Cardiology Flashcards
1
Q
What is Stable Angina?
A
Exertional sounding chest pain, relieved by PRN GTN
2
Q
What is the NICE approved 1st line investigation for stable angina?
A
CT coronary angiogram
3
Q
What is the NICE algorithm for treating stable angina?
A
1 - B-blocker
2 - AND/OR dihydropyridine CCB
3 - ADD one of:
ISMN, Ivabradine, Ranolazine, Nicorandil
4 - Revascularisation
4
Q
What is the 1st line treatment for Prinzmetal angina?
A
Dihydropyridine CCB (Amlodipine/Diltiazem)
5
Q
What is the method of action of ISMN?
A
Vasodilator
6
Q
What are the common side effects of ISMN?
A
Flushing, headaches, hypotension
7
Q
What advice should be given when starting ISMN?
A
Take between 08:00 & 14:00 to avoid nitrate intolerance
8
Q
What is the method of action of Ivabradine?
A
Slows HR down
9
Q
What key requirement is there for starting Ivabradine?
A
Patient needs to be in NSR w/ HR >70bpm
10
Q
When should Ivabradine be stopped?
A
In 3/12 if not working
11
Q
When is Ranolazine a good choice for stable angina?
A
If bradycardic - improves HR
12
Q
What are the side effects of Ranolazine?
A
Long QT
13
Q
What are the contraindications to Ranolazine?
A
Moderate cardiac/renal/liver failure
14
Q
What is the method of action of Nicorandil
A
Vasodilator
15
Q
What are the contraindications to Nicorandil?
A
Low BP
LV dysfunction
16
Q
What 2o prevention is given in stable angina?
A
Aspirin 75mg
Statins
ACE-i (if diabetic or LV dysfunction)
17
Q
What is the Qrisk2 score used for?
A
Quantify 10 year cardiovascular risk
18
Q
How often should Qrisk2 score be checked?
A
Every 5 years
(more frequently if known cardiovascular disease/high risk/>85)
19
Q
What Qrisk2 score indicates starting Statins?
A
> 10%
(or if lifestyle interventions ineffective)
20
Q
In what patient groups may Atorvastatin 20mg be used for 1o prevention without risk stratification?
A
> 85 y/o
CKD
21
Q
How should Statins be used in proven CVD?
A
2o prevention
High-intensity statins (80mg Atorvastatin)
22
Q
What are the treatment targets for high-intensity statins in proven CVD?
A
3/12 > 40% non-HDL reduction
(if not achieved inc dose)
23
Q
What are the side effects of statins?
A
Myositis
Rhabdomyolysis - rare
Hepatitis
CONSTIPATION
24
Q
What monitoring should be done for patients on statins?
A
LFTs at baseline, 3/12, 12/12
no need for CK if asymptomatic
25
In which patient group are statins contraindicated?
Pregnant women
26
What interaction does Amlodipine have with statins?
Interacts with simvastatin ONLY to increase level (acts as weak inhibitor)
27
How is Ezetibime used in lipid modification?
Monotherapy of 1o hypercholesterolaemia where statins are contraindicated
28
How are Fibrates used in lipid modification?
2o care
Better reduction of triglycerides
29
What are the risks of Fibrates?
Gallstones
Increased risk of Rhabdomyolysis when given w/ statins
30
How are Aliro/evoloCUmab used in lipid modification?
Specialist drug
1o heterozygous familial hypercholesterolaemia
Lowers LDL-C
31
What is Unstable Angina?
Cardiac sounding chest pain at rest
Troponin negative
32
How is risk determined in Unstable Angina?
GRACE score
If Low - DAPT + elective angiogram
If High (6/12 mortality >3%) - angiogram +/- proceed in SAME ADMISSION W/I 72HRS
33
What is Prinzmetal Angina?
Angina caused by a spasm in the coronary arteries (no lesion to stent)
34
How does Cocaine toxicity caused Prinzmetal Angina?
Sympathetic stimulation
35
What are the treatment options for Prinzmetal Angina?
Nitrates + CCB +/- angiogram (if not controlled)
36
What class of medications are used to control cocaine-induced hypertension?
Benzodiazepines
37
What is the protocol for conservative management of ACS?
MONA-BASH
Morphine, O2, nitrates (GTN S/L)
DAPT (Aspirin + Ticag/Clopi)
2o prevention
-Bisoprolol
-Aspirin
-Statins
Heparin (Fondaparinux)
38
What is the protocol for non-conservative management of ACS?
PPCI
-STEMI 90mins
-NSTEMI 72hrs
39
What medications are used for 2o prevention in ACS?
Bisoprolol
Aspirin
Statins
40
What are the ECG diagnostic criteria for STEMI?
>1mm STE in contiguous limb lead
>2mm STE in contiguous chest leads (1.5mm in women)
New LBBB
41
What patient groups may not present with chest pain in ACS?
Women
Diabetics
42
What ECG leads correspond to the inferior territory?
II, III, aVF
(RCA/LCx)
43
What ECG leads correspond to the anterior territory?
V1-V4
(LAD)
44
What ECG leads correspond to the lateral territory?
I, aVL, V5, V6
(LCx, LAD diagonal branch)
45
What is Wellen's Syndrome?
Biphasic T-wave in V1 & V2
-only during chest pain
-critical LAD stenosis
46
What are the ECG findings of Pericarditis?
Widespread concave ST elevation w/ PR depression
-later on ST normalises w/ TWI
47
What are the treatment options for Pericarditis
NSAIDs
Colchicine
48
What are the s/e of Colchicine?
Diarrhoea
Nausea
Vomiting
49
What are the ECG findings of Brugada Syndrome?
Coved STE in >1 of V1-V3 followed by TWI
50
What is Brugada Syndrome?
Coved STE in >1 of V1-V3 followed by TWI + at least one of the clinical criteria
51
What are the clinical criteria for diagnosis of Brugada Syndrome?
Documented VF/polymorphic VT
Family hx sudden cardiac death <45
Coved-type ECGs in family members
Syncope
Nocturnal agonal resp
VT induced by electrical stimulation
52
What factors can unmask Brugada Syndrome?
Fever
Ischaemia
Drugs (cardiac)
Hypo/Hyperkalaemia
Post DC cardioversion
Hypothermia
53
What is the management for Brugada Syndrome?
ICD
54
What are the ECG diagnostic criteria for Left Ventricular Hypertrophy?
Voltage Criteria
-sum of deep S wave in V1 and tall R wave in V5-V6 >35mm
Non Voltage Criteria
-ST depression & TWI in LEFT sided leads
55
What are the ECG findings of Hypertrophic Obstructive Cardiomyopathy?
Left Ventricular Hypertrophy
Asymmetrical deep septal hypetrophy (deep Q waves in inferolateral leads)
LEFT atrial enlargement (P mitrale)
56
What are the ECG findings of High take-off?
Widespread STE at J-point
(young, healthy men)
57
What commonly prescribed drug interacts with Clopidogrel?
Omeprazole
-CYP450 inhibitor
-reduces its effectiveness
-Lansoprazole doesn't interact, or Ticagrelor does not interact
58
When is Tirofiban used?
High-risk ACS patients
59
What are the side effects of Tirofiban?
Anaemia
Thrombocytopenia
60
What DVLA advice should be given to ACS patients?
Group 1
-no need to notify
-resume 1/52 if successful rx AND LVEF >40% AND no further revascularisation planned
-resume 4/52 otherwise
Group 2 (HGV)
-notify
-re-licensed >6/52 if LVEF >40% and ETT/ECG normal (Bruce protocol)
61
What are the complications of MI, and at what time do they occur?
<4hrs - cardiogenic shock/arrest, arrhythmias
4-24hrs - arrhythmias
1-3 days - fibrinous pericarditis
4-7 days - rupture of free wall, IV shunt, papillary muscle rupture (regurg)
Weeks-months - fibrosis of ventricular wall, weakn aneurysms w/ mural thrombosis, Dressler syndrome
62
What is Dressler Syndrome?
Autoimmune pericarditis post MI
63
When should ABPM be offered?
If clinic BP b/w 140/90-180/120
64
What are the diagnostic criteria for HTN?
Clinical BP >140/90 AND ABPM average >135/80
Stage 1 - clinical BP >140/90 AND ABPM average >135/80
Stage 2 - clinical BP >150/90 AND ABPM average >150/95
Stage 3 - SBP >180 or DBP >120 chronically
65
What is the NICE algorithm for HTN treatment?
1 - ACEi if <55 or T2DM, CCB if >55 or Afro/Carribean
2 - Add either CCB or Thiazide-like diuretic (Indapamide)
3 - ACEi + CCB + Indapamide
4 - Spironolactone if K+ <4.5, a/B-Blocker if K+ >4.5
66
What are the side effects of CCBs?
Ankle oedema
Headache
Flushing
GINGIVAL HYPERPLASIA
Constipation
Ulcers (Nifedipine)
67
What are the side effects of Thiazides?
IMPOTENCE
HYPERCa
HypoNa/K
Gout
68
What are the red flags requiring investigation for a 2o cause of HTN?
<40 y/o
Sudden worsening
Accelerated/malignant (>200 SBP)
Stroke <50
Refractory (>140/90 OR >130/80 w/ DM AND on 3x drugs)
69
What are the endocrine causes of HTN and what ix should be performed for each?
Acromegaly (OGTT, IGF-1)
Hyperthyroidism (TFTs)
Conn's Adenoma (Aldosterone:Renin ratio, if >40 for CT adrenal)
Cushing's (Dex suppresion test)
Phaechromocytoma (24hr urinary metanephrines)
70
What are the renal causes of HTN?
Adult polycystic kidney disease (USS renal tract)
Renal aa stenosis/fibromuscular dysplasia (MRA renal aa +/- angio)
Glomerulonephritis (dipstick, MCS, pro)
71
What is the drug of choice for HTN in systemic sclerosis renal crisis?
Ramipril
72
What are the drugs of choice for controlling HTN in Pre-eclampsia?
Labetalol
Nifedipine
Methyldopa
73
What are the drugs of choice for controlling HTN in Aortic dissection?
IV Labetalol/Esmolol
(target SBP 100-120)
74
What is the drug of choice for controlling HTN in Conn's syndrome?
Spironolactone
75
What are the drugs of choice for treating malignant HTN?
Nitrates
Nitroprusside
Labetalol
76
What is the drug of choice for controlling HTN in SAH?
Nimodipine (reduces vasospasm)
(hyperhydration w/ 3L IVI)
77
What are the NYHA classifications for Heart Failure?
Class 1 - no limitations
Class 2 - mild sx w/ normal activity, minimal limitation
Class 3 - mod sx w/ minimal activity, moderate limitation
Class 4 - sx at rest
78
What are the principles of managing patients with CCF in hospital?
Fluid balance - IP/OP charts, U&Es, fluid restrict, daily weights
Echo
Diuretics - IV Furosemide, consider PO Bumetanide
Consider ISMN/Hydralazine if renal function poor
79
What is the method of action of Furosemide in Heart Failure?
Loop diuretic to offload fluids
NO PROGNOSTIC BENEFIT
80
What are the side effects of Furosemide?
HypoK/Na
Exacerbation of hyperglycaemia
Gout
81
What diuretics can be added if oedema is refractory to Furosemide in heart failure?
Mineralocorticoid antagonist (Spironolactone) - PROGNOSTIC BENEFIT
Thiazides (Metolazone)
82
What is the method of action of ACEi in heart failure?
Remodel the heart by reducing afterload (BP)
PROGNOSTIC BENEFIT
83
What are the side effects of ACEi?
Hyperkalaemia
Dry cough
Angioedema
84
Which B-Blockers have prognostic benefit in heart failure?
Bisoprolol
Carvedilol (cardiac slsective)
Metoprolol
85
What contraindications are the to prescribing B-blockers in heart failure?
Caution in asthmatics
Not to be used w/ non-dihydropyridine CCB (Verapamil) - causes low cardiac output
86
What can be given to treat B-Blocker overdose?
IV Glucagon
87
What are the side effects of Spironolactone?
Painful gynaecomastia
Hyperkalaemia
Impotence
88
What alternative MRA can be considered if Spironolactone is not tolerated?
Eplerenone
89
What is Entresto and when is it indicated in heart failure?
Combination of Valsartan (PROGNOSTIC BENEFIT) and Sacubitril
Indicated if LVE <35%
90
What are the indications for Ivabradine in heart failure?
LVEF <35% AND NSR AND HR >75bpm
91
What are the indications for Digoxin in heart failure?
NSR to improve sx (+ve inotrope)
(requires loading)
92
What is the management of HFpEF?
No prognostic medications
Diuretics for sx
Avoid B-blockers
93
What is the acute management of pulmonary oedema?
A - sit patient up
B - high-flow O2, CPAP
C - if SBP >90-100 give nitrate, nitroprusside and opiates. Caution w/ IV Furosemide and IVI
D/E - treat underlying causes
Avoid B-blockers
If SBP <90 treat as cardiogenic shock (inotropes)
94
What is high output heart failure?
Failure of heart to meet increasing needs
-anaemia
-hyperthyroidism
-Paget's
-acromegaly
-AV malformations
-pregnancy
-malnutrition
95
When are ICDs used in heart failure?
Cases of narrow complex QRS w/o LBBB
96
When is CRT (biventricular pacing) used in heart failure?
LBBB or broad complex QRS
97
How does aortic stenosis present?
Angina
Syncope
SOBOE
LVF (LV outflow tract obstruction)
98
What commonly prescribed drugs can worsen aortic stenosis?
Vasodilators/ACEi (decrease afterload)
B-blockers/CCB (decrease contractility)
99
What is the characteristic murmur of aortic stenosis?
Ejection systolic murmur
-loudest at LEFT sternal edge
-radiating to carotids
-low-volume, slow rising pulse
100
What are the indications for surgical management of aortic stenosis?
Symptomatic AS
Asymptomatic w/ severe AS on ECHO
101
How should aortic stenosis be monitored?
Annual ECHO
102
What investigation should not be performed when investigating aortic stenosis?
Stress exercise test
103
How does mitral regurgitation present?
Usually mild/asymptomatic
Severe MR presents as heart failure (flash pulmonary oedema)
AF
104
What is the medical management of mitral regurgitation?
Control heart failure and AF
(severe cases require surgery)
105
What is the characteristic murmur of mitral regurgitation?
Apical panystolic murmur radiating to axilla
Apex displacement DOWN w/ LEFT parasternal heave
106
How should mitral regurgitation be monitored?
Annual ECHO
107
What is the most common causative organism of infective endocarditis?
Staph aureus
108
What is the gold standard investigation for infective endocarditis?
Transoesophageal EHO
(TTE often used)
109
Which valve is commonly affected in infective endocarditis in IVDU?
Tricuspid
(RIGHT sided due to venous introduction)
110
What are the complications of infective endocarditis?
Aortic valve vegetation
-can progress to abscess causing aortic root dilatation
Septic emboli to vascular beds
111
How can septic emboli in infective endocarditis be identified?
Kidneys - urine dipstick
Brain - MRI
Retina (Roth spots) - fundoscopy
Spleen - Splenomegaly, CT AP
Limbs - ischaemic limb, pulses, CTA
112
What isolated bacteria in infective endocarditis would indicate colonoscopy?
S. bovis/gut commensals
(screen for colorectal ca)
113
What are the diagnostic criteria for infective endocarditis?
Duke Criteria - 2 major OR 1 major + 3 minor OR all minor
MAJOR (BE) - 2x +ve BC, endocardium involvement (new murmur, abscess etc.)
MINOR - >38C, +ve BC, immunological phenomenon (glomerulonephritis, Olser nodes), vascular phenomenon (Janeway lesions), risk factors (IVDU, immunocompromise, artificial valve)
114
What is Libmann-Sacks endocarditis?
Sterile vegetations on both sides of valve in SLE
115
What is an atrial myxoma?
Atrial tumour
116
How do atrial myxomas present?
Positional dizziness
SOB
Palpitations
Pansystolic murmur
FEMALE
117
What are the symptoms of carcinoid syndrome?
Adult-onset refractory wheeze (mistaken for asthma)
Diarrhoea
Facial flushing
New murmur (RIGHT sided - PS or TR
118
What is carcinoid syndrome?
Syndrome of excess 5-HT production caused by neuroendrocrine tumour
119
What are the common sites of carcinoid tumours?
GI TRACT
-require liver mets to give rise to sx
Lungs
Kidneys
Breast
120
What are the treatment options for carcinoid syndrome?
Octreotide
Resection
121
What are the ECG findings of 1o AV block?
Prolonged PR (>200ms)
QRS relationship maintained
122
What are the ECG findings of Mobitz 1 (Wenckebach)?
Progressive prolongation of PR interval until dropped QRS
123
What are the ECG findings of Mobitz 2?
Normal PR interval
Randomly dropped QRS complexes
124
What are the ECG findings of 3o AV block?
AV dissociation
125
What are the ECG findings of Bifascicular block?
RBBB AND
LEFT ant OR post fascicular block (LEFT or RIGHT axis deviation respectively)
126
What are the ECG findings of Trifasicular block?
Classically - Bifascicular block and 1o AV block
Misnomer - true trifascicular block is a complete heart block
127
What are the ECG findings of Monomorphic VT?
Identical, concordant, broad QRS complexes
128
What are the ECG findings of Polymorphic VT?
Concordant, broad QRS complexes w/ multiple morphologies
129
What are the ECG findings of Torsades de Pointes?
Polymorphic VT w/ long QT
Discordant
130
What is the emergency treatment of Torsades de Pointes?
IV Magnesium
131
What are the ECG findings of VF?
Chaotic irregular waveforms of varying amplitude
No P/QRS/T
132
What are the EG findings of Tachy-brady syndrome?
Alternating brady and tachycardia
133
What is the management of Tachy-brady syndrome?
Pacemaker for bradycardia and rate-control
B-blockers for tachycardia
134
What are the ECG findings of PEA?
Any ECG rhythm but no pulse clinically
135
What are the ECG findings of Wolf-Parkinson White?
Slurred upstroke of QRS complex (delta wave)
Shortened PR
136
What are the ECG findings of arrhythomgenic RIGHT ventricular cardiomyopathy?
Small +ve deflection at end of QRS (epsilon wave)
Slightly wide QRS
137
What are the ECG findings of hypothermia?
Bradycardia w/ prolonged ventricular ectopic
Prolongation of P-wave, QRS, QTc
Positive deflection at J-point (Osborne wave)
138
What are the ECG findings of hypercalcaemia?
Short QTc
139
What are the ECG findings of hypocalcaemia?
Long QTc
-can degenerate to TdP
140
What are the ECG findings of hyperkalaemia?
Prolonged PR interval
Small/absent P-waves
Peaked T-waves
Widened QRS complexes
Degenerates to sinusoidal rhythm - VF - asystole
141
What are the ECG findings of hypokalaemia?
Deflection after T-wave (U-wave)
Flat T-waves
ST depression
142
What are the ECG findings of RBBB?
RSR findings V1-V3
143
What are the ECG findings of LBBB?
Deep S-wave in V1-V3 (W)
LAD
144
What are the ECG findings of pacemaker rhythms?
RV pacemaker leads to LBBB
LV pacemaker leads to RBBB
145
What are the ECG findings of PE?
SINUS TACHYCARDIA
RIGHT heart strain
-RAD
-ST depression
-TWI in V1-V3, II, III, aVF (anteroinferior)
Q1S3T3 (Q-wave in I, S&T inversion in III)
146
What are the causes of a prolonged QTc?
Drugs (Digoxin, TCA, macrolides, quinolones, anti-psychotics)
Hypos (Ca, Mg, K, thermia, thyroid, adrenalism)
Ischaemia/general illness
147
What are the ECG findings of Atrial Fibrillation?
Irregularly irregular
Narrow QRS complexes
Lack of P-waves
148
What are the ECG findings of Atrial Flutter?
P-waves w/ sawtooth baseline
300bpm limited by AV blocks (ie. 2:1)
149
What scoring systems are used to assess the need for anticoagulation in AF?
HASBLED/ORBIT
CHA2DS2VASC
150
What are the components of the HASBLED score?
HTN
Abnormal renal/liver function
Stroke hx
Bleeding history/predisposition
Labile INRs
Elderly
Drugs/Alcohol
151
What are the components of the ORBIT score?
Sex
Hb concentration
Age
Bleeding history
Antiplatelet therapy
152
What are the components of the CHA2S2VASC score?
C - Congestive HF
H - HTN
A2 - Age >75
D - Diabetes
S2 - Stroke/TIA/VTE
V - Vascular hx (MI/PVD)
A - Age 64-75
Sc - Female (ONLY IF ANY OTHER SCORE)
153
When should rhythm control be considered in AF?
Young patients
Reversible/acute onset <48hr
Sx of CCF
COMPROMISE
154
What are the options for rhythm control in AF?
Electrical
-DC cardioversion (ECHO, anticoag)
-ablation (oulmonary vv)
Chemical
-Amiodarone
-Flecanide
155
Why is an ECHO required prior to DC cardioversion in AF?
To check for intramural thrombus
156
How should anticoagulation be given around DC cardioversion in AF?
4 weeks prior AND 12 months after
157
In which patients is Amiodarone preferred for chemical cardioversion?
Patients w/ LV failure
158
What are the side effects of Amiodarone?
Photosenstivity
Slate grey pigmentation
Hepatotoxicitity
Hypo/Hyper thyroid
Pulmonary fibrosis
159
Which commonly prescribed cardiological drugs does Amiodarone interact with?
Warfarin
Digoxin
160
How is Flecanide used for chemical cardioversion?
For paroxysms
(pill in pocket)
161
In which patients is Flecanide contraindicated?
Patients w/ structural heart condition
162
What are the options for rate control in AF?
B-blocker
-preferred if angina/HTN
CCB (Diltiazem/Verapamil)
Digoxin
-sedentary patients
-CHF
163
What are the symptoms of Digoxin overdose?
N/V/D
Blurred vision w/ xanthopsia/haloes
Palpitations/syncope
Confusion
164
What is the treatment for Digoxin overdose?
Digibind
-fab fragment
165
In which patient group is rate control for AF contraindicated?
Pt w/ accessory pathway (WPW)
-favours conduction down that pathway
-loses AV node safety netting
166
What are the 4 adverse features of arrhythmias?
Shock
Syncope
MI
HF
167
What are the management options for profound bradycardia?
Atropine 500mcg
-up to 3mcg if risk of asystole
IV Isoprenalie
IV adrenaline
Transcutaneous pacing
-proceed to PPM
168
What features in a bradycardic patient suggest a higher risk of asystole?
Recent asystole
Mobitz II or 3o AV block
Pauses >3s
169
What is the management for an unstable tachycardia?
Synchronised DC shock x3
Amiodarone 300mg IV/10-20mins
Repeat shock
Amiodarone 900mg/24hrs
170
What is the management for a regular narrow complex tachycardia?
Vagal manoeuvres
Adenosine 6/12/12mg boluses
Rate control (atrial flutter)
171
What is the management for an irregular narrow complex tachycardia?
AF management
172
What is the management for a regular broad complex tachycardia?
Amiodarone 300mg IV/20-60mins THEN 900mg/24hrs
if SVT w/ abberancy give Adenosine
173
What is the management of an irregular broad complex tachycardia?
AF w/ BBB - treat as AF
Pre-excited AF - Amiodarone
Polymorphic VT/TdP - Mg 2g
174
What are the features of cardiac tamponade?
Beck's triad
-muffled heart sounds
-raised VP
-hypotension
Kussmaul's sign
Pulsus parodoxus
175
What is Kussmaul's sign?
Paradoxically raised JVP on inspiration
176
What is pulsus parodoxus?
Exaggerated BP variation w/ resp cycle
-falls during inspiration
177
What are the ECG findings of cardiac tamponade?
Low voltage QRS complexes alternating in amplitude
-electrical alternans
178
What is the management of cardiac tamponade?
IVI
Pericardiocentesis
179
What is the management of anaphylaxis?
IVI
IM adrenaline (500mcg/0.5ml 1:1000)
-if refractory to 2x doses for adrenaline infusion
180
What additional drugs may be given in anaphylaxis?
Chlorphenamine 10mg IM
Hydrocortisone 200mg IM
181
What are the key components of ALS in cardiac arrest?
30:2 compressions (2min cycle)
Adrenaline 1mg after 3-5mins
Amiodarone 300mg after 3x shocks
182
What are the shockable rhythms in cardiac arrest?
VF
Pulseless VT
183
What are the non-shockable rhythms in cardiac arrest?
PEA
Asystole
184
What are the reversible causes of cardiac arrest?
Hypoxia
Hypothermia
Hypovolaemia
Hypo/hyperkalaemia
Toxins
Tension Pneumothorax
Tamponade
Thrombus
