Cardiology Flashcards
SVT
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
Digoxin Toxicity
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
Complications of MI
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
ECG Calcium
High - shortened QT
Low - prolonged Qt
ECG: Potassium
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
Pericarditis
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
Pathway for STEMI Management
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
NSTEMI pathway
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
Aortic Dissection
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
DVLA issues
Angioplasty/ pacemaker - 1 week
ACS - 4 weeks if no angioplasty
Angina - stop if happens at rest
Aneurysm - DVLA review >6cm, no driving >6.5
Loop Diuretics
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
Aspirin
All patients with IHD should be on if no contra-indication
Potentiates steroids, warfarin and oral hypoglycaemics
Aortic Regurg
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)
Aortic Stenosis
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
Mitral Stenosis
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
Mitral Regurg
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
Heart Failure: Management
- ACEi and B-blocker
- Aldosterone Antagonist - monitor potassium
SGLT2 inhibitor
- specialist - ivabradine , sacubitril-valsartan, digoxin or hydralazine (^black), cardiac resynch (wide QRS)
+ annual Influenza and one-off pneumo
BiFasicular Block
Trifasicular
RBBB + LAD
+/- 1st degree heart block
Infective Endocarditis: Organisms
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)
PAD Management
-> 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
Methods of Action of AC
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
Warfarin Potentiation
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)
Atherosclerosis
- Endothelial dysfunction
- Changes to the endothelium including pro-inflmmatory, pro-oxidant and reduced NO
- LDL infiltrate subendothelial space
- Monocytes turn to macrophages and phagoctyose LDL coming foam cells.
5 Smooth muscle proliferation causes fibrous capsule over fatty plaque
ECG territories
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.
Secondary Prevention of MI
Aspirin + Clopidogrel
Beta-blocker
ACEi
Statin
Criteria for a STEMI
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
ACS: 30 Day Mortality
KIllip class system
- no signs of HF - 6% mort
- lung crackles or S3 - 17%
- Frank pulmonary oedema - 38%
- Cardiogenic Shock - 81%
ALS algorithms
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
Reversible Causes of Arrest
H’s - Hypoxia, Hypovolaemia, Hyperkalemia, hypothermia
The T’s - Thrombosis, tension, tamponade and toxins
Other met disorders e.g., hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia
Angina Management
All get GTN, aspirin and statin
- BB or CCB (rate-limiting e.g., v/d)
- Combine the two (a/n)
- Assess for PCR/ CABG, long-acting nitrates, ivabradine, nicorandil or ranolazine
Nitrates - need asymmetrical dosing, free time of 10-14hrs
Genetic Cardiomyopathies
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)
Mixed + Acquired Cardiomyopathies
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
Anticoagulation in AF
Assess using CHA2DS2- VASc (+/- ORBIT)
Treat if 1 in M if 2 in F
Do TTE to excl. valve disease if suggests no treatment
AF: Rate Control
1st line unless; reversible cause, causing HF, new onset (<48hrs)
-> BB, CCB (d/v), digoxin
+ heparin
AF: Rhythm Control
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)
ASD
Most common CHD in adults (^secundum)
= ejection systolic murmur, louder on insp, fixed split s2, stroke
Primum = RBBB +LAD
Secundum = RBBB + RAD
AV block
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
BNP
Hormone produced by the left myocardium once strained
Causes - MI, valvular heart disease, CKD
Reduced by ACEi, ARB, diuretics
Brugada Syndrome
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
Buerger’s disease
Thromboangitis obliterans, small and medium vessel vasculitis, ^smokers
= extremity ischaemia, superficial thrombophlebitis, Raynaud’s
Cardiac Enzymes
Myoglobin - first to rise
CK-MB - useful for re-infarction, normal after 2-3d
Trop T stays high
Cardiac Tamponade
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
NYHA classification
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
Hypothermia ECG
= bradycardia, J waves (small hump end QRS), first degree HB, ^QT
Ischaemic ECG changes
Hyperacute T waves
T invert in first 24 hours (lasts day to months)
Q waves after days (permanent)
Wellen’s Syndrome
High grade stenosis in LAD
= biphasic or deep T wave inversion in V2 - 3, minimal ST elevation
Acute HF: Management
-> 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
Heart Sounds
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)
Diagnosis of HTN
-> 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)
HTN: Management
Low salt diet. Reduce caffeine. Other general advice
- ACEi (< 55 or T2DM), CCB (55+, black)
- +thiazide or the alternative (ARB > ACE if black)
- ACEi/ ARB + CCB + TD
? adherence, expert, postural
4 - K < 4.5 add spironolactone, K > 4.5 alpha or beta blocker
Blood pressure targets
<80 - 140/90 or 135/85 in ABPM
> 80 - 150/90 or 145/85 ABPM
Infective Endocarditis
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
Long QT
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)
MV prolapse
CHD
Turners, Fragile X
Marfan’s
Osteogenesis imperfectica
WPW
Long QT
EDS
PCKD
Cardiomyopathy
= chest pain, palp, mid systolic click, late systolic murmur
Myocarditis
Cause - viral, autoimmune, doxorubicin
= young, acute onset chest pain, SOB, arrhythmia
Inv - ^inflam, trop, BNP, ECG (tachy, arrhythmia, ^ST, T inversion)
Orthostatic Hypotension
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
Rheumatic Fever
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
Takayasus Arteritis
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
Torsades
Polymorphic ventricular tachycardia
Cause - ^QT
-> IV magnesium sulphate
Management of a High INR
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
Grading Murmurs
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
VT
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)
Constrictive Pericarditis
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)
Bradycardia ALS
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)
Coarctation of the Aorta
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
Components of the ORBIT Score
Hb / haematocrit low
Age over 74
Hx GI/ IC bleed or stroke
GFR <60
Antiplatelets
= low 0-2, med 3, high 4-7
QT interval
Time between the start of the Q wave and the end of the T wave
PR segment
End of P wave to start of R
PR interval
Start of P to start of R
AAA
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)
Familial Hypercholesterolaemia
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
Arteries and their supply
RCA - RA, RV and posterior septum
Circumflex - Left atrium and Posterior LV
LAD - Anterior aspect of LV and septum
Types of MI
1 - spontaneous (plaque rupture)
2 - Ischaemia
3 - death without biomarkers
4 - a) PCI, b) stent thrombosis
5 - CABG
Acute HF
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
HF: CXR
Alveolar oedema (bat wing)
kerley B lines (interstitial oedema)
Cardiomegaly - cardiothoracic ratio > 0.5
Dilated upper lobe vessels
pleural Effusion
Cor Pulmonale
Right-sided HF 2nd to resp disease, ^pressure and resistance in pulmonary arteries, backpressure
= cyanosis, oedema, JVP, S3, TR, hepatosplenomegaly, tall p waves
MOA of Alteplase
Activates plasminogen to form plasmin
Use - thrombolysis
Pacemakers
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
ECG changes in pacemakers
Line before the QRS indicates a lead in the ventricle
Line before the P wave indicates a lead in atria.
AC and AP therapy
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
CHA2DS2VASC
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
