Cardiology Flashcards
Helpful mnemonics for acute and longer term management of MI?
MONA:
Morphine and anti-emetic
O2 if hypoxic
Nitrates (GTN spray)
Aspirin
DABS:
Dual antiplatelet therapy
ACEi
BB
Statin
When can PCI be carried out?
If the MI presents within 12 hours of onset AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given
If PCI cannot be delivered in 120 mins give immediate fibrinolysis
Poor prognostic factor in ACS?
Cardiogenic shock
ECG changes in pericarditis? Tx?
‘saddle-shaped’ ST elevation (concave)
PR depression: most specific ECG marker for pericarditis
Tx is NSAIDs
How should suspected aortic dissection be investigated?
What is the key finding?
CT angiography of the chest, abdomen and pelvis is the investigation of choice
TOE for unstable patients who are too risky to take to the scanner
the key finding suggestive of aortic dissection on CT angiography is a false lumen
Will also see widening of the mediastinum on CXR
How do you treat acute onset AF?
If haemodynamically stable you do not need to cardiovert immediately
If the patient is stable and onset ≥ 48 hours - rate control initially (e.g. bisoprolol) and delay cardioversion until they have been maintained on therapeutic anticoagulation (e.g. apixaban) for a minimum of 3 weeks
If very unstable with acute onset AF- can do TOE to look for left atrial thrombi before urgent cardioversion
Tx for angina where BB contraindicated?
Nicorandil - can cause ulcers along the GI tract
What protein marker is most useful for determining reinfarction in the weeks following MI?
Creatine kinase (CK-MB)
- it remains elevated for only 3 to 4 days following infarction. Troponin remains elevated for 10 days.
Main ECG change in hypercalcaemia?
shortening of the QT interval
How do you manage HOCM (hypertrophic obstructive cardiomyopathy)?
ABCDE:
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator (If they have arrested once, implant a cardioverter defibrillator to prevent recurrence)
Dual chamber pacemaker
Endocarditis prophylaxis
Outline the acute management of key peri-arrest rhythms : unstable VT, stable VT, and SVT
Unstable VT (dropping bp)= cardioversion, then maybe IV amiodarone
Stable VT = IV amiodarone
Supraventricular tachy= IV adenosine
How do you determine the cause of orthostatic htn?
How do you treat?
Orthostatic hypotension (A fall in SBP of >20mmHg on standing) accompanied by an exaggerated increase in HR = due to anaemia or hypovolemia
Orthostatic hypotension with minimal/no change in heart rate = neurogenic (e.g. due to diabetes)
Tx= Fludrocortisone and midodrine
Outline the key points of PE investigation
- Wells score
Wells score 4 or less = D-dimer to exclude PE
Wells score- over 4 = likely PE
- Do an ECG - sinus tachy commonest finding in PE (S1Q3T3 characteristic but rare)
- Do a CXR - clear/ wedge shaped opacification in PE
- Do a CTPA (unless contraindicated e.g. allergy to contrast/renal impairment in which case VQ scan used as an alternative)
Strong suspicion of PE but delay in the scan - start tx dose anticoagulant and monitor closely in the meantime
If CTPA +ve proceed with treatment (thrombolyse or give DOAC)
If CTPA -ve but DVT strongly suspected then consider a proximal leg vein ultrasound scan
Outline the key points of PE management
What is the target INR for pts with recurrent PEs?
Tx:
If there is massive PE + hypotension - thrombolyse immediately
For haemodynamically stable PE (not hypotensive/tachycardic):
3 months DOAC for provoked PE (obvious temporary risk factor)
6 months DOAC for people with active cancer and confirmed proximal DVT/PE
Lifelong tx for patients with unprovoked PE or persistent risk factors such as antiphospholipid syndrome, active cancer or thrombophilia
Target INR for patients with recurrent PEs is 3.5
If the patient has a PESI class 1 or 2 (very low risk PE) and do not want to be admitted, they can be managed as an outpatient with rivaroxaban.
Key contraindications to thrombolysis?
Contraindications to thrombolysis:
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
bleeding disorders
intracranial neoplasm
recent head injury
stroke < 3 months
aortic dissection
severe hypertension
What is Takayasu’s arteritis? Give features, association and tx
Common in young Asian women - fibrous thickening of aortic branches
Features:
systemic features of a vasculitis e.g. malaise, headache
carotid bruit and tenderness
unequal blood pressure in the upper limbs
limb claudication on exertion
absent/ weak peripheral pulses
Associations: renal artery stenosis
Management: steroids
1st and 2nd line tx for patients with stable impaired LV function? Vaccinations offered?
1st: ACE inhibitor + beta-blocker
2nd: aldosterone antagonist
Yearly flu jab and one off pneumococcal
Posterior MIs cause reciprocal changes in V1-3 - describe them
Remember- ‘ugh don’t STRRT”
horizontal ST depression
tall, broad R waves
dominant R wave in V2
upright T waves
Outline the tx for the 2 types of aortic dissection
type A - ascending aorta - control BP (IV labetalol) + surgery*
type B - descending aorta - control BP(IV labetalol)
*Proximal aortic dissections are generally managed with surgical aortic root replacement as opposed to stenting
What do p mitrale (bifid p wave) and p pulmonale (tall p wave) represent ?
P mitrale- left atrial hypertrophy/strain e.g. in mitral stenosis (seen more in lead 2)
P pulmonale- right atrial hypertrophy e.g. tricuspid regurgitation and pulmonary hypertension
What part of the ECG is DC cardioversion synchronised with? Why?
the R wave to minimise the risk of inducing ventricular fibrillation
A patient develops acute heart failure 10 days following a myocardial infarction.
On examination he has a raised JVP, pulsus paradoxus (dramatic drop in bp on inspiration) and diminished heart sounds- what is the diagnosis?
left ventricular free wall ruputure- Urgent pericardiocentesis and thoracotomy are required.
ECG features in hypokalaemia?
“In Hypokalaemia, U have no T, but a long PR and a long QT”
U waves
Small/absent T waves
prolonged PR and QT intervals
What is a CHA2DS2-VASc score?
Used to determine need for anticoagulation in AF
one point would be allocated for each of the following:
Congestive heart failure
Hypertension (controlled or uncontrolled)
Age of 65-74 years
Diabetes
Vascular disease
Sex (female)
2 points for:
An age of 75 years or over
Prior stroke or thromboembolism.
How do you differentiate between cardiac tamponade and constrictive pericarditis? (both present with dyspnoea and signs of HF)
Kussmaul’s sign positive in c. pericarditis - JVP that raises/ doesn’t drop on inspiration
What drugs are given to someone receiving PCI?
prasugrel + unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor
When should statins be taken to improve efficacy?
at night as this is when the majority of cholesterol synthesis takes place
What is Dressler’s syndrome?
Dressler’s syndrome (postmyocardial pericarditis) is secondary pericarditis
If a pt presents with central, pleuritic chest pain and fever 2-6 weeks following a myocardial infarction and the ESR is elevated - think Dressler’s syndrome!!
Describe Beck’s triad for cardiac tamponade
How is cardiac tamponade investigated?
muffled heart sounds, hypotension and a raised jugular venous pressure
an echocardiogram. It can show an enlarged pericardium or collapsed ventricles.
Give causes of ejection systolic murmur that are louder on inspiration and louder on expiration
Ejection systolic
louder on inspiration:
- pulmonary stenosis
- atrial septal defect
also: tetralogy of Fallot
louder on expiration:
- aortic stenosis
- hypertrophic obstructive cardiomyopathy
Sign of hypothermia on ECG? On bloods?
J waves
Bloods can show high haemoglobin due to haemoconcentration, and low platelets and WCC due to splenic sequestration
First line management of acute pericarditis?
combination of NSAID and colchicine
What is Torsades de points? risk factors? tx?
a form of polymorphic ventricular tachycardia associated with a long QT interval- can lead to v fib and death
presents with dizziness, shortness of breath, palpitations
increased risk with macrolides e.g. azithromycin
tx with IV magnesium sulphate
Give 3 causes of pansystolic murmur and differentiate between them
mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)
- tricuspid regurgitation becomes louder during inspiration, unlike mitral regurgitation (bc during inspiration, the venous blood flow into the right atrium and ventricle are increased)
ventricular septal defect (‘harsh’ in character)
What can cause a late systolic murmur?
mitral valve prolapse
coarctation of aorta
Outline the referral criteria for people presenting to the GP with chest pain
current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
chest pain 12-72 hours ago: refer to hospital the same-day for assessment
chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action
How do you categorise angina as typical or atypical?
NICE define anginal pain as the following:
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN in about 5 minutes
patients with all 3 features have typical angina
patients with 2 of the above features have atypical angina
patients with 1 or none of the above features have non-anginal chest pain
How should you manage angina ?
Medication:
all patients should receive aspirin and a statin in the absence of any contraindication
NICE recommend using either a beta-blocker or a calcium channel blocker first-line
sublingual glyceryl trinitrate to abort attacks
How can you treat Pulseless electrical activity and asystole?
They are non-shockable rhythms and therefore are unresponsive to defibrillation.
The patient should immediately receive 1mg of IV adrenaline whilst continuing high-quality CPR.
For a person < 80, with stage 1 hypertension, only treat medically if:
diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage
Otherwise patients with stage 1 are given lifestyle advice
What is Eisenmenger’s syndrome?
reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension
Give 5 key features of aortic regurgitation
- early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
- collapsing pulse
- wide pulse pressure
- Quincke’s sign (nailbed pulsation)
- De Musset’s sign (head bobbing)
Outline the acute management of SVT
vagal manoeuvres:
- Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe
- carotid sinus massage
intravenous adenosine
- rapid IV bolus
- 6mg → 12mg → 18 mg escalation if rhythm isn’t terminated
Broad complex tachycardia following a myocardial infarction is almost always due to…
ventricular tachycardia
Who should be prescribed a statin?
How should patients be monitored after this prescription?
When should it be discontinued?
all people with established cardiovascular disease
anyone with a Q-risk >= 10%
patients with T1DM who were diagnosed > 10 years ago OR are > 40 OR have established nephropathy
Monitoring:
LFTs at baseline, 3 months and 12 months
Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
Patient presents with poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l (in normal range). What is the next step?
What about if the potassium is low (< 4.5)?
add an alpha- or beta-blocker
K+ < 4.5mmol/l - add spironolactone
How should you manage patients on warfarin with an INR over 5 and minor bleeding?
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart warfarin when INR < 5.0
How should you manage patients on warfarin with an INR of 5.0 - 8.0 but no bleeding?
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
How do you manage patients on warfarin who have a major bleed?
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate
The ORBIT score is now the recommended scoring tool to assess bleeding risk in patients with AF who are being considered for anticoagulation. What are its five parameters?
- age (75+ years)
- anaemia (haemoglobin <130 g/L in males, <120 g/L in females)
- bleeding history
- renal impairment (eGFR <60 mL/min)
- tx with antiplatelets
Acute heart failure not responding to treatment -
CPAP
What is the treatment for acute onset heart failure?
IV loop diuretics
e.g. furosemide or bumetanide
May add O2
May add vasodilators (not if hypotensive)
How should you treat complete heart block following an inferior MI ?
How would this be different if it was following anterior MI?
Atropine - AV block and bradyarrhythmias are usually transient (hours to days) when caused by inferior MI so external pacing is not usually required
Anterior MI is more likely to cause prolonged or permanent arrhythmia so more likely to need external pacing
What is NSTEMI management for patients with a GRACE score > 3% ?
coronary angiography within 72 hours of admission, NOT emergency PCI as this is reserved for STEMIs
What type of heart failure can occur with HOCM?
HFpEF- Hypertrophic obstructive cardiomyopathy typically causes diastolic dysfunction
Tx for hypertensive emergencies?
IV:
1. Sodium nitroprusside
2. Labetalol
3. GTN (1 - 10 mg/hr)
4. Esmolol
Give the major causes of heart failure
- Ischaemic heart Disease (most common)
- Hypertension
- Valvular heart disease (Rheumatic fever in elderly)
- Atrial fibrillation
- Chronic lung disease
- Cardiomyopathy (Hypertrophic, dilated and right ventricular, post viral, post-partum)
- Previous cancer chemo drugs
- HIV
How is infective endocarditis treated?
Endocarditis caused by streptococci eg. Viridans streptococci: benzylpenicillin IV (or vancomycin if penicillin-allergic) plus low dose gentamicin
Endocarditis caused by enterococci eg. Enterococcus faecalis: amoxicillin IV (or vancomycin if penicillin-allergic) plus low-dose gentamicin IV
Endocarditis caused by staphylococci eg. Staph. aureus, Staph. Epidermidis: flucloxacillin (or vancomycin if penicillin allergic or MRSA) plus gentamicin
What underlying pathology is indicated by a sawtooth appearance on ECG? What is the most common aetiology?
Atrial flutter - a form of supraventricular tachycardia characterised by a succession of rapid atrial depolarisation waves
The most common aetiology for this is re-entry circuits around the tricuspid annulus
What is Brugada syndrome?
How does it appear on ECG? What clinical criterion must it be associated with?
A sodium channelopathy which is a cause of sudden death in patients with structurally normal hearts
On ECG: ‘coved’ (concave) ST-segment elevation in V1-V3, followed by T wave inversion
must be associated with one clinical criterion:
- documented v fib or polymorphic ventricular tachycardia
- family history of sudden cardiac death at <45 years old 3. coved-type ECGs in family members
- inducibility of VT with programmed electrical stimulation
- syncope
- nocturnal agonal respiration
High-output heart failure refers to a situation where a ‘normal’ heart is unable to pump enough blood to meet the metabolic needs of the body.
What can cause this? (AAPPTT)
Causes
anaemia (severe)
arteriovenous malformation
Paget’s disease
Pregnancy
thyrotoxicosis
thiamine deficiency (wet Beri-Beri)
How is aortic stenosis managed?
If symptomatic, automatically qualifies for AVR surgery
If asymptomatic, the cut-off for surgery is an aortic valve gradient of 40 mmHg
surgical AVR for low/medium operative risk patients
transcatheter AVR for high operative risk patients
Infective endocarditis in intravenous drug users most commonly affects…
the tricuspid valve
Why is Hypertrophic obstructive cardiomyopathy associated with sudden death in young athletes?
Causes ventricular arrhythmia
How should you treat pulseless VT?
a single shock ASAP followed by 2 minutes of CPR
In AF, if a CHA2DS2-VASc score suggests no need for anticoagulation, what is the next step?
do an echo to exclude valvular heart disease
Wolff-Parkinson White syndrome is caused by a congenital accessory conducting pathway between the atria and ventricles leading to an AVRT. It carries a risk of rapid degeneration into VF.
How does it present on an ECG?
How can it be treated?
Possible ECG features include:
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway
right axis deviation if left-sided accessory pathway
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol, amiodarone, flecainide
If a patient treated with PCI for MI is experiencing extreme pain or haemodynamic instability in the hours post PCI, what does this suggest? How is it managed?
suggests the procedure has failed and that myocardial ischaemia is ongoing
urgent coronary artery bypass graft (CABG) is recommended
In ALS, once adrenaline has been initially given, how often should it be repeated ?
it should be repeated every 3-5 minutes whilst ALS continues
How much of an increase in serum creatinine is acceptable when starting ACEi?
An increase in serum creatinine up to 30% from baseline is acceptable
New onset LBBB is…
always pathological and NEVER normal
Cushing’s triad (hypertensive, bradycardic, tachypnoeic with signs of Cheyne-Stokes breathing) is a sign of what?
Associated ECG changes?
Brain herniation
widespread T wave inversion, also known as ‘cerebral T waves’ - ‘Global’ T wave inversion (not fitting a coronary artery territory) - think non-cardiac cause of abnormal ECG
Give some signs and symptoms of malignant hypertension
Papilloedema (must be present before a diagnosis of malignant hypertension can be made)
Retinal bleeding
Increased cranial pressure causing headache and nausea
Chest pain due to increased workload on the heart
Haematuria due to kidney failure
Nosebleeds which are difficult to stop
How should you manage a witnessed cardiac arrest while on a monitor?
up to three successive shocks before CPR initiated
Example: Deliver three quick successive stacked unsynchronised DC shocks followed by 2 minutes of 30:2 compressions
In a newly diagnosed patient with hypertension (> 55 years), what drug should be offered?
CCB
signs of right-sided heart failure:
raised JVP, ankle oedema and hepatomegaly
How should T2DM be managed in ACS patients on CCU?
Stop other diabetes medications e.g. metformin and convert to IV insulin for tight glycaemic control
How should palpitations be investigated after initial bloods/ECG?
Holter monitoring
It is said that the causes of mitral stenosis are rheumatic fever, rheumatic fever and rheumatic fever!
Give 6 key features it presents with.
atrial fibrillation
secondary to ↑ left atrial pressure → left atrial enlargement
dyspnoea
↑ left atrial pressure → pulmonary venous hypertension
haemoptysis
- due to pulmonary pressures and vascular congestion
& ranges from pink frothy sputum to sudden haemorrhage secondary to rupture of dilated bronchial veins
mid-late diastolic murmur (best heard in expiration)
loud S1, opening snap
low volume pulse
malar flush
How should mitral stenosis be managed?
asymptomatic patients:
monitored with regular echocardiograms
percutaneous/surgical management is generally not recommended
symptomatic patients:
percutaneous mitral balloon valvotomy
mitral valve surgery (commissurotomy, or valve replacement)
Causes of pulsus paradoxus? (decrease in bp on inspiration)
severe asthma, cardiac tamponade
Causes of a collapsing pulse?
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
What causes a ‘jerky’ pulse?
HOCM
Give the ECG changes for thrombolysis or percutaneous intervention:
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL)
OR
New Left bundle branch block
What drugs should be considered during CPR if a PE is suspected?
Thrombolytics e.g. alteplase
What is the STEMI ECG criteria?
≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men < 40 years, or ≥ 2.0 mm ST elevation in leads V2-3 in men > 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB
Rupture of the papillary muscle due to a myocardial infarction →
acute mitral regurgitation → widespread systolic murmur, hypotension, pulmonary oedema
What may exacerbate orthostatic hypotension in day to day life?
venous pooling during exercise (exercise-induced), after meals (postprandial hypotension) and after prolonged bed rest (deconditioning)
Define syncope
Syncope may be defined as a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery.
Give reflex (neural) causes of syncope
vasovagal: triggered by emotion, pain or stress. Often referred to as ‘fainting’
situational: cough, micturition, gastrointestinal
carotid sinus syncope
Give orthostatic causes of syncope
primary autonomic failure: Parkinson’s disease, Lewy body dementia
secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
drug-induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhage, diarrhoea
Give cardiac causes of syncope
arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
structural: valvular, myocardial infarction, hypertrophic obstructive cardiomyopathy
others: pulmonary embolism
Sxs and signs of acute pericarditis?
How should a patient with these features be investigated?
sxs:
chest pain: may be pleuritic. Is often relieved by sitting forwards and exacerbated by lying down
non-productive cough, dyspnoea and flu-like symptoms
Signs:
pericardial rub
tachypnoea
tachycardia
transthoracic echocardiography
What should be given to patients with bradycardia and signs of shock?
Atropine (500mcg IV) is the first line treatment in this situation.
If there is an unsatisfactory response the following interventions may be used:
atropine, up to maximum of 3mg
transcutaneous pacing
isoprenaline/adrenaline infusion titrated to response
What are the most common causes of endocarditis?
Staphylococcus aureus
Staphylococcus epidermidis if < 2 months post valve surgery
What should be done if the blood pressure is >= 180/120 mmHg?
admit for specialist assessment if:
- signs of retinal haemorrhage or papilloedema (accelerated hypertension) OR
- life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury OR
- if a phaeochromocytoma is suspected
if none of the above then arrange urgent investigations for end-organ damage (e.g. bloods, urine ACR, ECG)
What is the recommended blood pressure target for type 2 diabetics?
What is the first line drug for achieving this?
< 140/90 mmHg
ACE inhibitors/A2RBs are first-line regardless of age
Patients should be treated even with only stage 1 htn
How might coarctation of the aorta present in a newborn? Management?
Growth failure, tachycardia and tachypnoea in the context of weak femoral pulses
While surgery is the only definitive treatment, IV prostaglandins are used in neonates to maintain a patent ductus arteriosus to allow adequate circulation until it is possible to attempt corrective surgery
Persistent ST elevation and left ventricular failure after previous MI is very suggestive of what ?
a left ventricle aneurysm
Blood stagnates around a left ventricle aneurysm, thereby promoting platelet adherence and thrombus formation. Embolisation of left ventricular thrombi can lead to embolic stroke or other systemic embolisms.
How should AF be managed longer term post stroke?
warfarin or a direct thrombin or factor Xa inhibitor
Patients should all be offered dual antiplatelet therapy prior to PCI in the form of aspirin and one other anticoagulant. How do you know which anticoagulant to give?
Prasugrel is offered if the patient is not taking an oral anticoagulant, whereas clopidogrel is offered if they are.
If fibrinolysis is given for an ACS, what is the most appropriate plan regarding revascularisation?
Repeat ECG in 60-90 minutes and transfer for urgent PCI if ST-elevation has not resolved
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination →
Ventricular septal defect
Define stage 1, stage 2 and severe hypertension
1: Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
2: Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
severe: Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
What drugs can cause Long-QT syndrome ?
- amiodarone, sotalol, class 1a antiarrhythmic drugs
- tricyclic antidepressants, SSRIs (especially citalopram)
- methadone
- chloroquine
- erythromycin
- haloperidol and ondanestron
First line investigation for stable angina?
Contrast-enhanced CT coronary angiogram
Concerning features in patient presenting with an abnormal ECG?
shock, syncope, myocardial ischaemia or heart failure
Occlusion of which coronary artery is more likely to cause arrhythmias? Why?
RCA- it supplies the AVN
Right coronary infarcts (e.g. inferior STEMI) can often cause arrhythmias including sinus bradycardia and atrioventricular block.
Occlusion of which coronary artery is associated with left ventricular thrombus formation?
LAD as this supplies the majority of the left ventricle
A left ventricular thrombus can occur after MI due to ‘stunning’ of the myocardium resulting in blood pooling and clotting.
Occlusion of which coronary artery is associated with arrhythmias that originate below the AVN e.g. RBBB?
LAD- Anterior MIs
Occlusion of which coronary artery is associated with ventricular free wall rupture? (relatively uncommon)
How does it present?
LAD- Anterior MIs
Rupture tends to occur within the first few weeks after the event and can present as cardiac tamponade or with cardiac arrest.
When should beta blockers be stopped in acute HF?
if the patient has heart rate < 50/min, second or third degree AV block, or shock
Coarctation of the aorta describes a congenital narrowing of the descending aorta, that is more common in males (despite association with Turner’s syndrome).
What features does it present with?
infancy: heart failure
(acute circulatory collapse at 2 days of age when the duct closes- heart failure & absent femoral pulses.)
adult: hypertension
radio-femoral delay
mid systolic murmur, maximal over back
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
What are the key associations of coarctation of the aorta?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
In a patient of Black African ethnicity, which is the next step on the tx ladder for htn after CCB?
ARB- more effective than ACEi
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited CVD which may present with syncope or sudden cardiac death. It is the second most common cause of sudden cardiac death in the young after hypertrophic cardiomyopathy.
What is the inheritance pattern?
How does it present?
What is the classical ECG finding?
Tx?
Autosomal dominant
Presentation:
- palpitations
- syncope
- sudden cardiac death
Epsilon wave (a small positive deflection at the end of the QRS complex)
T wave inversion in V1-V3
Tx: sotalol, catheter ablation to prevent vtach, implantable cardioverter-defibrillator
What is Buerger’s disease (also known as thromboangiitis obliterans)?
a small and medium vessel vasculitis that is strongly associated with smoking, often present in younger people
Features:
extremity ischaemia
- (intermittent claudication and ischaemic ulcers)
superficial thrombophlebitis
Raynaud’s phenomenon
Give a major drug interaction for statins
macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course
Which murmur is heard loudest over the apex?
Mitral stenosis
What are the key ECG features of digoxin toxicity?
down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia
What is the first line investigation for chronic heart failure?
All patients with suspected chronic heart failure should have an NT‑proBNP test first-line
if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
What can be used to reverse:
1.warfarin
2.unfractionated heparin
3.dabigatran
- Vit K
- Protamine sulphate
- Idarucizumab- monoclonal ab
Outline NYHA classification for HF
NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
Widespread joint hypermobility, skin changes indicated by striae and mitral regurgitation -
think collagen disorders e.g. Marfans and Ehlers-Danlos
Atrial myxoma is a benign tumour most commonly occurring in the left atrium. How does it present?
triad of mitral valve obstruction, systemic embolisation and constitutional symptoms such as breathlessness, weight loss and fever.
Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the anterior leaflet of mitral valve on echocardiogram or cMR support what diagnosis?
HOCM
Myocarditis describes inflammation of the myocardium. How does it present?
What is seen on investigation?
Usually young patient with an acute history
Often following viral infection
Chest pain (often sharp) that does not change with position
SOB
Dull heart sounds due to inflamed and thickened myocardium
On investigation:
Bloods:
↑ inflammatory markers,↑cardiac enzymes,↑ BNP
ECG:
tachycardia/arrhythmias
ST/T wave changes including ST-segment elevation and T wave inversion
How are murmurs graded?
The Levine Scale:
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
What causes a continuous machine-like murmur?
patent ductus arteriosus
If a patient presents acutely with muscle weakness and hypotonia as a drug reaction it is most likely to be what?
Electrolyte disturbance - hypokalaemia , hypophosphataemia, hypomagnesiaemia e.g. due to potent diuretic
What criteria is used for definitive diagnosis of infective endocarditis?
Duke criteria
Major criteria:
2 positive blood cultures, persistent bacteraemia, positive serology for known cause of endocarditis
Minor criteria:
predisposing heart condition or IV drug use
fever > 38ºC
vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
immunological phenomena: glomerulonephritis, Osler’s nodes (pulps of fingers), Roth spots (retina)
What valvular abnormality is associated with PKD?
Mitral valve prolapse
What is Wellen’s syndrome?
Critical occlusion of the LAD
ECG finding of deeply inverted or biphasic T waves in V2-3 in a person with the previous history of angina is characteristic.
What is a pathological Q wave?
Q wave more than 2 small squares broad or deeper than the following R wave , seen in V1-V3
Indicates previous MI in that territory
If a patient with AF has a stroke or TIA what should be the anticoagulant of choice? When should it be started?
warfarin or a direct thrombin or factor Xa inhibitor
After haemorrhage excluded:
2 weeks later in stroke
Immediately in TIA
Rheumatic fever develops following an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection.
Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria
What are the major and minor criteria?
How is it treated?
Major criteria:
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis
subcutaneous nodules
Minor criteria:
raised ESR or CRP
pyrexia
arthralgia
prolonged PR interval
Tx: Oral Penicillin V
If new BP >= 180/120 mmHg + new-onset confusion, chest pain, signs of heart failure, or acute kidney injury, what should the immediate management be?
admit for specialist assessment
What are the differentials for a broad complex tachycardia? How would you manage?
Regular:
assume ventricular tachycardia (unless previously confirmed SVT with bundle branch block)
loading dose of amiodarone followed by 24 hour infusion
Irregular:
seek expert help. Possibilities include:
atrial fibrillation with bundle branch block - the most likely cause in a stable patient
atrial fibrillation with ventricular pre-excitation
torsade de pointes
What are the differentials for a narrow complex tachycardia?
Regular:
sinus tachycardia, SVT or atrial flutter
Irregular:
AF
Which are the lateral leads?
I, aVL +/- V5-6
Which drug is contraindicated in VT?
Verapamil- may precipitate cardiac arrest!!!
In heart failure if the patient has sinus rhythm > 75/min and a LVEF < 35% and have not responded to to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy, what drug should be considered next?
Ivabradine
Outline acute NSTEMI tx
BATMAN
BB
Aspirin 300mg stat dose
Ticagrelor 180mg stat dose
Morphine
Anticoagulant e.g. enoxaparin 1mg/kg BD
Nitrates
Give the 6 major complications of MI
DREAD
Death
Rupture of septum or papillary muscle
oEdema
Arrythmia and Aneurysm
Dressler’s syndrome
What can cause a raised BNP other than HF?
tachycardia
sepsis
PE
renal impairment
COPD
Immediate management of acute LVF?
Pour SOD
pour away IV fluids (stop)
Sit up
O2
Diuretics
What is cor pulmonale?
Key causes?
Presentation?
Signs on examination?
Right sided HF caused by respiratory disease- pulmonary hypertension means RV has to strain to pump blood against resistance
COPD most common
PE
ILD
CF
Primary pulmonary htn
Early cor pulmonale: asymptomatic or SOB
May also have chest pain, syncope & peripheral oedema
Signs:
Cyanosis
Raised JVP
Peripheral oedema
3rd heart sound and murmur (e.g. pan-systolic in tricuspid regurge)
Hepatomegaly due to back pressure
Wha is first line for pharmacological cardioversion in AF?
flecainide / amiodarone if there is no evidence of structural or ischaemic heart disease
or
amiodarone if there is evidence of structural heart disease
What is needed to diagnose orthostatic hypotension?
a drop in BP (usually >20/10 mm Hg) within three minutes of standing
3 key symptoms of aortic stenosis?
SAD
syncope, angina, dyspnoea on exertion
most likely cause of an irregular broad complex tachycardia in a stable patient?
AF with bundle branch block
Signs of Left Heart Failure?
Cyanosis
Tachycardia
Elevated jugular venous pressure
Displaced apex beat
Chest signs: classically bibasal crackles but may also cause a wheeze
S3-heart sound
What dose of statin should be given in cardiovascular disease?
atorvastatin 20mg for primary prevention, 80mg for secondary prevention
How long before planned surgery should warfarin be stopped?
5 days
once the person’s INR is less than 1.5 surgery can go ahead
Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.
When should you use rhythm control to treat AF?
when there is coexistent heart failure, first onset AF or an obvious reversible cause
first-line for patients with atrial fibrillation that are being anticoagulated?
DOACs e.g. rivaroxaban
Which anti-hypertensive drug should you avoid prescribing in a patient with a poorly controlled Hba1c?
thiazides - can worsen glucose tolerance
What is the most common cause of death in patients following a myocardial infarction?
V fib
What abnormality in the heart is the most common cause of Long-QT syndrome?
loss-of-function/blockage of K+ channels
How should you manage a patient with worsening HF and deranged electrolytes?
160mg IV fuoresmide infusion
The patient has cardiorenal syndrome
Increased doses of loop diuretics may be required in patients with poor renal function to ensure sufficient concentration is achieved within the tubules
What murmur may HOCM present with?
ejection systolic murmur, louder on performing Valsalva and quieter on squatting
(due to subaortic hypertrophy of the ventricular septum resulting in left ventricular outflow tract obstruction and functional aortic stenosis)
most common cause of aortic stenosis?
younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification
DVLA advice post MI ?
should not drive for 4 weeks
