Cardiology Flashcards
What murmur can be heard in pulmonary stenosis?
Ejection systolic murmur
Louder on inspiration
What is arrhythmogenic right ventricular cardiomyopathy?
form of inherited cardiovascular disease, 2nd most common cause of sudden cardiac death in the young after HOCM
what are the features of Beck’s triad and what is it related to?
hypotension
raised JVP
Muffled heart sounds
cardiac tamponade
what feature is present in cardiac tamponade that is not present in constrictive pericarditis?
pulsus paradoxus - an abnormally large drop in BP during inspiration is present in cardiac tamponade but not in constrictive pericarditis
What are the features of aortic regurgitation?
early diastolic murmur
collapsing pulse
wide pulse pressure
Quincke’s sign - nailbed pulsation
De Musset’s sign - head bobbing
Which patients with NSTEMI should have coronary angiography?
Immediate: patients who are clinically unstable e.g. hypotensive
Within 72 hours: patients with a GRACE score > 3% I.e. those at intermediate, high or highest risk
What is 1st degree heart block?
PR interval >0.2 seconds
What is Mobitz I?
Progressive PR prolongation of the PR interval until a dropped beat occurs
What is Mobitz II?
PR interval is constant but the P wave is often not followed by a QRS complex
How is Mobitz II treated?
pacemaker insertion
what can be given to prevent reoccurrence of hyperkalaemia?
calcium resonium
NICE guidelines suggest all patients with AF should have rate control as first line unless?
there is a reversible cause for their AF
it is new onset (within last 48 hrs)
their AF is causing heart failure
they remain symptomatic despite being effectively rate controlled
what are the options for rate control of AF?
- Beta blockers are first line e.g. atenolol
- Calcium channel blocker e.g. diltiazem
- Digoxin but this needs to be monitored due to risk of toxicity
what is the first-line investigation for stable chest pain of suspected coronary artery disease aetiology?
contract-enhanced CT angiography
What are the eligibility criteria for PCI?
- should be offered if presentation is within 12 hours of onset of symptoms and PCI can be delivered within 120 mins of the time when fibrinolysis could have been given
- if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered
What is the most common cause of death in patients following an MI?
ventricular fibrillation
What are the x-ray findings you would see in heart failure?
ABCDE:
A - Alveolar oedema
B - Kerley B lines
C - Cardiomegaly
D - Dilated prominent upper lobe vessels
E - Effusion (pleural)
What is the treatment of cardiac tamponade?
urgent pericardiocentesis
percutaneous balloon pericardiotomy - used to treat cardiac tamponade when the patient has a neoplastic disease
What are the features of WPW on ECG?
delta waves (slurred upstroke in QRS)
short PR interval (<120ms)
Broad QRS
IF a re-entrant circuit has developed the ECG will show a narrow-complex tachycardia
st elevation in which leads would indicate an occlusion of the RCA?
II, III, AVF
st elevation in which leads would indicate an occlusion of the LAD?
V1-V2 = proximal LAD
V3-V4 = LAD
V5-6 = distal LAD/LCx/RCA
st elevation in which leads would indicate an occlusion of the left coronary?
I, aVL
what indicates a posterolateral MI on ecg?
st depression v1-v3
How are STEMIs diagnosed by ECG?
ST segment elevation >2mm in adjacent chest leads
ST segment elevation >1mm in adjacent limb leads
New LBBB with chest pain or suspicion of MI
what long term anticoagulation should be used for patients with a mechanical heart valve?
Warfarin
What are the causes of mitral valve prolapse?
primary - related to degeneration in the absence of other causes, can be familial
secondary - to other identifiable disorders e.g. Marfan’s syndrome, Ehlers-Danlos, Turner syndrome
What are the symptoms of mitral valve prolapse?
symptoms are inconsistent but may include:
- chest pain
- palpitations
- exertional dyspnoea
- exercise intolerance
- dizziness
majority of cases remain asymptomatic until prolapse is severe
what are the examination findings in mitral valve prolapse?
- non-ejection click -
- pansystolic murmur (mitral regurg)
what are the examination findings in mitral valve prolapse?
- non-ejection click -
- pansystolic murmur (mitral regurg)
what should be offered to afro-caribbean patients with heart-failure as third-line therapy?
sacubitril-valsartan
how is angina pectoris managed?
all patients should receive aspirin and a statin in the absence of any contraindication
sublingual gtn to abort angina attacks
NIVE recommend using either a beta-blocker or a calcium channel blocker first line
What are the ECG features of hypokalaemia?
U waves
small or absent T waves (occasionally inversion)
prolonged PR interval
ST depression
long QT
how is stable angina managed?
immediate symptomatic relief: GTN,
long term symptomatic relief: beta blocker or calcium channel blocker
secondary prevention: aspirin, atorvastatin, acei,
what does the GRACE score calculate?
6 month risk of death or repeat MI after having an NSTEMI
<5% = low risk
5-10% = medium risk
>10% risk = high risk
if they are medium or high risk they are considered for early PCI - within 4 days of admission
what does the GRACE score take into account?
age, heart rate, bp, cardiac and renal function, cardiac arrest on presentation, ECG findings, trop levels
how does acute mitral regurg present after MI?
Acute hypotension and pulmonary oedema may occur
an early-to-mid systolic murmur is typically heard
patients are treated with vasodilator therapy but often require emergency surgical repair
it is more common with infero-posterior infarction and may be due to ischaemia or rupture of the papillary muscle
how does ventricular septal defect present post-MI?
rupture of the IV septum usually occurs in the first week and is seen in around 1-2% of patients
presents with acute heart failure associated with a pan-systolic murmur
an echo is diagnostic and will exclude acute mitral regurg with presents in a similar fashion
urgent surgical correction is needed
how does left ventricular free wall rupture present post-MI?
seen in around 3% of MIs
occurs 1-2 weeks after
patient presents with acute heart failure 2ndary to cardiac tamponade - raised JVP, pulsus paradoxus, diminished heart sounds
urgent pericardiocentesis and thoracotomy are required
what is dressler’s syndrome?
tends to occur around 2-6 weeks following an MI
underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers
it is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR
treated with NSAIDs
What are the most common causes of AF?
remember that AF affects mrs SMITH:
Sepsis
Mitral valve pathology - stenosis or regurg
Ischaemic heart disease
Thyrotoxicosis
Hypertension
How is paroxysmal AF treated?
patients are anticoagulated based on CHADSVASC score
“pill in pocket” approach - take a pill to terminate their AF only when they feel the symptoms are starting
to be eligible for this approach they need to have infrequent episodes without an underlying structural heart disease
flecainide is the usual treatment for “pill in pocket” approach
without anticoagulation what is the risk of stroke in patients with AF?
5% Risk of stroke each year depending on CHADSVASc
what is the CHADSVASC score and what is it used for?
for assessing whether a patient with AF should be started on anticoagulation - it is a list of risk factors and if you have one or more of these risk factors then anticoagulation should be considered or started
the higher the score the higher the risk of developing a stroke or TIA and the greater the benefit from anticoagulation
what is the CHADSVASC score and what is it used for?
for assessing whether a patient with AF should be started on anticoagulation - it is a list of risk factors and if you have one or more of these risk factors then anticoagulation should be considered or started
the higher the score the higher the risk of developing a stroke or TIA and the greater the benefit from anticoagulation
what are the important scores for the CHADS-VASC TOOL?
0- no anticoagulation
1 - consider anticoagulation
>1- offer anticoagulation
what does the CHA2DS2-VASc mnemonic stand for?
C-congestive heart failure
H-hypertension
A2-age>75 (scores 2)
D-diabetes
S2-stroke or tia previously (scores 2)
V-vascular disease
A-age 65-74
S-sex (female)
what is the ORBIT tool?
assesses a patients risk of major bleeding whilst on anticoagulation - score is based on:
low Hb or haematocrit - 2
age 75 or above - 1
previously bleeding - gi or intracranial - 2
renal function (GFR less than 60) - 1
antiplatelet medications - 1
when is the ORBIT tool used?
used prior to initiating anticoagulation or as a monitoring tool in patients with a high risk of bleeding
it is useful in practice for comparing the risk of stroke to the risk of bleeding to help pts and doctors make an informed decision about whether to start anticoagulation or not
usually the risk of stroke significantly outweighs the risk of bleeding
most bleeding can be treated, whereas a stroke often leads to significant long term morbidity and a lower quality of life
what is atrial myxoma?
most common primary cardiac tumour
75% occur in left atrium, most commonly attached to fossa ovalis
more common in females
what is the recommended dose of adrenaline in cardiac arrest?
1mg - 10ml of 1:10,000 IV ot
1ml of 1:1000 IV
what do changes in V1-V3 usually indicate?
posterior MI - usually left circumflex/right coronary
blockage of which artery may lead to complete heart block following MI?
right coronary artery
what murmur can be heard in HOCM?
ejection systolic murmur - due to left ventricular outflow tract obstruction - increases with valsalva manouvre and decreases on squatting
What is the NYHA classification of chronic heart failure?
I: no symptoms, no limitation, ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
II: mild symptoms, slight limitation of physical activity, comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
III: moderate symptoms, marked limitation of physical activity, comfortable at rest but less than ordinary activity results in symptoms
IV: severe symptoms, unable to carry out any physical activity without, symptoms of heart failure are present even at rest with increased discomfort with any physical activity
How do you make a diagnosis of takayasu’s arteritis?
either MRA or ct angiography
when should you consider aortic valve replacement in someone with aortic stenosis?
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 40mmHg and with features such as left ventricular systolic dysfunction then consider surgery
what is the DVLA guidance post MI?
4 weeks off driving
1 week if successfully treated by angioplasty
