to 110 in: 3 - 12 hours (emergency) 24 hours (urgency)
117
How is hypertensive emergency treated
Sodium nitroprusside Labetalol GTN Esmolol
118
How is hypertensive urgency treated
Amlodipine Diltiazem Lisinopril ACE inhibitor + calcium antagonist
119
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)

Medicine (9 decks)

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