Cardiology Flashcards
Stable Angina
*Constant stenosis
*Ischaemia with no necrosis
*Effort dependent and predictable symptoms
*No biomarker rise, may have reversible ECG changes
Unstable Angina
*Dynamic stenosis
*Ischaemia with no necrosis
*Unpredictable or worsening symptoms
*No biomarker rise, may have reversible ECG changes
NSTEMI
*Obstruction to flow
*Cardiomyocyte necrosis
*Prolonged symptoms
*Occurs at any time
*May have irreversible ECG changes
*Biomarker rise
STEMI
*Obstruction to flow
*Cardiomyocyte necrosis
*Prolonged symptoms, occurs at any time
*ST elevation in the distribution of affected coronary artery
*Biomarker rise
What are the non modifiable risk factors for coronary artery disease?
*Age
*Sex: increased risk in men
*Genetic predisposition
*Existing coronary artery disease
What are the modifiable risk factors for coronary artery disease?
*Smoking
*Hypertension
*Diabetes mellitus
*Dyslipidaemia
What are the investigations for CAD?
*ECG to look for ST elevation
*Cardiac markers e.g. troponin
Where would you see ECG changes in an anterior STEMI and what artery is most likely affected?
*V1-V4
*Left anterior descending
Where would you see ECG changes in an inferior STEMI and what artery is most likely affected?
- II, III, aVF
*Right coronary artery
Where would you see ECG changes in a lateral STEMI and what artery is most likely affected?
*I, V5, V6
*Left circumflex
What is the management of a STEMI?
*Morphine
*Oxygen if SATS<94%
*Nitrates
*Aspirin + prasugrel (if having PCI)
*Percutaneous coronary intervention if within 120 minutes of presentation to hospital and within 12 hours of symptom onset; if not possible then fibrinolysis
What is the management of a NSTEMI?
*Morphine
*Oxygen if SATS<94%
*Nitrates
•Aspirin
•Use GRACE stratification tool, if high risk then coronary angiography
• Antithrombin therapy with fondaparinux sodium should also be offered, unless the patient is undergoing immediate coronary angiography
What is the secondary prevention of CAD?
*Aspirin
*Clopidogrel
*Beta blocker
*ACEi
*Statin
What can be used to predict the prognosis post MI?
*KIllip class
What are the potential complications post MI?
*Cardiac arrest
*Cardiogenic shock
*Chronic heart failure
*Tachy or Brady arrhythmia
*Pericarditits
*Dressler’s syndrome
*Left ventricular aneurysm
*Left ventricular wall rupture
*Ventricular septal defect
*Acute mitral regurgitation
Grade 1 Hypertension
*Clinic: ≥140/≥90
*ABPM: ≥135/≥85
Grade 2 hypertension
*Clinic: ≥160/≥100
*ABPM: ≥150/≥95
Grade 3 hypertension
*Clinic: ≥180/≥110
What are the complications of hypertension?
*Atherosclerosis: increased risk of MI, stroke and peripheral vascular disease
*Renal damge
*Cardiac: increased after load increases LV work leading to LV hypertrophy and then heart failure
*Arrhythmia: increased AF risk
*Retinal damage: retinal haemorrhage and papilloedema leading to visual disturbance
What investigations should be carried out in those diagnosed with hypertension?
*Blood tests: renal function, electrolytes, lipids, HbA1c
*Urine dipstick: microscopic haematuria or proteinuria
*ECG: any LVH evidence
*Consider an echocardiogram
What is the treatment pathway for hypertension in someone under the age of 55?
Step 1: ACEi or ARB
Step 2: ACEi or ARB plus CCB (amlodipine) or thiazide like diuretic (indapamide)
Step 3: ACEi or ARB plus CCB plus Thiazide like diuretic
Step 4: discuss adherence, confirm resistant hypertension, consider expert advice or adding low dose spironolactone if K+≤4.5 or an alpha or beta blocker if K+>4
What is the treatment pathway for hypertension in someone over the age of 55?
Step 1: CCB
Step 2: CCB (amlodipine) plus ACEi or ARB or thiazide like diuretic (indapamide)
Step 3: ACEi or ARB plus CCB plus Thiazide like diuretic
Step 4: discuss adherence, confirm resistant hypertension, consider expert advice or adding low dose spironolactone if K+≤4.5 or an alpha or beta blocker if K+>4
What is the treatment pathway for hypertension in someone with type 2 diabetes?
Step 1: ACEi or ARB
Step 2: ACEi or ARB plus CCB (amlodipine) or thiazide like diuretic (indapamide)
Step 3: ACEi or ARB plus CCB plus Thiazide like diuretic
Step 4: discuss adherence, confirm resistant hypertension, consider expert advice or adding low dose spironolactone if K+≤4.5 or an alpha or beta blocker if K+>4
What is the treatment pathway for hypertension in someone of black African or African-caribbean family origin?
Step 1: CCB
Step 2: CCB (amlodipine) plus ARB or thiazide like diuretic (indapamide)
Step 3: ARB plus CCB plus Thiazide like diuretic
Step 4: discuss adherence, confirm resistant hypertension, consider expert advice or adding low dose spironolactone if K+≤4.5 or an alpha or beta blocker if K+>4
What are the symptoms of AF?
*Palpitations
*Dyspnoea
*Chest pain
*Irregualrly irregular pulse
Rate control of AF
*Beta blocker or rate limiting calcium channel blocker (diltiazem)
*If one drug alone doesn’t control the rate, add a second of beta blocker or diltiazem or digoxin
When would you offer rhythm control of AF
*Offered if reversible cause or if onset <48 hours, if heart failure or if remain symptomatic despite rate control
Rhythm control of AF
*Cardioversion pharmacologically via flecanide or amiodarone
*Electrically using a defibrillator
What is used to calculate stroke risk in AF?
*CHA2DS2-VASc
Explain the interpretation of the CHA2DS2-VASc score
*0: no anticoagulation
*1: consider anticoagulation
*>1: offer anticoagulation
*Offer a choice between warfarin and a DOAC
What are the causes of an irregularly irregular pulse?
*AF
*Ventricular ectopics
Explain the CHA2DS2-VASc scoring system
*Congestive heart failure
*Hypertension
*Age: 65-74: 1, ≥75: 2
*Diabetes mellitus
*Prior Stroke or TIA or thromboembolism
*Vascular disease (PAD, IHD)
*Sex (female)
*S
Describe supraventricular tachycardia on an ECG
*Fast, narrow complex tachycardia
*QRS<0.12s
What are the three main types of SVT?
*Atrioventricualr nodal re-entrant tachycardia
*Atrioventricualr re-entrant tachycardia: Wolff-PArkinson White syndrome
*Atrial tachycardia
Explain the management of supraventricular tachycardia
- Continuous ECG monitoring
*Valsalva manoeuvre: blow hard against resistance
*Carotid sinus massage
*Adenosine: initially 6mg then 12
*Verapamil
*DC cardio version if treatment fails
Explain the management of ventricular tachycardia
*If adverse signs then immediate cardioversion is indicated
*Amiodarone ideally via a central line or lidocaine
*If drug therapy fails then electrophysiological study, implantable cardioverter defibrillator
What are the causes of a prolonged QT interval?
*Congenital: Jervell-lange-neilsen syndrome, romano-ward syndrome
*Medications: amiodarone, tricyclic antidepressants, macrolides, sotalol, citalopram
What is the management of sinus bradycardia?
*If stable then observe
*If unstable or chance of asystole, then atropine 500mcg IV up to 6 doses, then other inotropes e.g. noradrenaline or transcutaneous cardiac pacing
First degree heart block
PR interval >0.2 seconds
Mobitz type I heart block
Progressive prolongation of the PR interval until a dropped beat occurs
Mobitz type II heart block
*PR interval is constant but the P wave is often moot followed by QRS (usually a set ratio)
Third degree heart block
No association between P waves and QRS complex
What is the management of heart block?
*If stable, observe
*Mobitz type II +
- Atropine 500mcg then other inotropes then temporary transvenous cardiac pacing/ permanent implantable pacemaker
Presentation of Heart Failure
*Breathlessness - worse on exertion
*Cough: white/pink frothy sputum
*Orthopnoea: how many pillows?
*Paroxysmal nocturnal dyspnoea
*Peripheral oedema
What are the signs of heart failure on examination?
*Bibasal crackles
*Signs of right sided heart failure: JVP, ankle oedema, hepatomegaly
*Displaced apex beat
Investigations for heart failure
*NT-proBNP
*ECG
* Echocardiogram
*Consider chest x ray
What is the medical management of heart failure?
*ACEi/ARNI
*Beta blocker
*MRA- spironolactone
*SGLT2i - Empagliflozin or dapagliflozin
*Loop diuretic
What is the management of acute heart failure?
*Nitrates for vaso and venodilation
*Furosemide
*CPAP for preload reduction
*Inotropes: dobutamine/dopamine
*Ultrafiltration
What is the most common cause of infective endocarditis?
Staphylococcus aureus
What is the second most common cause of infective endocarditis?
Streptococcus viridans
In patients following prosthetic valve surgery, what is the most common cause of infective endocarditis?
Staphylococcus epidermidis
What is used to diagnose infective endocarditis?
Duke criteria
When is infective endocarditis diagnosed using Dukes?
*Pathalogical criteria are positive
* 2 major
*1 major and 3 minor
*5 minor
In Duke’s criteria, what are the major criteria
1) 2 positive blood culturesshowing typical organsims
2) Persistent bacteraemia from blood cultures taken >12 hours apart (3 if the pathogen is less specific)
3) Positive echocardiogram
4) New valvular regurgitation
In Duke’s criteria, what are the minor criteria
1) Predisposing heart condition or IV drug use
2) Microbiological evidence that doesn’t meet the major criteria
3) Fever >38 degrees
4) Vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, janeway lesions, petechiae or purpura
5) Immunological phenomena: glomerulonephritis, osler’s nodes, roth spots
What is the initial blind therapy for infective endocarditis?
*Native valve: amoxicillin
*Pen allergy/MRSA/severe sepsis: vancomycin and low dose gentamicin
*Prosthetic valve: vancomycin + rifampicin +low dose gent
What is the therapy for staphylococci infective endocarditis?
*Native valve: flucloxacillin
*Prosthetic valve: flucloxacillin, rifampicin, low dose gentamicin
*Penicillin allergy: Vancomycin +rifampicin
What is the therapy for streptococci infective endocarditis?
*Benzylpenicillin
*If penicillin allergy: Vancomycin +low dose gent
What are the indications for surgery for infective endocarditis?
*Recurrent emboli after antibiotic therapy
*Aortic aneurysm
*Infection resistant to antibiotics/fungal infections
*Severe valvular incompetence
*Cardiac failure refractory to standard medical treatment
What is postural hypotension?
A fall of systolic BP >20mmHg on standing
What is the treatment of postural hypotension?
mineralcorticoid: fludrocortisone 0.1-0.2mg once daily
