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Cardiology Flashcards

1
Q

SVT

A

Sudden onset of a regular narrow complex tachycardia, ^AVNRT than AVRT

-> 1) valsalva (empty syringe, carotid sinus massage), 2) IV adenosine (6-12-18) or verapamil if asthma, DC cardioversion if unstable

Prevent - b-blockers, RF ablation

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2
Q

Digoxin Toxicity

A

Causes - v K/ Mg, ^Ca/ Na, v PH, v temp, age, renal failure, MI, v thyroid, v albumin, amiodarone, verapamil, ciclosporin, thiazides, loops

= lethargy, nausea, anorexia, confusion, arrythmia, gynaecomastia, yellow-green vision

Inv - ECG (sloping ST depression, short QT, flat/ inverted T, AV block, brady)

-> digibind, only routinely monitor in toxicity, measure 8-12hrs from last dose, monitor K

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3
Q

Complications of MI

A

Death
Arrhythmia - VF -> arrest, AV block after inf.
Rupture - free wall, IV septum, papillary muscle
Tamponade
Heart failure

Valvular - acute VSD, MR (pansystolic)
Aneurysm of ventricle - persistent ST elevation
Dressler’s - AI pericarditis 2-6wks (vs normal 2 days)
Embolus - stroke
Recurrence

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4
Q

ECG Calcium

A

High - shortened QT

Low - prolonged Qt

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5
Q

ECG: Potassium

A

High

= tall tented T, short QT, no p, broad QRS, sine waves, VF

Mild 5.5-6, Mod 6.0-6.5, Severe >6.5

= all with severe/ ECG changes need calcium gluconate (stabilises myocardium), insulin/ dextrose infusion (drives K into cells), neb salbutamol, calcium resonoum (enema, removes it)

*If in AKI and and persistent high K+ consider dialysis

Low

= U waves (upward deflection after T) , small T waves, long PR, ST depression

U have no Pot and no T but a long PR and QT

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6
Q

Pericarditis

A

Inflammation of pericardial sac, <6wks (normally 2wk)

Causes - virus (cox), TB, post-MI, radiotherapy, uraemia, SLE/ RA, v thyroid, lung/ breast cancer, trauma

= pleuritic pain, better leaning forward, tachycardia, SOB, pericardial rub, flu-liek, fever

Inv - ^ESR, ^trop, ECG (widespread saddle ST elevation, PR depression), all get TT ECHO

-> NSAIDs, Colchicine

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7
Q

Pathway for STEMI Management

A

All get aspirin 300mg

Symptoms <12hrs + PCI possible <120 min

Yes - Angiography + follow-on PCI, Prasugrel + aspirin, UFH + bailout gp25/3ai

No - Fibrinolysis, Antithrombin, ECG 60-90min after, Ticagrelor + aspirin

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8
Q

NSTEMI pathway

A

All get Aspirin 300mg.

Fondaparinux if PCI not immediately planned (i., not unstable)

GRACE mortality score (6m)

> 3% - immediate PCI if unstable, or angiography <72hrs, prasugrel/ ticagrelor + aspirin, UFH

<3% - ticagrelor + aspirin

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9
Q

Aortic Dissection

A

Tear in the intima

RF- HTN, trauma, bicuspid aortic valve, Marfan, EDS, syphilis, Turner’s, Noonan’s, preg

= sudden severe sharp chest pain, upper back if desc, pulse deficit, AR, HTN, angina (coronary), paraplegia (spinal), limb ischaemia (distal aorta)

Inv - CXR (wide mediastinum), CT angiography (CAP, false lumen), TO ECHO (if not fit for CT)

Type A - ascending aorta
Type B - distal to left subclavian

-> BP control, surgery for type A, IV labetalol and bed rest for type B

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10
Q

DVLA issues

A

Angioplasty/ pacemaker - 1 week
ACS - 4 weeks if no angioplasty
Angina - stop if happens at rest
Aneurysm - DVLA review >6cm, no driving >6.5

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11
Q

Loop Diuretics

A

Inhibit the Na/K/cl transporter in thick ascending limb

SE: v BP, v Na, v Mg, v Na, v K, v Cl alkalosis, ototoxic, gout, ^glucose, renal impairment

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12
Q

Aspirin

A

All patients with IHD should be on if no contra-indication

Potentiates steroids, warfarin and oral hypoglycaemics

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13
Q

Aortic Regurg

A

Causes - rhematic fever, calcification, RA, SLE, dissection, IE, bicuspid aortic valve, syphilis, marfans, EDS, ank spond

= early diastolic, collapsing pulse, wide pulse pressure and head bobbing (de mussets) and nailbed pulsation (quinckes)

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14
Q

Aortic Stenosis

A

Cause - calcified, bicuspid, William, HOCM, RF

= chest pain, SOB, syncope, ejection systolic murmur, radiates to carotids, v with valsalva

^Severity = narrow pulse pressure, slow rising pulse, soft S2, S4, thrill, duration

-> treat symptomatic or gradient >40mmHg, surgical or transcatheter AVR

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15
Q

Mitral Stenosis

A

Cause - RF, carcinoid

= SOB, haemoptysis, mid-late diastolic murmur, loud S1, low volume pulse, opening snap, malar flush, AF

^Severe = duration, snap close to S2

-> observe and regular ECHO if no symptoms, balloon valvotomy

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16
Q

Mitral Regurg

A

RF - F, v BMI, age, renal dysfunction, CTD

Cause - post-MI, IE, RF

= blowing pansystolic murmur, to axilla, quiet S1, split S2 if severe

Inv - ECG (broad P), CXR (cardiomegaly)

-> repair > replacement

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17
Q

Heart Failure: Management

A
  1. ACEi and B-blocker
  2. Aldosterone Antagonist - monitor potassium

SGLT2 inhibitor

  1. specialist - ivabradine , sacubitril-valsartan, digoxin or hydralazine (^black), cardiac resynch (wide QRS)

+ annual Influenza and one-off pneumo

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18
Q

BiFasicular Block

Trifasicular

A

RBBB + LAD

+/- 1st degree heart block

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19
Q

Infective Endocarditis: Organisms

A

Staph Aureus - most common

Strep Viridans - developing countries, poor dental hygiene

Staph epidermidis - valve surgery <2m ago, lines

Strep bovis - CRC

Non-infective - SLE (libman-sacks)

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20
Q

PAD Management

A

-> stop smoking, statin 80mg, clopidogrel, exercise training

Severe PAD / critical ischaemia
-> endovascular revascularisation (<10cm or aortoiliac disease) or surgical (>10cm, multifocal, common fem, infrapop alone)

E.g., angioplasty, bypass, amputation

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21
Q

Methods of Action of AC

A

Dabigatran - direct thrombin inhibitor, reverse with Idarucuzumab

Rivaroxaban/ apixaban - direct Xa inhibitor, reverse with Andexanet alpha

Edoxaban - Xa inhibitor, no reversal

Heparin - activates antithrombin 3

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22
Q

Warfarin Potentiation

A

Metabolised by CYP450

^INR with;
liver disease
P450 inhibitors
cranberry juice
brocolli, spinach, kale, sprouts (high Vit K)
NSAIDs (displace warfarin from plasma albumin/ inhibit platelet function)

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23
Q

Atherosclerosis

A
  1. Endothelial dysfunction
  2. Changes to the endothelium including pro-inflmmatory, pro-oxidant and reduced NO
  3. LDL infiltrate subendothelial space
  4. Monocytes turn to macrophages and phagoctyose LDL coming foam cells.
    5 Smooth muscle proliferation causes fibrous capsule over fatty plaque
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24
Q

ECG territories

A

Anterior - V1-V4 - LAD
Inferior - 2,3 and AvF - right coronary
Lateral - 1, V5 and 6 - left circumflex

PAILS - ST elevation changes in these leads cause depression in the next. ie elevation in posterior causes depression in anterior.

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25
Q

Secondary Prevention of MI

A

Aspirin + Clopidogrel
Beta-blocker
ACEi
Statin

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26
Q

Criteria for a STEMI

A

Clinical features + persistent ECG features in 2 contiguous leads:

2.5mm St elevation in V2-3 in men under 40 or over 2.0 in over 40 year olds
1.5mm elevation in these leads for women
1mm other leads
New LBBB

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27
Q

ACS: 30 Day Mortality

A

KIllip class system

  1. no signs of HF - 6% mort
  2. lung crackles or S3 - 17%
  3. Frank pulmonary oedema - 38%
  4. Cardiogenic Shock - 81%
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28
Q

ALS algorithms

A

30:2 compressions to ventilation breaths

Non-shockable - PEA/ asystole -> 1mg adrenaline

Shockable - VF/ pulseless VT

-> 1 shock (3 if witness + monitored), up to 3, 1mg adrenaline every 3-5mins, amiodarone (300mg after 3 shocks, 150mg after 5)

Extend CPR by 60-90min if given thromolytic drug

IV> IO, tracheal not recommended

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29
Q

Reversible Causes of Arrest

A

H’s - Hypoxia, Hypovolaemia, Hyperkalemia, hypothermia

The T’s - Thrombosis, tension, tamponade and toxins

Other met disorders e.g., hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia

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30
Q

Angina Management

A

All get GTN, aspirin and statin

  1. BB or CCB (rate-limiting e.g., v/d)
  2. Combine the two (a/n)
  3. Assess for PCR/ CABG, long-acting nitrates, ivabradine, nicorandil or ranolazine

Nitrates - need asymmetrical dosing, free time of 10-14hrs

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31
Q

Genetic Cardiomyopathies

A

HOCM
AD, ^sudden cardiac death, beta mysoin heavy chain gene mutation, diastolic dysfunction
Link - Friedreich’s ataxia, WPW
= functional AS (^ Valsalva, v squat), exertional SOB, syncope, ventricular arrhythmias, Bisferiens (double) pulse
Inv - ECHO (MR SAM ASH), biopsy (myofibrillar hypertrophy, myocytes ‘disarray’ and fibrosis)
-> amiodarone, BB, ICD, dual pacemaker and endocarditis prophylaxis (NO ACEI)

RA Arrhythmogenic
AD, 2nd common, RV myocardium replaced by fibrous fatty tissue
= T wave inversion in V1-3 or terminal notch in QRS (epsilon)

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32
Q

Mixed + Acquired Cardiomyopathies

A

Dilated (90%)
Causes - alcohol, baby (pregnancy), wet beri beri (v thiamine), Coxsackie B, Chaga’s, cocaine, Duchenne’s, doxorubicin
= systolic dysfunction and murmur, S3
Inv - CXR (balloon)

Restrictive
Causes - amyloid, TB, post-radiotherapy

Acquired
Takotsubo
= apical ballooning of myocardium after stress, chest pain, HF
Inv - ST elevation, normal angio

Secondary; haemochromatosis, sarcoidosis, DM, thyrotoxicosis, acromegaly, myotonic dystrophy, SLE

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33
Q

Anticoagulation in AF

A

Assess using CHA2DS2- VASc (+/- ORBIT)

Treat if 1 in M if 2 in F

Do TTE to excl. valve disease if suggests no treatment

34
Q

AF: Rate Control

A

1st line unless; reversible cause, causing HF, new onset (<48hrs)

-> BB, CCB (d/v), digoxin

+ heparin

35
Q

AF: Rhythm Control

A

Immediate CV if <48hrs or unstable
-> electrical (no AC after), flecanide, amiodarone (SHD)

Delayed CV if >48hrs and stable
-> 3wks AC before electrical (+/- amiodarone), rate-control while waiting

Long-term rhythm control
-> B-blocker (not sotolol), dronedarone, amiodarone (if HF)

No response/ don’t want drugs
-> RF ablation (AC 4wks before and during, 2m after then reassess)

36
Q

ASD

A

Most common CHD in adults (^secundum)

= ejection systolic murmur, louder on insp, fixed split s2, stroke

Primum = RBBB +LAD
Secundum = RBBB + RAD

37
Q

AV block

A

1st - PR > 0.2secs, no need to treat

2nd
- T1 (Wenckebach): progressive prolongation until dropped beat
- T2: constant PR but often p wave not followed by QRS

3rd - no association between atria and ventricles

38
Q

BNP

A

Hormone produced by the left myocardium once strained

Causes - MI, valvular heart disease, CKD

Reduced by ACEi, ARB, diuretics

39
Q

Brugada Syndrome

A

AD, inherited CVD, SCN5A gene (sodium channel), ^Asian

= sudden cardiac death

Inv - ECG (convex st elevation in V1-3, inverted T, may have partial RBBB), more obvious with flecainide

-> ICD

40
Q

Buerger’s disease

A

Thromboangitis obliterans, small and medium vessel vasculitis, ^smokers

= extremity ischaemia, superficial thrombophlebitis, Raynaud’s

41
Q

Cardiac Enzymes

A

Myoglobin - first to rise
CK-MB - useful for re-infarction, normal after 2-3d
Trop T stays high

42
Q

Cardiac Tamponade

A

Accumulation of pericardial fluid under pressure

= v BP, ^JVP, muffled heart sounds, SOB, tachycardia, absent Y descent, Pulsus paradoxus (v BP on inspiration), electrical alternans

-> pericardiocentesis., PC balloon pericardiotomy if cancer

43
Q

NYHA classification

A

1 - no symptoms and no limitation

2 - mild symptoms and slight limitation (comfy at rest).

3 - moderate symptoms and marked limitation (still comfy at rest)

4 - severe symptoms and even at rest

44
Q

Hypothermia ECG

A

= bradycardia, J waves (small hump end QRS), first degree HB, ^QT

45
Q

Ischaemic ECG changes

A

Hyperacute T waves
T invert in first 24 hours (lasts day to months)
Q waves after days (permanent)

46
Q

Wellen’s Syndrome

A

High grade stenosis in LAD

= biphasic or deep T wave inversion in V2 - 3, minimal ST elevation

47
Q

Acute HF: Management

A

-> IV loop diuretic, oxygen, vasodilators (if associated MI or severe HTN), CPAP if resp failure,

Severe v BP - inotropes i.e, dobutamine.

Continue regular HF meds, stop BB if HR <50

48
Q

Heart Sounds

A

S1 - closure of M and T (soft in MR, loud in MS)

S2 - closure of A and P (soft in AS, loud in pulm HTN, normal to split on insp)

Pulmonary HTN - valves closing with more force due to higher pressure

S3 - diastolic filling of LV (normal <30, or MR, LVF, constrictive pericarditis)

S4 - atrial contraction against stiff LV (AS, HOCM, HTN)

49
Q

Diagnosis of HTN

A

-> treat all stage 2, stage 1 if <80yrs + CVD/ DM/ kidney/ 10% Qrisk

Stage 1 > 140/90 (ABPM 135/85)

Stage 2 >160/100 (ABPM 150/95)

Stage 3 >180 systolic or >120 diastolic
-> admit for assessment if retinal bleed, papilloedema, confusion, chest pain, AKI (if none then urgent inv. for organ damage)

50
Q

HTN: Management

A

Low salt diet. Reduce caffeine. Other general advice

  1. ACEi (< 55 or T2DM), CCB (55+, black)
  2. +thiazide or the alternative (ARB > ACE if black)
  3. ACEi/ ARB + CCB + TD

? adherence, expert, postural

4 - K < 4.5 add spironolactone, K > 4.5 alpha or beta blocker

51
Q

Blood pressure targets

A

<80 - 140/90 or 135/85 in ABPM

> 80 - 150/90 or 145/85 ABPM

52
Q

Infective Endocarditis

A

RF - 50% normal valves (^m), prev. IE, IVDU (t), prosthetic valves, RHD, CHD, recent piercings

Modified Dukes (2 major, 1 major + 3 minor, 5 minor)

Major - two typical cultures (3+ atypical), ECHO (oscillation, abscess, dehiscence of prosthetic), or new regurg

Minor - RF, don’t meeting major, >38, vascular (emboli, clubbing, splenomegaly, splinter, janeway) or immunological issues (GN, roth spots, osler nodes)

-> Abx (amox +/- gent empirical), surgery if aortic abscess (^PR), not responding, cardiac failure and recurrent emboli

53
Q

Long QT

A

Causes
Jervell-Lange-Nielsen (deaf), Romano-Ward (not)
Drugs - amiodarone, sotalol, TCA, SSRIs (^citalopram), methadone, erythromycin, haloperidol, ondansetron
Electrolytes - v Ca/ K/ Mg
Other - acute MI, myocarditis, hypothermia, SAH

Long QT1 - exertional syncope (swimming)
Long Qt2 - following stress or auditory stimuli
Long QT3 - at night or at rest

-> b-blockers (NOT sotolol)

54
Q

MV prolapse

A

CHD
Turners, Fragile X
Marfan’s
Osteogenesis imperfectica
WPW
Long QT
EDS
PCKD
Cardiomyopathy

= chest pain, palp, mid systolic click, late systolic murmur

55
Q

Myocarditis

A

Cause - viral, autoimmune, doxorubicin

= young, acute onset chest pain, SOB, arrhythmia

Inv - ^inflam, trop, BNP, ECG (tachy, arrhythmia, ^ST, T inversion)

56
Q

Orthostatic Hypotension

A

A drop in BP (20/10) within 3min of standing

RF - old, neurogenic (Parkinson’s), autonomic (DM), alcohol, a-blockers, L-dopa, diuretics, anti-depressants

-> midodrine, fludrocortisone

57
Q

Rheumatic Fever

A

Cause - group A strep pyogenes infection 2-6wks ago (molecular mimicry of the M protein)

Revised Jones criteria - 2 major or 1 major and 2 minor, + evidence of recent group A strep)

Major
Joint polyarthritis
Organ inflammation (carditis, valvulitis)
Nodules (SC)
Erythema marginatum
Sydenham’s chorea

Minor
^ESR / CRP, ^temp, ^PR, arthralgia

-> PO penicillin V, NSAIDs

58
Q

Takayasus Arteritis

A

Large vessel vasculitis, causes occlusion of the aorta

Link - renal artery stenosis

= young asian F, absent peripheral pulses, unequal BP in arms, limb claudication on exertion, AR, carotid bruit, vasculitis features

Inv - CTA or MRA

-> steroids

59
Q

Torsades

A

Polymorphic ventricular tachycardia

Cause - ^QT

-> IV magnesium sulphate

60
Q

Management of a High INR

A

Major Bleed:
-> Stop warfarin, IV Vit K 5mg, prothrombin complex concentrate

Minor Bleed:
-> stop warfarin, IV vit K 1-3mg (INR >8 repeat if still high at 24hrs), restart when INR <5

No Bleeding:
-> INR >8 - stop warfarin, PO vit K (repeat if still high at 24hrs), restart when INR <5
-> INR 5-8 - withhold 1-2 doses and reduce maintenance dose

61
Q

Grading Murmurs

A

Levine Scale

1 - very faint
2 - slight murmur
3 - moderate murmur no thrill
4 - loud and palpable thrill
5 - very loud and heard with edge of stethoscope
6 - extremely loud - stethoscope not touching chest

62
Q

VT

A

Broad-complex tachycardia, from ventricular ectopic focus

Causes - MI (mono), ^QT (poly)

-> amiodarone via central line, cardiovert unstable

If irregular - seek expert help (AF with BBB is most likely cause)

63
Q

Constrictive Pericarditis

A

Cause - TB pericarditis

= SOB, right HF (^JVP, ascites, oedema, hepatomegaly), pericardial knock (loud S3), +ve Kussmaul’s (paradoxical JVP rise on inspiration)

Inv - JVP (prominent x and y descent), CXR (pericardial calcification)

64
Q

Bradycardia ALS

A

Treat if;
Shock
Syncope
MI
HF

-> Atropine 500mcg IV up to 6 times

TC pacing, isoprenaline infusion, adrenaline IV if fails

TV pacing (expert, if risk of asystole)
- consider all with complete heart block + wide QRS, recent asystole, ventricular pause >3 seconds and Mobitz type 2 (even if good atropine response)

65
Q

Coarctation of the Aorta

A

Congenital arrowing of descending aorta

RF - ^men, Turner’s, bicuspid aortic v, NF, berry aneurisms

= infant HF, HTN, radio-femoral delay, apical click, mid systolic murmur (heard on back), notching of inferior border of ribs

66
Q

Components of the ORBIT Score

A

Hb / haematocrit low
Age over 74
Hx GI/ IC bleed or stroke
GFR <60
Antiplatelets

= low 0-2, med 3, high 4-7

67
Q

QT interval

A

Time between the start of the Q wave and the end of the T wave

68
Q

PR segment

A

End of P wave to start of R

69
Q

PR interval

A

Start of P to start of R

70
Q

AAA

A

Routine screening occur in men at 65 with abdo US

<3 cm - normal - no action
3-4.5 - small - scan every year
4.5 - 5.5 - medium - every 3 months
5.5+ - large - 2WW referral

Also 2WW; increase in 0.5cm in 6m or 1cm in year, symptoms (^risk of rupture)

71
Q

Familial Hypercholesterolaemia

A

AD, mutation encoding LDL receptor, high LDL and total cholesterol, 1 in 500

Simon Broome criteria
TC >7.5 + LDL >4.9 in adults +
Definitive - FHx, tendon xanthoma
Possible - FHx MI <50 or high cholesterol

-> high dose statins, refer to lipid clinic

72
Q

Arteries and their supply

A

RCA - RA, RV and posterior septum

Circumflex - Left atrium and Posterior LV

LAD - Anterior aspect of LV and septum

73
Q

Types of MI

A

1 - spontaneous (plaque rupture)
2 - Ischaemia
3 - death without biomarkers
4 - a) PCI, b) stent thrombosis
5 - CABG

74
Q

Acute HF

A

Sudden onset or worsening of HF symptoms

25% de-novo, 75% decompensation

= SOB, v exercise tolerance, oedema, fatigue, cyanosis, ^JVP, displaced apex, bibasal crackles, wheeze, S3

75
Q

HF: CXR

A

Alveolar oedema (bat wing)

kerley B lines (interstitial oedema)

Cardiomegaly - cardiothoracic ratio > 0.5

Dilated upper lobe vessels

pleural Effusion

76
Q

Cor Pulmonale

A

Right-sided HF 2nd to resp disease, ^pressure and resistance in pulmonary arteries, backpressure

= cyanosis, oedema, JVP, S3, TR, hepatosplenomegaly, tall p waves

77
Q

MOA of Alteplase

A

Activates plasminogen to form plasmin

Use - thrombolysis

78
Q

Pacemakers

A

Deliver controlled electrical impulses to heart areas

Pulse generator and pacing leads, placed under axilla or left anterior chest wall

Single Chamber
= RA if SAN issue, RV if AVN

Dual Chamber
= lead in the right atrium and right ventricle.

Triple chamber
= RA, RV and LV, normally for HF (cardiac resynchronization)

ICD - monitor the heart and apply defib shock to cardiovert back

79
Q

ECG changes in pacemakers

A

Line before the QRS indicates a lead in the ventricle

Line before the P wave indicates a lead in atria.

80
Q

AC and AP therapy

A

Stable CVD (mono AP) + AF (mono AC)
= AC

Post ACS / PCI (2AP) + AF (mono AC)
= 2AP and 1AC for <6 months, then 1AP and 1AC until 12 months total

CVD (AP) + VTE (3-6m AC)
= stop AP if high risk of bleeding with both

81
Q

CHA2DS2VASC

A

C Congestive heart failure 1
H Hypertension (or treated hypertension) 1
A2 Age >= 75 years 2
Age 65-74 years 1
D Diabetes 1
S2 Prior Stroke, TIA or thromboembolism 2
V Vascular disease (incl. IHD/ PAD) 1
S Sex (female) 1

ALS (22 decks)

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