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Clinical Medicine > Cardiology 🫀 > Flashcards

Cardiology 🫀 Flashcards

1
Q

when is surgery recommended for AAA

A

when the abdominal aorta diameter is greater than 5.5cm

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2
Q

what does the term acute coronary syndrome cover

A

an umbrella term covering a number of presentation of ischaemic heart disease:

STEMI
NSTEMI
unstable angina

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3
Q

what does the term ischaemic heart disease mean

A

synonymous with coronary heart disease and coronary heart disease

it describes the gradual build up of fatty plaques within the walls of coronary arteries co

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4
Q

modifiable risk factors of ACS

A

smoking
diabetes
hypertension
hypercholesterolaemia
obesity

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5
Q

unmodifiable risk factors of ACS

A

increasing age
male gender
family history

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6
Q

presentation of ACS

A

chest pain - most typical presentation
others include
dyspnoea
sweating
nausea and vomiting

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7
Q

how does the chest pain in ACS present
SOCRATES

A

site - central/left-sided
onset - sudden
character - crushing
radiation - jaw, neck and left arm
associated sx - nausea, sweating, clamminess, sob
timing - constant
exacerbating/relieving factors - exercise and GTN spray
severity - extreme

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8
Q

diagnosis depends on a combination of clinical, ECG and biochemical findings
what would you find for unstable angina

A

cardiac chest pain
abnormal/normal ECG
normal troponin

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9
Q

diagnosis depends on a combination of clinical, ECG and biochemical findings
what would you find for NSTEMI

A

cardiac chest pain
abnormal/normal ECG
raised troponin

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10
Q

diagnosis depends on a combination of clinical, ECG and biochemical findings
what would you find for STEMI

A

cardiac chest pain
persistent ST elevation
no need for troponin

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11
Q

when should you test troponin levels

A

3 hours at least after pain started
may need to be repeated 6-12 hours after start of pain if result is ambiguous - mildly raised
but ECG ALWAYS first - if STEMI present then troponin is irrelevant

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12
Q

mx of STEMI

A

300MG ASPIRIN
if <2 hours - PCI
if >2 hours - thrombolysis

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13
Q

why is IV morphine/diamorphine prescribed in STEMIs and NSTEMIs

A

causes vasodilation so reduces preload on heart

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14
Q

when do you prescribe primary precutaneous coronary intervention

A

for STEMI
patients who present within 12 hours of onset of pain AND are <2 hours since first medical contact

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15
Q

mx of NSTEMI

A

BATMAN
beta blocker
aspirin 300mg
ticagrelor 180mg
morphine
anticoagulant -LMWH
nitrates - GTN

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16
Q

describe the procedure of percutaneous coronary intervention

A

blocked arteries are opened up using a balloon following which a stent may be deployed to prevent artery occluding against
done via a catheter inserted into radial or femoral artery

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17
Q

mx of unstable angina

A

MONA
Morphine IV
Oxygen
Nitrates GTN
Aspirin

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18
Q

post successful PCI how long do you wait to drive a car

A

1 week
no need to inform DVLA

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19
Q

post unsuccessful PCI or no PCI and MI how long to wait to drive a car

A

4 weeks
no need to inform DVLA

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20
Q

post unsuccessful PCI or no PCI and MI how long to wait to drive a bus/lorry

A

6 weeks and must inform DVLA

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21
Q

post successful PCI how long to wait to drive a BUS/LORRY

A

6 weeks and must inform DVLA

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22
Q

difference between stable and unstable angina

A

stable angina is triggered usually whereas there is no trigger for unstable

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23
Q

what does an U wave represent on ECG

A

hypokalaemia

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24
Q

what does saw tooth baseline show

A

atrial flutter

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25
Q

what does tall-tented T waves mean

A

hyperkalaemia

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26
Q

what does upward-sloping QRS complex mean

A

wolf parkinson white syndrome
these are called delta waves

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27
Q

sx of pericarditis

A

pleuritic chest pain relieved by sitting forwards + pericardial rub

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28
Q

ix pericarditis
ECG/troponin/ECHO

A

saddle shaped ST elevation
raised troponin!
PR depression

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29
Q

mx pericarditis first line - viral

A

NSAIDs + restrictive exercise
adjunctive: colchicine

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30
Q

ax of myocarditis

A

proceeding viral illness 2-3 weeks prior

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31
Q

sx myocarditis

A

chest pain
dyspnoea
pulmonary oedema
palpitations
raised JVP
bibasal crackles

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32
Q

ix myocarditis

A

ECG: sinus tachycardia with non-specific ST
segment/ T wave inversion
prolonged QRS/QT
raised troponin

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33
Q

ax infective endocarditis

A

staph aureus/strep.viridans

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34
Q

risk factors infective endocarditis

A

IVDU
poor dentition and dental infections
tricuspid valve disease
male sex

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35
Q

sx infective endocarditis

A

fever + pansystolic/early diastolic murmur
janeway lesions
oslers nodes
features of heart failure
night sweats

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36
Q

ix of infective endocarditis

A

Duke’s criteria + transthoracic ECHO
3x sets of blood cultures
septic screen

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37
Q

what is duke’s criteria

A

classify cases into definite IE, possible IE and rejected IE
definite IE - 2 major criteria, 1 mqajor +3 minor or all 5 minor criteria

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38
Q

tx Infective endocarditis

A

long term antibiotics
staph -> flucloaxcillin
strep -> benzylpenicillin
surgical replacement

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39
Q

what would indicate surgery for an infective endocarditis patient

A

PR interval prolongation

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40
Q

what shows on an ECG in a patient with AF

A

absence of P waves
narrow QRS complex tachycardia
irregularly irregular ventricular rhythm

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41
Q

sx of AF

A

palpitations
SoB
syncope
symptoms of associated diseases

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42
Q

Tx of AF

A

assess haemodynamic stability
unstable -> immediate DC cardioversion
Stable - rate control - over 48 hours
rhythm control - less than 48 hours

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43
Q

causes of AF

A

SMITH
sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
HTN

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44
Q

rate control how is it done

A
  1. beta blocker e.g atenolol or CCB e.g diltiazem (contraindicated in heart failure)
  2. digoxin
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45
Q

rhythm control how is it done

A

electrical cardioversion
pharmacological cardioversion

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46
Q

examples of medication used in pharmacological conversion

A

flecainide - younger patients
amiodarone - older
sotalol - beta blocker with rhythm control action

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47
Q

components of CHA2DS2-VASc

A

Congestive heart failure
HTN
Age >75V (2)
Diabetes
Stroke/TIA (2)
Vascular disease
Age 65-74
Sex (female)

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48
Q

what score of CHA2DS2-VASc do you consider anticoagulation

A

0: none
1: consider
2+ : offer it

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49
Q

ix heart failure NTproBNP

A

NT-proBNP
- >2000 bnp = urgent 2WW +ECHO
- 400-2000bnp = 6WW +ECHO

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50
Q

ix heart failure ECHO

A

ECHO
ejection fraction -
<40% = heart failure with reduced ejection fraction
greater than 40% but raised BNP = heart failure with preserved ejection fraction

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51
Q

ix heart failure CXR what are you looking for

A

Alveolar oedema - batwing appearance
kerley B lines
Cardiomegaly
upper lobe Diversion
pleural Effusion
Fluid in horizontal fissure

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52
Q

firs line treatment heart failure

A

ABAL + annual flu vaccine
Ace inhibitor
Beta-blocker
Aldosterone antagonist
Loop diuretics
also consider MRAs if symptoms persist

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53
Q

what is cor pulmonale

A

right-sided heart failure caused b y pulmonary hypertension stemming from underlying lung disease

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54
Q

symptoms of cor pulmonale

A

peripheral oedema
raised JVP
hepatomegaly
SoB
exertion dysponea + syncope
cyanosis
hypoxia

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55
Q

how many days before surgery to stop warfarin

A

5 days

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56
Q

signs and symptoms of aortic stenosis

A

ejection systolic murmur (2nd ICS right sternal edge) louder on expiration radiates to carotids
slow rising pulse
narrow pulse pressure
syncope
heart failure
angina

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57
Q

signs and symptoms of mitral regurgitation

A

pan-systolic murmur (5th ICS,MCL) louder on expiration which radiates to the axilla
SoB
exertional dyspnoea

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58
Q

signs and symptoms of aortic regurgitation

A

early diastolic soft murmur (2nd ICS R sternal edge)
collapsing pulse
widened pulse pressure

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59
Q

signs and symptoms of mitral stenosis

A

mid-diastolic low pitched “rumbling” murmur (5th ICS MCL) which radiates to axilla

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60
Q

acute causes of aortic regurgitation

A

infective endocarditis
aortic dissection

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61
Q

chronic causes of aortic regurgitation

A

marfans syndrome
rheumatic heart disease
infective endocarditis

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62
Q

which leads on an ECG would be affected by RCA

A

II, III, aVF

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63
Q

What is heart failure

A

Heart failure is result of an inability of the heart to maintain adequate cardiac output

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64
Q

What is heart failure commonly secondary to

A

Ischaemic heart disease
Hypertensive heart disease

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65
Q

What is heart failure characterised by

A

SoB
Fluid overload
Fatigue

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66
Q

What re the common causes of acute heart failure

A

Acute myocardial dysfunction
Acute valvular
Pericardial tamponade

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67
Q

Describe systolic heart failure

A

Reduction in left ventricular ejection fraction
Other words; heart is pumping out a proportion of the blood that fills the ventricles during diastole

The increase in blood at the end of systole leads to ventricular stretch, dilation and eccentric remodelling

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68
Q

Describe diastolic heart failure

A

Refers to impaired ventricular filling or relaxation
LVEF is preserved as systole is not affected
Ventricular hypertrophy tends to develop
Characterised by concentric remodelling

69
Q

Describe low output heart failure

A

Heart cannot maintain an adequate cardiac output
Results in increased systemic vascular resistance to maintain mean arterial pressure
Clinically patients have weak pulse, cool peripheries and low blood pressure

70
Q

Describe high output heart failure

A

Characterised by high cardiac output and low systemic vascular resistance
Heart fails to meet grossly increased demands
Can occur in a healthy heart

71
Q

What is stroke volume

A

Amount of blood pumped out of heart from each contraction

72
Q

Cardiac output

A

Amount of blood pumped out heart in one minute
HR * SV

73
Q

Preload

A

Stretching of cardiomyocytes at end of diastole

74
Q

After load

A

Pressure or load against which ventricles must contract

75
Q

Inotropy

A

Refers to myocardial contractility I.e force of muscular contractions

76
Q

Sx of heart failure

A

SoB
Wheeze
Fatigue
Weight loss
Paroxysmal nocturnal dyspnoea
Orthopnoea
Ankle swelling

77
Q

What is BNP

A

Protein released by cardiomyocytes in response to excessive stretching

78
Q

pathophysiology of cor pulmonale

A

chronic lung disease makes it harder to oxygenate blood
pulmonary arteries respond by vasoconstriction
this increases resistance and therefore causes pulmonary hypertension
RV finds it harder to pump blood into pulmonary circulation as a result of hypertension
concentric hypertrophy of RV occurs -> diastolic heart failure
causes backlog of blood in venous system

79
Q

dx of cor pulmonale

A

echocardiogram for evidence of increased pressure
spirometry for lung disease
right heart catheterization to measure lung pressures

80
Q

treatment cor pulmonale

A

treat the underlying lung condition

81
Q

define sinus tachycardia

A

HR>100 bpm
it is a normal physiological response when the body is put under stress

82
Q

management of torsades de pointes

A

management is aimed at shortening the QT interval with IV magnesium sulphate
if a patient is unstable they should undergo immediate DC cardioversion

83
Q

describe VF

A

this arrhythmia is incompatible with life and will result in loss of consciousness and cardiac arrest
VF occurs when the ventricular muscle fibres contract independently

84
Q

what would you see on an ECG for VF

A

no coordinated electrical activity with a chaotic fibrillating baseline

85
Q

A 43-year-old woman is seen on the ward following an episode of feeling her heart pounding. This came on 2 minutes
ago and is not associated with any other symptoms. She is normally fit and healthy. Her current stay in the hospital is for
elective cosmetic surgery. An ECG carried out by her nurse shows a narrow-complex tachycardia at a rate of 220 bpm.
There are no other abnormalities in the ECG.
Apart from her tachycardia, her vital signs are stable.
Which of the following represents the first-line immediate management?

A) Bilateral carotid sinus massage
B) DC cardioversion
C) Valsalva manoeuvre
D) IV adenosine
E) 2222 crash call

A

C) Valsalva manoeuvre
Vagal manoeuvres such as carotid sinus massage and Valsalva can be used as the first line management in stable patients with a narrow complex tachycardia

86
Q

Buzz words for wolf Parkinson white syndrome

A

Pre-excitation
Intermittent QRS complexes
Short PR interval

87
Q

Tx wolf Parkinson white syndrome

A

Radio frequency ablation of the accessory pathway (definitive)

88
Q

Tx of VF

A

Shock

89
Q

Describe VF

A

Uncoordinated electrical activity with a chaotic fibrillating baseline

90
Q

Tx torsades de pointes

A

IV magnesium sulfate + stop offending drug + correct electrolyte imbalance

91
Q

Medications that can cause torsades de pointes

A

Anti-psychotics
Citalopram
Flecainide
Sotalol
Amiodarone
Macrolides
Ketoconazole

92
Q

What do you do with pulseless VT

A

Unsynchronised Biphasic shock

93
Q

What do you do with pulsed VT + adverse features

A

Synchronised DC cardio version (up to 3 attempts)
Then IV amiodarone 300mg

94
Q

What do you do with pulsed VT without adverse features

A

IV amiodarone

95
Q

Bradycardia with adverse features

A

IV atropine 500 mcg
Repeat to maximum of 3g

96
Q

Describe 1st degree heart block

A

Prolonged PR interval

97
Q

describe 2nd degree type 1 heart block

A

Progressively prolonged PR interval until a QRS complex drops

98
Q

Describe 2nd degree type 2 heart block

A

Same PR interval until a QRS complex drops

99
Q

Describe 3rd degree heart block

A

Complete dissociation between P waves and QRS complexes

100
Q

Causes of LBBB

A

Aortic stenosis
Digoxin toxicity
Hyperkalaemia

101
Q

Describe what you would see on an ecg for LBBB

A

In V1 you’ll see a w shape
In v2 you’ll see a M shale

102
Q

Causes of RBBB

A

normal variant
RV hypertrophy
PE

103
Q

Describe what you would see on an ecg for RBBB

A

v1 M shape
V6 W shape

104
Q

MOA amiodarone

A

Blocks potassium Channels

105
Q

Infective endocarditis in a patient positive for IVDU most commonly affects what structure

A

Tricuspid valve
All valves in the heart are derived from the endocardia cushion

106
Q

What is hypertrophic cardiomyopathy caused by

A

Aysmmetric septal hypertrophy

107
Q

What is S3 (third heart sound) caused by

A

Caused by diastolic filling of the ventricle
Heard in left ventricular failure, constrictive pericarditis and mitral regurgitation

108
Q

What is S4 (fourth heart sound) caused by

A

Caused by atrial contraction against a stiff ventricle
May be heard in aortic stenosis, HOCM, hypertension and therefore coincides with the P wave on an ecg

109
Q

How does clopidogrel work

A

Anti-platelet agent that works by inhibiting the P2Y12 ADP receptor which in turn inhibits the activation of platelets

110
Q

What is the physiological role of troponin I

A

Binds to actin to hold the troponin-tropomyosin complex in place

111
Q

Where is the SA node found

A

Right atrium

112
Q

Where is the AV node found

A

Atrioventricular septum

113
Q

What is Ebstein’s anomaly

A

Congenital defect leading to a large right atrium and a small right ventricle which is known as “atrialisation”
Typically accompanied by tricuspid regurgitation

114
Q

Describe the phases of cardiac action potential

A

Phase 0 - rapid depolarisation - rapid sodium influx
Phase 1 - early depolarisation - efflux of potassium
Phase 2 - plateau - slow influx of calcium
Phase 3 - efflux of potassium
Phase 4 - restoration of ionic concentrations - resting potential is restored by Na+/K+ ATPase

115
Q

Pathophysiology of hypertrophic obstructive cardiomyopathy

A

Results in predominantly diastolic dysfunction - left ventricle hypertrophy - decreased compliance - decreased cardiac output

Characterised by myofibrillar hypertrophy with chaotic and disorganised fashion myocytes and fibrosis on biopsy

116
Q

Features of hypertrophic obstructive hypertrophy

A

Often asymptomatic
Exertional dyspnoea
Angina
Syncope typically following exercise
Sudden death

117
Q

ECHO findings for hypertrophic obstructive cardiomyopathy

A

MR SAM ASH
Mitral regurgitation MR
Systolic anterior motion SAM of anterior mitral valve leaflet
Asymmetric hypertrophy ASH

118
Q

ECG findings for HOCM

A

left ventricular hypertrophy
Non-specific ST segment and T wave abnormalities
Deep Q waves
AF occasionally

119
Q

MOA of tirofiban

A

glycoprotein IIb/IIIa antagonist

120
Q

what is arrhythmogenic right ventricular cardiomyopathy

A

a form of inherited cardiovascular disease that can present with syncope or sudden cardiac death

121
Q

pathophysiology of arrhythmogenic right ventricular cardiomyopathy

A

autosomal dominant
right ventricular myocardium is replaced by fatty and fibrofatty tissue

121
Q

pathophysiology of arrhythmogenic right ventricular cardiomyopathy

A

autosomal dominant
right ventricular myocardium is replaced by fatty and fibrofatty tissue

122
Q

presentation of arrhythmogenic right ventricular cardiomyopathy

A

palpitations
syncope
sudden cardiac death

123
Q

management of arrhythmogenic right ventricular cardiomyopathy

A

sotalol
catheter ablation
implantable cardioverter-defibrillator

124
Q

what’s the first line secondary prevention of stroke

A

clopidogrel

125
Q

moa of warfarin

A

vitamin k antagonist

126
Q

moa of aspirin

A

COX inhibitor

127
Q

moa of heparins

A

activation of antithrombin II

128
Q

moa of bivalirudin

A

reversible direct thrombin inhibitor

129
Q

What should you consider for patients with recurrent proximal DVT or PE despite adequate anticoagulation treatment

A

Inferior vena cava filter

130
Q

Where is BNP mainly secreted from

A

Ventricular myocardium

131
Q

What conditions are associated with hypertrophic obstructive cardiomyopathy

A

Friedreich’s ataxia
Wolff-Parkinson white

132
Q

What embryological structure gives rise to the ascending aorta

A

Truncus arteriosus

133
Q

What is dressler syndrome

A

Complication of MI that can occur any time between 2 weeks to several months post MI
Symptoms include fatigue malaise pleuritic chest pain mild dyspnoea
Decreased BP on inspiration is associated with DS

134
Q

Why would mitral stenosis cause an enlarged left atrium

A

Mitral stenosis means mitral valve has thickened that results in impaired blood flow into the left ventricle
This increases pressure in the left atrium which causes enlargement of the left atrium

135
Q

Features of mitral stenosis

A

Dyspnoea due to increased atrial pressure causing pulmonary venous hypertension
Haemoptysis- pink frothy sputum
Mid late diastolic murmur best heard expiration
Loud S1
opening snap
Low volume pulse
Malar flush
AF

136
Q

What would you see on an ECG for a posterior STEMI

A

ECG will show reciprocal changes e.g ST depression in leads V1-4
May also see upright t waves and tall broad R waves

137
Q

Classic signs of cardiac tamponade

A

Becks triad
Muffled heart sounds
Raised JVP
hypotension

138
Q

treating heart failure if symptoms persist after first-line medications

A

consider second-line treatment
ivabradine
sacubitril/valsartan
hydralazine
digoxin
dapagliflozin

139
Q

treating heart failure if pt remains symptomatic after first and second line meds

A

ICD - poor LVEF + reasonable QoL + eps of VT/VF
CRT - only appropriate in its with prolonged QRS
LVAD - end stage HF - used as interim
transplant - also last point intervention

140
Q

An 8-year-old girl is brought to the GP by her mother with a sore throat for the past five days. Incidentally, on examination, a harsh pan systolic murmur is heard during cardiac auscultation at the left lower sternal region. Echocardiogram reveals a small septal defect located apical to the aortic annulus but below the crista supraventricularis.

Which of the following best describes the type of ventricular septal defect?

A

membranous ventricular septal defect

141
Q

what is ventricular septal defect?

A

VSD is most common congenital cardiac anomaly in children

typically have a pan-systolic murmur promninently heard at left lower sternal border

142
Q

diagnosing aortic dissection

A

CT angiogram
TOE can also be used if CT isn’t available

143
Q

clinical signs on examination of aortic dissection

A

radio-radial delay
radio-femoral delay
blood pressure differential between arms

144
Q

initial mx aortic dissection

A

resus if necessary
cardiac monitoring
strict blood pressure control

145
Q

definitive management aortic dissection

A

type a - surgery
type b - normally managed conservatively

146
Q

clinical features of aortic dissections

A

usually presents in men over the age of 50
sudden onset tearing chest pain or interscapular pain radiating to the back

147
Q

symptoms of digoxin toxicity

A

abdominal pain, nausea, vomiting, arrhythmias and yellow-green visual disturbances

148
Q

digoxin effects on ECG

A

downsloping ST depression
T wave changes
the morphology of the QRS complex/ST segment is variously described as resembling a reverse tick

149
Q

what is brugada syndrome

A

genetic condition caused by sodium channelopathies
high incidence in south east asian males

150
Q

clinical features of brugada syndrome

A

patients may be asymptomatic or present with palpitations and syncope due to arrhythmias

151
Q

risk factors that can increase the risk of arrhythmia in patients with brugada syndrome

A

fever - biggest risk
excess alcohol intake
dehydration
medication
electrolyte abnormalities

152
Q

management of brugada syndrome

A

definitive management is an ICD to reduce the risk of sudden death from arrhythmias

153
Q

management of cardiac tamponade

A

first line in patients who are haemodynamically unstable is pericardiocentesis

154
Q

complications of pericardiocentesis

A

pneumothorax - pts should have a CXR post procedure
damage to myocardium, coronary vessels
thrombus
arrhythmias/cardiac arrest
damage to peritoneum

155
Q

First line investigation for carotid artery stenosis

A

Duplex ultrasound

156
Q

what is peripheral arterial disease

A

narrowing of the arteries supplying the limbs and peripheries, reducing the blood supply to these areas

157
Q

signs and symptoms of peripheral arterial disease

A

sx: walking impairment + pain in buttocks and thighs relieved at rest

signs: hair loss, pale, arterial ulcers, weak/absent pulses, poorly healing wounds

158
Q

ix peripheral arterial disease

A

full CVS risk assessment + ABPI

159
Q

treatment of peripheral arterial disease medical

A

atorvastatin 80mg + clopidogrel 75mg OD

160
Q

what is acute limb ischaemia

A

severe symptomatic hypoperfusion of a limb occurring for <2 weeks

SURGICAL EMERGENCY

161
Q

sx and presentation of acute limb ischaemia

A

6 Ps
pain
pulselessness
paraesthesia
paralysis
pallor
perishingly cold

162
Q

Ix of acute limb ischaemia

A

handheld arterial doppler

163
Q

mx of acute limb ischaemia

A

analgesia + IV heparin + vascular review

164
Q

what is critical limb ischaemia

A

end point of PAD

165
Q

sx of critical limb ischaemia

A

night pain relieved by hanging limb out of bed
resting pain >2 weeks
ulceration
gangrene
absent pulses
cold limb

166
Q

management of critical limb ischaemia

A
  1. conservative
  2. endovascular
  3. open surgery
  4. amputation
167
Q

what electrolyte abnormality is most likely seen in a patient with acute digoxin toxicity

A

hyperkalaemia

168
Q

indications for a permanent pacemaker

A

severe heart failure not responding to treatment
complete heart block
mobitz type 2 heart block
symptomatic bradycardia
drug- resistant tachyarrythmias
sick sinus syndrome

Clinical Medicine (26 decks)

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