Cardiology Flashcards
1
Q
How do you calculate cardiac output?
A
Heart rate x stroke volume
2
Q
What three factors influence stroke volume?
A
Preload (depends on diastolic filling, and fiber stretch)
Contractility
After load (depends on arterial pressure)
3
Q
What generates S1?
A
S1 - first heart sound - generated by closure of atrioventricular valves.
Left side - mitral valve (closes first)
Right side - tricuspid valve
4
Q
What generates S2?
A
S2 - second heart sound - generated by the closure of the semilunar valves.
Left - aortic valve (first, slightly)
Right - pulmonary valve
5
Q
What are the 7 stages of the cardiac cycle?
- _____ _____
- Isovolumetric ___
- Rapid ______
- Reduced _____
- Isovolumetric _____
- Rapid ______ _____
- ______
A
- Atrial systole (sometimes S4)
- Isovolumetric contraction (S1)
- Rapid ejection
- Reduced ejection
- Isovolumetic relaxation (S2)
- Rapid ventricular filling (sometimes S3)
- Diastasis
6
Q
What type of murmur does aortic stenosis cause?
A
Ejection systolic murmur (crescendo-decrescendo)
7
Q
What type of murmur does mitral regurgitation cause?
A
Pansystolic murmur
8
Q
What type of murmur does mitral valve prolapse cause?
A
Late systolic murmur with a midsystolic click
9
Q
What type of murmur does aortic regurgitation (or pulmonary regurgitation) cause?
A
Early diastolic murmur
10
Q
What type of murmur does mitral stenosis cause?
A
Mid-diastolic murmur, with opening snap
11
Q
Rearrange these in order from inner lining to outer supporting tissue
Tunica adventitia, tunica intima, tunica media
A
Tunica intima - inner lining, single layer flattened endothelial cells. Supported by basement membrane and delicate collagenous tissue
Tunica media - intermediate muscular layer
Tunica adventitia - outer supporting tissue
12
Q
What type of ischemia does ST elevation show on an ECG?
A
Transmural ischemia (all layers of the heart - endocardium, myocardium, epicardium)
13
Q
What are the three signs of subendocardial ischemia on ECG?
A
ST depression - horizontal
ST depression - downsloping
T wave inversion
14
Q
Where the subendocardial layer of the heart?
What does it contain?
Damage to this layer can result in what?
A
Between the endocardium and myocardium
Purkinje fibres
Arrhythmias
15
Q
What are acute coronary syndromes?
A
MI - STEMI and NSTEMI
Unstable angina
16
Q
Which are the lateral leads on an ECG?
A
I, aVL, V5 and V6
17
Q
Which coronary artery do the lateral leads on an ECG correlate to?
A
Left circumflex artery
18
Q
What are the inferior leads on an ECG?
A
II, III and aVF
19
Q
What coronary arteries do the inferior leads on an ECG correlate to?
A
Right coronary artery
20
Q
Which are the septal leads on an ECG?
Which artery does this correlate to?
A
V1 and V2
Left anterior descending (LAD)
21
Q
Which are the anterior leads on an ECG?
Which artery does this correlate to?
A
V3 and V4
Left anterior descending (LAD)
22
Q
What does lead I measure on an ECG?
A
Right arm (-) to left arm (+)
23
Q
What does ECG lead II measure?
A
Right arm (-) to left leg (+)
24
Q
What is the normal cholesterol range?
Which is ‘good’ cholesterol HDL or LDL?
What does HDL cholesterol do?
What does LDL cholesterol do?
A
Normal range 3.5-6.5 mmol/L
HDLs ‘good cholesterol’ carry cholesterol away from arteries and back to the liver where it can be excreted
LDLs ‘bad cholesterol’ build up in the walls of the arteries, making them more narrow and less flexible
25
Give four examples of drug classes used to treat hypertension
26
What drug class is candesartan?
Angiotensin II receptor blocker (ARB)
2nd choice for hypertension behind ACE inhibitors
27
What type of diuretic is used for heart failure? Give an example.
Loop diuretic - furosemide
28
What type of diuretic is used for hypertension? Give an example.
Thiazide diuretic - bendroflumethiazide
29
What type of diuretic is used for heart failure and hypertension together? Give an example
Potassium-sparing : Spironolactone
30
Give examples of calcium channel blockers.
For which group of people would you prescribe this as first line for hypertension?
Amlodipine, Nifedipine, Verapamil, Diltiazdem
Aged over 55 years or if black/African/Caribbean family origin of any age
31
Give examples of ACE & ARB
For which group of people would you prescribe this as first line for hypertension?
ACE - Ramipril
ARB - Candesartan
Under 55 years (not black)
32
What does ECG lead III measure?
Left arm (-) to left leg (+)
33
On an ECG, If lead I is positive, and lead aVF is negative, what is the axis?
Possible left axis deviation
34
On an ECG, if lead I is negative and lead aVF is positive, what is the axis?
Right axis deviation
35
In a normal ECG, most leads are positive, but which are negative?
If lead I is positive, and aVF is positive, what is the axis?
Normally aVR, V1 and V2 are negative.
Normal axis
36
What class of drugs blocks the conversion of angiotensin I to angiotensin II?
Give an example
ACE inhibitors (angiotensin converting enzyme)
Ramipril, lisinopril, enalapril, captopril,
37
What type of diuretic is used for treating acute heart failure in the emergency department?
Give an example
Loop diuretic
Furosemide
38
For a 53 year old Caucasian male with uncomplicated hypertension what are the first line drug choices? Give classes and examples.
ACE inhibitor eg Enalapril
And ARB - eg Losartan
39
A 74 year old lady has high blood pressure, what drug is first line?
Calcium channel blocker eg Amlodipine, is first line for hypertension in over 55’s. Amlodipine also helps with angina.
40
Does sympathetic stimulation increase or decrease heart rate?
Sympathetic - increases eg adrenaline
Parasympathetic - decreases eg acetylcholine
41
Which type of cardiomyopathy causes increased ventricular wall thickness?
Hypertrophic cardiomyopathy
42
Which type of cardiomyopathy causes increased ventricular cavity size?
And decreased?
Dilated cardiomyopathy - increased
Hypertrophic cardiomyopathy - decreased
43
Which types of cardiomyopathy cause systolic dysfunction? And which cause diastolic dysfunction?
Systolic dysfunction - dilated CM
Diastolic dysfunction - hypertrophic and restrictive CM
44
Which cardiomyopathies cause an S3 heart sound and which an S4?
Dilated and restrictive - S3
Hypertrophic - S4
S3 = DCM (three letters)
S4= HOCM (four letters)
45
How does restrictive cardiomyopathy appear on an ECG?
Low amplitude signals
Short QRS complexes
(Restrictive cardiomyopathy (the least common type) is characterised by rigid ventricles which are unable to stretch appropriately and fill with blood. This causes diastolic dysfunction and normal systolic function. Causes include familial amyloid, hemochromatosis, senile amyloidosis, post radiation myocardial fibrosis, scleroderma)
46
What drugs can cause drug induced long QT syndrome?
Acronym - ABCDE
Eg. Haloperidol, ondansetron
47
What does NT-proBNP stand for?
What is it?
What condition does it indicate?
N-terminal pro-B type natriuretic peptide
B type natriuretic peptides are substances made by the myocardial cells in response to wall stress such as in heart failure.
Normally only low levels are found in the bloodstream. High levels mean the heart isn’t pumping as much as the body needs - heart failure.
48
What is a normal level for NT-proBNP?
What level requires referral to cardiologist (to be seen with in 6weeks) and urgent referral (to be seen within 2 weeks?
Normal = less than 400 pg/ml
Referral = 400-2000
Urgent referral = above 2000
49
What is this rhythm?
VF = Ventricular fibrillation
50
What is a channelopathy?
Give examples of two channelopathies
Malignant arrhythmias in a normal heart resulting from genetic alterations in ion channels or associated proteins.
Brugada
Long QT syndrome
Normal QTc values:
QTc is prolonged if > 440ms in men or > 460ms in women (approx 2 and a bit big squares)
QTc > 500 is associated with an increased risk of torsades de pointes
QTc is abnormally short if < 350ms
A useful rule of thumb is that a normal QT is less than half the preceding RR interval. Unless tachycardia.
51
Where are there baroreceptors? What do they detect? Where do they send info to?
Carotid artery (carotid sinus, where common carotid bifurcates into internal and external carotid) and aortic arch.
They detect changed in blood pressure
Send info to medullary cardiovascular control centre
52
Where is the carotid sinus?
Carotid sinus is where common carotid artery bifurcates into external and internal carotid arteries
53
In control of blood pressure, sympathetic nervous system speeds up or slows down heart rate?
What neurotransmitter is released?
Sympathetic speeds up heart rate. Releases noradrenaline.
54
In control of blood pressure, parasympathetic nervous system speeds up or slows down heart rate?
What neurotransmitter is released?
Acts on what receptors?
Parasympathetic slows down. Acetylcholine to alpha receptors.
55
What hormone converts angiotensinogen to angiotensin I?
This hormone increases or decreases blood pressure?
Released from where?
An increase in BP will lead to increase or decrease in renin production?
Renin
Decreases blood pressure
Kidneys
Increases
Renin is a hormone made by the kidneys. It controls the production of another hormone called aldosterone, which is made in the adrenal glands. These are two small glands located above the kidneys. Aldosterone helps manage blood pressure and maintain healthy levels of potassium and sodium in the body.
56
What are the three features of Beck’s triad?
And what do they indicate?
- muffled/quiet heart sounds
- hypotension
- raised JVP / jugular venous distension
Beck’s triad: the three medical signs associated with acute CARDIAC TAMPONADE
(a medical emergency where excessive fluid accumulated in the pericardial sac around the heart and impairs it’s ability to pump blood).
57
What is Dressler’s syndrome? Typical presentation? Treatment?
Pericarditis post-MI
Persistent fever and pleuritic chest pain 1-6 weeks post MI, pain worse on lying down
Management - high dose aspirin
58
What does this ECG show?
What valve problem can be associated with this?
LBBB - signs are widened QRS complex, deep S wave in V1. Sometimes notched R wave. Sometimes ‘WilliaM’ visible - W in V1 and M in V6.
Aortic stenosis
59
What drug and dose is given for bradycardia?
What drug is given for beta blocker / CCB overdose?
Then what?
Atropine 500mcg boluses up to 3mg
Glucagon
Transcutaneous pacing
60
What can a J wave (aka Osborn wave) indicate? (2)
How is J wave different to the J point?
Hypothermia (most common)
Hypercalcaemia
J point is normal feature on all ECGs - marks the end of QRS and start of ST segment
J wave is abnormal
61
What drugs should be given for heart failure?
First and second line.
First line:
ACE inhibitor and Beta-blocker (mortality) (ARB if intolerant to ACE)
Furosemide /bumetanide (symptoms)
Second line:
Spironolactone / epleronone (mortality)
62
Name a side effect for each of the following drugs
- beta blockers
- ACE inhibitors
- Spironolactone
- furosemide
- hydralazine / nitrate
- digoxin
63
Name 6 chest x-ray findings in heart failure
ABCDEF
(A)lveolar oedema (Batwing shadowing)
Kerley (B) lines (interstitial oedema)
(C)ardiomegaly
Upper lobe blood (D)iversion
Pleural (E)ffusions
(F)luid in the horizontal fissure
64
What investigations would you do in heart failure?
Echo
Bloods - NT-proBNP, U&E, LFT, TFT, glucose and lipid profile
65
What is the acute management for MI?
66
What drugs should a patient be on post-MI?
67
What is the CHADSVASc score used for? What do the letters stand for?
To determine if a patient with AF needs anticoagulation, to prevent embolic stroke
68
At what CHADSVASC score would treatment be considered/started for a
a) Man
b) Woman ?
Man - Consider treating at 1, treat at 2
Woman - Treat at 2 (because scores 1 for gender)
69
What electrolyte abnormalities most commonly cause VT? 1st and 2nd most common.
1. Hypokalaemia, most commonly.
2. Hypomagnesaemia.
70
First line treatment for atrial flutter?
Beta blocker (even if not tachycardic)
71
What medications are prescribed for rate control for AF? (3 in order of preference)
Rate control
1. Beta blocker: most commonly bisoprolol.
Or
2. Rate limiting calcium channel blocker eg diltiazem or verapamil. Contraindicated in heart failure.
Or
3. Digoxin. For sedentary older people.
72
Rhythm control in AF - when is electrical cardioversion used?
Electrical cardioversion used:
- If patient is unstable
- Or if AF is acute <48 hrs onset
(if onset longer then ideally need 3 weeks anticoagulation before cardioversion) or TOE to rule out thrombus first.
73
Rhythm control in AF - What medications are used for pharmacological cardioversion?
Which is preferred in young patients
Which is preferred in older patients
Flecainide
Amiodarone
Sotalol
74
What scores 2 points in the CHADSVASc score?
(A) 2 points for age 75 or over
(S) 2 points for if patient had previous stroke or TIA
75
What scores 1 point in the CHADSVASC score?
1 point for congestive heart failure (C)
1 point for hypertension (H)
1 point for diabetes mellitus (D)
1 point for known vascular disease (V)
1 point for age 65-74 (A)
1 point for female gender (Sc)
76
What scores can help assess bleeding risk?
Which one is newer/preferred?
HASBLED and ORBIT
Orbit is newer and usually preferred
77
What does the HASBLED score assess?
What are the criteria in the HASBLED score?
Bleeding risk in patients with AF - to guide whether to commence anticoagulation. (ORBIT scoring system is newer).
78
What does the ORBIT score assess?
What are the criteria?
Assesses bleeding risk for people with AF, for whom anticoagulation is being considered.
Sometimes preferred to HASBLED score.
79
JVP waveforms
What causes a normal A wave
What causes a cannon A wave
What does cannon A wave look like in physical examination?
Normal A wave - contraction of the atria.
Cannon waves are very large A waves that occur when the right atrium contracts against a closed tricuspid valve.
They occur irregularly in arrhythmias such as complete heart block and ventricular tachycardia, conditions that are characterised by atrioventricular dissociation with random occasional simultaneous atrial and ventricular contractions.
The A waves are easily visible in the neck. They are short and sharp, and precede the carotid pulse that is palpated on the other side of the neck.
A waves are absent in atrial fibrillation, since coordinated atrial contraction is necessary to produce them, and so are not always seen in tricuspid stenosis.
80
What is the first choice antihypertensive for a patient…
1. Under 55?
2. Over 55?
3. Black any age
4. Diabetic
1. ACE inhibitor eg Ramipril (or ARB)
2. Calcium channel blocker eg Amlodipine
3. CCB
4. ACE (or ARB)
Over 55 and Black have same treatment of CCB - think Morgan Freeman, drinking a glass of milk for Calcium Channel Blocker
81
What does this chest X-ray show?
- Condition
- Signs
Heart failure
Signs:
- CARDIOMEGALY. CTR cardio thoracic ratio = 18/30 so >50%
- Upper zone vessel enlargement (area 1) a sign of pulmonary venous hypertension
- Kerley B /septal lines (area 2) a sign of interstitial oedema
- airspace shadowing (area 3) due to alveolar oedema, acutely in a peri-hilar (Batwing) distribution
- Blunt costophrenic angles (area 4) due to pleural effusions
NB. Pulmonary oedema manifests in two forms - interstitial oedema (Kerly lines) and alveolar oedema (Batswing shadowing at first, then can spread all over)
https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page8
82
What rhythm is this?
How should patients with this rhythm be managed:
- with no pulse
- with a pulse and adverse features (list some adverse features)
- with a pulse and no adverse features?
Ventricular Tachycardia (VT)
Pulseless VT - CPR and defibrillation (unsynchronised shock), follow ALS algorithm
VT with a pulse + adverse features (eg shock, MI, heart failure) - Synchronised DC shock, amiodarone
VT with a pulse and no adverse features - Amiodarone
83
AF management - new onset AF of 5 days ago, 140 bpm, no adverse features or evidence of heart failure. How is this managed?
A) otherwise healthy patient
B) asthmatic
A) BB or CCB
B) CCB eg diltiazem or verapamil (beta blockers are contraindicated in asthma)
84
What are the signs of hypokalaemia and hyperkalaemia on ECG?
Hypokalaemia
- T wave inversion
- ST depression
- prolonged PR interval
- long QT interval
- U waves
Hyperkalaemia
- Peaked T waves
- prolonged PR interval
- wide, sometimes bizarre QRS
https://litfl.com/hyperkalaemia-ecg-library/
85
What medications are given for heart failure with reduced ejection fraction? (HFrEF)
Initial therapy and second line
If no pedal oedema
Initial therapy: Beta blocker and ACE inhibitor
If still symptomatic: add Spironolactone
MRA = mineralocorticoid receptor antagonist eg. Spironolactone, epleronone
86
What are the indications for using
1. Adenosine
2. Atropine
3. Amiodarone
In cardiac patients
Adenosine - TACHYcardia. SVT.
Eg. Regular narrow complex tachycardias (SVT). After trying vagal manoeuvres - carotid sinus massage or valsalva manoeuvre)
6mg, then 12mg, then 12mg.
Adenosine = a-DOWN-Asine → heart rate goes DOWN
Atropine - BRADYcardia.
Atropine = a-TOP-ine - heart rate goes UP.
Used in bradycardia with adverse features (shock, syncope, MI or heart failure). If doesn’t work go to transcutaneous pacing.
Dosage 500mcg IV, repeat every 3-5 mins to a total of 3mg
Amiodarone - tachycardia - VT. regular broad complex tachycardia
First line treatment in haemodynamically stable VT. Also used in cardiac arrest.
87
What medication beginning with A is used in :
1. VT with a pulse
2. SVT
3. Bradycardia
1. Amiodarone
2. Adenosine
3. Atropine
88
Heart failure with reduced ejection fraction (HFrEF) is typically systolic or diastolic dysfunction?
Give examples of causes
HFrEF is typically systolic dysfunction - impaired myocardial contraction during systole
89
Is HFpEF typically systolic or diastolic dysfunction?
Give examples of causes.
HFpEF (preserved ejection fraction) is typically diastolic dysfunction
(Impaired ventricular filling during diastole)
90
What is high output heart failure?
Give examples of causes
Where a ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body.
91
What does this ECG show?
Symptoms?
Treatment?
- PR depression
- ST elevation (saddle shaped)
Changes are widespread as opposed to territories seen in MI
→ pericarditis
Pericarditis is acute inflammation of the pericardial sac
Symptoms - pleuritic chest pain, relieved by sitting forwards. Dyspnoea, flu-like symptoms, non-productive cough, pericardial rub.
Treatment - NSAIDs and colchicine until resolution of inflammatory markers. Normally viral so no antibiotics. Avoid strenuous physical activity until symptom resolution.
92
What leads of an ECG is atrial flutter likely to be visible in?
What heart rates are likely?
Causes of atrial flutter?
Management?
II, III and aVF
Atrial rate: 300bpm
Ventricular rate: 75 (4:1), 100 (3:1), 150 (2:1), 300 (1:1)
60 (5:1) rare
Or block might be variable
Atrial flutter is a type of narrow complex supraventricular tachycardia
Causes: coronary artery disease, heart valve disease, hypertension, previous cardiac surgery.
Management is similar to atrial fibrillation - rate control with BB or CCB
Electrical cardioversion may be needed, or pharmacological cardioversion eg Amiodarone, sotalol, verapamil.
93
What leads of an ECG is atrial flutter usually visible in?
II, III and aVF
94
How does Atropine work?
When is it given?
Dose?
Atropine blocks the vagus nerve activity on the heart, which increases the firing rate of the SA node.
Atropine is used to treat bradycardia with adverse clinical features eg. shock, syncope, myocardial ischaemia or heart failure).
Dose - atropine 500 mcg IV is given.
Repeat boluses can be given up to 3mg
_______________
According to the ALS adult bradycardia algorithm patients should first be assessed using DR ABCDE, ECG monitoring and any reversible causes should be identified and treated.
95
Treatment for SVT of 140bpm
1. Initial management
2. Next step
3. Alternative to 2. if patient asthmatic
4. If adverse features? (eg. shock, syncope, MI)
1. Vagal manoeuvres eg. Valsalva manoeuver
2. Adenosine
3. Verapamil
4. Emergency synchronised DC cardioversion
96
1. How much time does 1 small square on ECG represent?
2. 1 large square?
3. What size is considered narrow QRS complex?
4. What size is wide QRS complex?
5. What size is normal for PR interval?
1. 0.04 sec
2. 0.2 sec
3. In narrow complex tachycardias the QRS complex is shorter than 0.12s/120ms (three small squares on the ECG).
4. Broad is > 3 small squares (>0.12 seconds)
5. PR interval - 0.2s (5 small squares / 1 big square)
97
Quick ECG rate analysis, when regular:
1 QRS for every 1 big square = ? bpm
1 QRS for every 2 big squares = ? bpm
1 QRS for every 3 big squares = ? bpm
1 QRS for every 4 big squares = ? bpm
1 QRS for every 5 big squares = ? bpm
300 bpm
150 bpm
100 bpm
75 bpm
60 bpm
98
What are the signs of RBBB on ECG?
1. QRS duration greater than 120 milliseconds
2. rsR’ “bunny ear / M” pattern in the anterior precordial leads (leads V1-V3)
3. Slurred S waves in leads I, aVL and frequently V5 and V6
https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-topic-reviews-and-criteria/right-bundle-branch-block-review
99
For each location of ST elevation on an ECG, what area of the heart does this correspond with and which coronary artery supplies that area?
100
What does this ECG show?
Official image description:
Right ventricular strain pattern due to RVH:
ST depression and T-wave inversion in V1-4 and lead III
Other features of RVH are present, including right axis deviation, and a dominant R wave in V1
Right heart strain - if low SATS and increased response rate think pulmonary embolism
Right heart strain is caused by pathologies affecting the pulmonary vasculature such as
Pulmonary emboli
Pulmonary hypertension
Chronic lung disease
Pulmonary stenosis
Pneumothorax
ECG features of right heart strain
Sinus tachycardia (most common)
Right ventricular strain pattern (ST depression and T wave inversion in right ventricle and inferior leads)
RBBB
Right axis deviation
P pulmonale
S1Q3T3
Atrial arrhythmias
S1Q3T3 - A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
https://litfl.com/right-ventricular-strain-ecg-library/
101
Angina - immediate treatment?
Long term treatment?
immediate treatment - GTN spray. 2 doses 5 mins apart if needed. If not relieved call ambulance.
Long term treatment - BB eg. Bisoprolol 5mg OD and/or CCB eg. Amlodipine 5mg OD.
(Other options that may be considered by a specialist - long acting nitrates eg. Isosorbide mononitrate (ISMN), Ivabradine, Nicorandil, Ranolazine.)
102
Secondary prevention of cardiovascular disease?
"4 A's "
Aspirin
Atorvastatin 80mg OD
ACE Inhibitor eg. Ramipril
Atenolol or other BB
103
What investigation and intervention for MI?
Investigation - Coronary angiogram
Interventions:
- PCI (percutaneous coronary intervention). Coronary angioplasty (dilating the blood vessel with a balloon), sometimes with insertion of stent.
- CABG for severe stenosis (slower recovery)
104
Where to listen/feel for carotid pulse?
Side of the trachea, lower half of the neck to avoid the carotid sinus.
105
Where to listen for heart sounds?
Aorta = 2nd intercostal space, R sternal border
Pulmonary = 2nd intercostal space, L sternal border
Tricuspid = 4th intercostal space, L sternal border
Mitral = 5th intercostal space. Mid clavicular line?
"A Plane To Mexico"
106
Where in the cardiac cycle does an S3 heart sound occur?
What causes an S3 heart sound?
Early diastolic. Lub dub-da.
Dilated left ventricle.
- Can be normal in young people.
- Restrictive cardiomyopathy
- Dilated cardiomyopathy
107
Where in the cardiac cycle does an S4 heart sound occur?
What causes an S4 heart sound?
Late diastolic. La-lub dub.
Heart contracting against a restricted vessel.
- Heart failure
- Hypertrophic obstructive cardiomyopathy
108
Investigations for chest pain?
- Cardiovascular exasmination
- Detailed history for risk factors
- ECG (ST elevation, ST depression, deep T wave invertion, pathological Q waves, LBBB)
- Venous BLOOD GAS (quick Hb), sodium, potassium, lactate
- BLOODS - FBC, U&E, LFT, TFT, CRP, lipid profile, HBA1C - TROPONIN (high sensitivity - sensitive within 2 hours of onset of chest pain. Can be raised with PE)
- CXR (to check for pulmonary oedema and other causes of chest pain, pleural effusion, cardiomegaly, malignancy).
- Bedside ULTRASOUND (dissections, difficult cannulations, pneumothorax)
- Bedside ECHO to assess damage to heart
- D-dimer (dissection - clot)
- CT coronary angiogram to assess for coronary disease / blockages.
109
When are Q waves...
- Normal?
- Pathological?
NORMAL Q WAVES
- Small Q waves are normal in most leads, except V1-V3
- Deeper Q waves (>2 mm) may be seen in leads III and aVR as a normal variant
PATHOLOGICAL Q WAVES
> 40 ms (1 mm) wide
> 2 mm deep
> 25% of depth of QRS complex
Seen in leads V1-3
Pathological Q waves usually indicate current or prior myocardial infarction.
CAUSES - PATHOLOGICAL Q WAVES
- Myocardial infarction
- Cardiomyopathies — Hypertrophic (HCM), infiltrative myocardial disease
- Rotation of the heart — Extreme clockwise or counter-clockwise rotation
- Lead placement errors — e.g. upper limb leads placed on lower limbs
Loss of normal Q waves
The absence of small septal Q waves in leads V5-6 should be considered abnormal.
Absent Q waves in V5-6 is most commonly due to LBBB.
https://litfl.com/q-wave-ecg-library/
110
Differential diagnoses for chest pain (name at least 5)
1. ACS (unstable angina - negative trop, NSTEMI - positive trop, STEMI - positive trop and ST elevation)
2. Stable angina / prinzmetal angina (spasm)
3. Dissecting thoracic aortic aneurysm / aortic dissection
4. Pericarditis / tamponade
5. Acute CCF (congestive cardiac failure)
6. Arrhythmias
7. Pulmonary causes eg. PE, pneumothorax, pneumonia, asthma, lung cancer, pleural effusion.
8. GI causes - acute pancreatitis, oesophageal rupture, GORD, acute cholecystitis, oesophageal spasm
9. MSK causes - rib fracture, costochondritis, spine eg. prolapsed disc, RA, psoriatic arthritis, fibromyalgia, trauma
10. Other eg. psychological, shingles, drugs eg cocaine
111
What are the 5 chest pain 'big killers'?
ACS
Dissection
PE
Pneumonia
Pneumothorax
ACS (unstable angina - negative trop, NSTEMI - positive trop, STEMI - positive trop and ST elevation)
112
Treatment for ACS?
Particular things for STEMI?
NSTEMI?
Check local policy.
- MONA
Morphine, oxygen (if needed), nitrates (GTN spray), Aspirin.
- Consider other anticoagulants eg. Clopidogrel, ticagrelor, fondaparinux (not if going for PCI)
- Betablocker (anti-ischaemic agent)
STEMI - if presenting within 12 hours → PCI if available within 2 hours, otherwise thrombolysis if PCI not available within 2 hours.
NSTEMI - BATMAN. Betablockers, Aspirin 300mg stat, Ticagrelor/clopidogrel, morphine, anticoagulant (LMWH treatment dose), Nitrates (GTN). Oxygen is sats <95.
Adjuvant therapy - statin, ACE inhibitor
113
What is troponin?
What are 5 causes of raised troponin?
Troponin are proteins found in cardiac muscle. Troponin are released from the ischaemic muscle in the heart that has been damaged. Check local policy for normal levels. Diagnosis of ACS typically requires serial troponins eg. at baseline and 6 or 12 hours later.
Not specific - raised troponin does not always mean ACS. See below.
RAISED TROPONIN CAUSES
- NSTEMI & STEMI
- Chronic renal failure
- Sepsis
- Myocarditis
- PE
- Aortic dissection
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Complications of MI?
'DREAAD'
- Death
- Rupture of septum or papillary muscles
- oEdema / heart failure
- Arrhythmia / Aneurysm in ventricle wall
- Dressler's syndrome (pericarditis 2-3 weeks post MI) Pleuritic chest pain, pericardial rub. global ST elevation and T wave inversion. Raised CRP/ESR. Echo shows pericardial effusion. May need pericardiocentesis.
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Secondary prevention of MI ?
- Medication
- Lifestyle changes
6 A's
- Aspirin 75mg OD
- Another Antiplatelet eg. clopidogrel/ticagrelor for up to 12 months
- Atorvastatin 80mg OD
- ACE Inhibitor eg. Ramipril
- Atenolol (or other Betablocker)
- Aldosterone antagonist eg. epleronone / spironolactone.
Lifestyle measures
- Stop smoking
- Reduce alcohol
- Healthy diet
- Cardiac rehabilitation / exercises
- Reduce alcohol
- Optimise treatment for other conditions eg Diabetes, HTN.
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Calcium channel blockers.
How do they work?
CCBs reduce the amount of calcium entering cells of the heart and blood vessel walls. Calcium normally helps muscles contract. So less calcium means the blood vessels relax and the heart muscle receives more oxygenated blood.
CCBs thereby are able to lower blood pressure and treat angina.
Some CCBs also block calcium going into the conducting cells in the heart and have the added effect of slowing the heart rate.
https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/drug-cabinet/calcium-channel-blockers
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What are the two different types of CCB? Give examples.
There are two distinct chemical classes of CCBs: the dihydropyridines (such as nifedipine and amlodipine) and the nondihydropyridines aka Rate limiting CCBs (diltiazem and verapamil).
The two classes both help to relax and widen arteries but non-dihydropyridines have an additional effect on the heart’s conduction system and can help to control certain fast heart rhythms (such as atrial fibrillation). This is because non-dihydropyridines also block calcium going into the conducting cells in the heart, which has the effect of slowing down the heart rate.
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What are possible side effects of CCB?
Both classes - low blood pressure → dizziness.
Dihydropyridine CCBs eg. Amlodipine, nifedipine:
- ankle swelling
- flushing
- palpitations.
Non-dihyropyridines (Rate-limiting CCBs) especially verapamil:
- constipation
- bradycardia
(So should NOT be used in bradycardia / heart block / heart failure).
(Patients should be advised not to stop taking their CCB without discussing it as it could result in a flare-up of angina).
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What is wrong with this ECG?
RBBB
- QRS duration >0.12 seconds
- Slurred S wave in lead I, aVL, V5, and V6 (Depolarization moving away from these leads)
- RSR’ in V1 and V2 with R’ > R (Depolarization moving toward these leads)
In RBBB, the last depolarization to occur is in the right ventricle therefore the left ventricle depolarizes first, which means the conduction is moving toward V1 (Left to Right).
https://rebelem.com/bundle-branch-blocks101/
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What is wrong with this ECG?
LBBB
- QRS duration >0.12 seconds
- Broad monomorphic R waves in I, aVL, V5, and V6 (Depolarization moving toward these leads)
- Broad, dominant, monomorphic S wave in V1 and V2 (Depolarization moving away from these leads)
In LBBB, the last depolarization to occur is in the left ventricle therefore the right ventricle depolarizes first, which means the conduction is moving away from V1 (Right to Left).
NB. Once you spot LBBB on an ECG you can't reliably interpret anything else eg. ST elevation
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What are these vessels?
What view of the heart is this?
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Post defibrillator /cardiac arrest care and investigations?
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What drugs can you give during defib?
When do you give them?
.
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What are the 4 H's and 4 T's causes of reversible cardiac arrest?
