Cardiology Flashcards
1
Q
Which scoring system can be used to calculate the risk that a patient will have a stroke or MI in the next 10 years?
A
Q risk 3
2
Q
What should all patients with CKD or DMT1 for over 10 years be offered?
A
Atorvastatin 20mg
3
Q
What is the monitoring for statins? Why?
A
LFTs should be checked within 3 months of starting a statin. This is because statins cause a transient and mild rise in ALT and AST
4
Q
What should be given as secondary prevention of CVD?
A
A- Aspirin and a second antiplatelet (clopidogrel)
A-Atorvastatin (80mg)
A-Atenolol (or bisoprolol)
A-ACE inhibitor (ramipril)
5
Q
What are the common side effects of statins?
A
Myopathy (check CK)
Type 2 diabetes
6
Q
What causes angina?
A
Ischaemia during times of high demand because there is a narrowing of coronary arteries
7
Q
What is the difference between stable and unstable angina?
A
Stable is when symptoms are relieved by rest or GTN. Unstable is when symptoms come on randomly at rest
8
Q
What is the gold standard investigation for angina?
A
CT angiography
9
Q
What is the management of angina?
A
GTN spray (advise take one dose, repeat after 5 mins, if still pain then call 999)
Beta blocker or CCB (bisoprolol or amlodipine both 5mg daily)
4 As for CVD (aspirin, atorvastatin, ACE-i and atenolol)
10
Q
What should be offered to people with proximal or extensive disease causing angina?
A
PCI
11
Q
What does the right coronary artery supply?
A
Right atrium
Right ventricle
Inferior aspect of the left ventricle and
Posterior septal area
12
Q
What does the circumflex artery supply?
A
Left atrium
Posterior aspect of the left ventricle
13
Q
What does the left anterior descending artery supply?
A
Anterior aspect of the left ventricle
Anterior aspect of the septum
14
Q
What are the 3 types of acute coronary syndrome?
A
Unstable angina
ST elevation myocardial infarction
Non-ST elevation myocardial infarction
15
Q
What confirms a diagnosis of STEMI?
A
ST elevation or new left bundle branch block
16
Q
What investigations should be done in ACS where there is no ST elevation on ECG?
A
Troponin.
If raised/ there are other ECG changes then the diagnosis is NSTEMI
If troponin is normal and there are no ECG changes then the diagnosis is unstable angina
17
Q
What are alternative causes of raised troponin?
A
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
PE
18
Q
What investigations should be done for ACS?
A
Physical exam
Bloods (FBC,LFT,U&E, lipid, thyroid, HbA1C, troponin)
ECG
CXR
Echo
CT angio
19
Q
What is the management of acute STEMI
A
20
Q
What is the management of NSTEMI
A
21
Q
What is a GRACE score?
A
It assess for PCI in NSTEMI by calculating the 6 month risk of death or repeat MI
22
Q
What are the complications of MI?
A
DREAD
D- death
R- rupture
E- Edema
A- Arrhythmia/ aneurysm
D- Dressler’s syndrome
23
Q
What is Dressler’s syndrome?
A
Occurs 2-3 weeks after MI. Caused by a localised immune response and causes pericarditis.
24
Q
How does dressler’s syndrome present?
A
Pleuritic chest pain
Pericardial rub
Low grade fever
Global ST elevation and T wave inversion
25
What are the common triggers for left ventricular failure?
Iatrogenic
Sepsis
Myocardial infarction
Arrythmias
26
How does acute LVF present?
rapid onset breathlessness
Type 1 respiratory failure
SOB
Feeling unwell
Increased RR and HR
Reduced O2 sats
3rd heart sound
Hypotension
Bilateral basal crackles
27
How can a diagnosis of acute LVF be confirmed?
BNP or echo
28
What is a normal ejection fraction for ventricles?
above 50%
29
What does cardiomegaly look like on CXR?
The cardiothoracic ratio is >0.5
30
What does acute LV Heart failure look like on CXR?
ABCDE
- A= Alveolar oedema
- B= kerly B lines
- C = Cardiomegaly
- D = Dilated upper lobe vessels
- E = pleural Effusion
31
What is the management of acute LVF?
Pour SOD
Pour away fluids
S-sit up
O-Oxygen
D- diuretics
32
What are the 2 types of chronic heart failure?
Systolic and diastolic
33
What are the key features of heart failure?
Breathlessness worsened by exertion
Cough
Orthopnoea
Paroxysmal nocturnal dyspnoea
Peripheral oedema
34
How is chronic heart failure diagnosed?
Clinical presentation
BNP
Echo
ECG
35
How should chronic heart failure first be managed?
Refer to cardiology
Lifestyle changes
Flu and pneumococcal vaccines
ABAL:
ACE-i
Beta-blocker
Aldosterone antagonist: spironolactone
Loop diuretic (furosemide)
36
What is cor pulmonale?
Right sided heart failure caused by respiratory disease
37
What is the most common cause of cor pulmonale?
COPD
38
What is the presentation of cor pulmonale?
Usually asymptomatic
SOB
Peripheral oedema
Syncope
39
What is the management of cor pulmonale?
Treating symptoms and the underlying cause
Long term O2 therapy
40
What are the readings which suggest a diagnosis of hypertension?
>140/90 in clinic or
>135/85 ambulatory
41
What are the causes of secondary hypertension?
ROPE:
Renal disease
Obesity
Pregnancy/ pre-eclampsia
Endocrine (Conn's syndrome)
42
What are the 3 stages of hypertension?
1= 140/90
2-160/100
3=180/120
43
Which tests should be done to assess for end organ damage in all new patients with a diagnosis of HTN?
Urine albumin: creatinine ratio
Urine dipstick for blood
HbA1c, renal function and lipids
Fundus examination
ECG
44
What are the potential antihypertensives which can be used?
A- ACE-i (ramipril)
B- Beta-blocker (bisprolol)
C- CCB (amlodipine)
D- Diuretic (thiazide like, indapamide)
ARB candasartan
45
What is the medical management of HTN?
1= A if <55 and white, C if >55 or black
2= A+C, if black ARB+C
3= A+C+D
4=A+C+D+ spironolactone, B, alpha blocker (doxazosin)
46
What can be used when thiazide like diuretics cause hypokalaemia in management of HTN and why?
Potassium sparing diuretics like spironolactone because it causes sodium excretion and potassium reabsorption by blocking aldosterone
47
What causes the first heart sound?
Closing of the AV valves
48
What causes the second heart sound?
Closing of the semilunar valves
49
What causes a third heart sound?
Rapid ventricular filling causing the chordae tendineae to twang like a guitar string. It can indicate heart failure
50
What kind of hypertrophy does mitral stenosis cause?
Left atrial hypertrophy
51
What kind of hypertrophy does aortic stenosis cause?
Left ventricular hypertrophy
52
What causes hypertrophy and what causes dilatation?
Stenosis= Hypertrophy
Regurgitation= dilatation
53
What are the common causes of mitral stenosis?
Rheumatic heart disease
Infective endocarditis
54
What is heard when there is mitral stenosis
A low, rumbling mid-diastolic murmur
55
Name some symptoms/complications of mitral stenosis?
Malar flush
Atrial fibrilation
Dyspnoea
Haemoptsis
56
What type of murmur is heart in mitral regurgitation?
Pan-systolic, high pitched whistling
57
What are the causes of mitral regurgitation
Ehlers Danlos syndrome or Marfan syndrome
58
What does aortic stenosis sound like?
Ejection systolic, high pitched murmur which has a crescendo-decrescendo character
59
What does aortic regurgitation sound like?
Early diastolic, soft murmur
60
What is aortic regurgitation associated with?
Corrigan's pulse (collapsing pulse)
61
What are the major complications of mechanical heart valves?
Thrombus
Infective endocarditis
Haemolysis
62
What are the presenting features of atrial fibrilation?
Palpitations
SOB
Syncope
63
What are the 2 differentials for an irregularly irregular pulse?
AF
Ventricular ectopics
64
What is seen on an ECG of AF?
Absent P waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm
65
What are the most common causes of AF?
SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension
66
What are the contraindications for rate control in AF?
There is a reversible cause of AF
AF is of new onset in the last 48 hours
AF is causing heart failure
67
What are the options for rate control in AF?
Beta blocker
CCB (diltiazem)
Digoxin
68
When can rhythm control be offered in AF?
New, reversible cause of AF
New onset < 48 hours
Causing heart failure
Symptomatic
69
What are the 2 types of cardioversion for AF?
Immediate and delayed. If someone has delayed cardioversion they must be anticoagulated for a minimum of 3 weeks prior
70
What are the 2 choices of pharmacological cardioversion?
Flecanide
Amiodarone
71
What is the management of paroxysmal AF?
If no structural heart defect then "pill in the pocket" approach can be appropriate
If there is a defect, manage as normal
72
What is the mechanism of action of warfarin?
Vitamin K antagonist. Prolongs the prothrombin time
73
What is the target INR for someone on warfarin?
2-3
74
How do you reverse apixaban and rivaroxaban?
Andexanet alfa
75
Why are DOACs better than warfarin?
No monitoring required
No major interaction problems
76
What should the CHADSVASC score be to offer coagulation?
1 for male, 2 for female
77
Which scoring system assesses the risk of a bleed?
Now ORBIT, previously was HASBLED
78
What are the 2 shockable rhythms?
Pulseless VT
VF
79
What are the 2 non-shockable rhythms
Asystole
Pulseless activity
80
How are supraventricular tachycardias managed?
Vagal maoeuvres and adenosine
81
What causes atrial flutter?
Re-entrant rhythm
82
What is seen on an ECG of atrial flutter?
atrial contraction 300bpm, ventricular contraction 150 bpm and sawtooth appearance
83
What is the management of atrial flutter?
Rate and rhythm control
Radiofrequency ablation of re-entrant rythm
84
What happens in supraventricular tachycardia?
Electrical signal re-enters the atria from the ventricles causing a self perpetuating loop
85
What are the ECG changes seen in Wolf-Parkinson White?
Short PR
Wide QRS
Delta wave (slurred upstroke of the QRS)
86
What is toursades de pointes?
Polymorphic ventricular tachycardia
87
What is wenkebach's phenomenon
Present in mobitz type 1 where atrial impulses become gradually weaker until they dont pass through the AV node. There is then no QRS complex and the pattern repeats
88
What is type 1 heart block
Delayed conduction through the AV. There is a QRS after every P but the PR interval is greater than 0.2s (1 big square)
89
What is mobitz type 2 block?
Failure or interruption of AV conduction. 3:1 block, 3 p waves to every 1 QRS
90
What is 3rd degree heart block?
Complete heart block, there is no relationship between P and QRS
91
How are heart blocks managed?
Pacing or atropine
92
What is eisenmenger syndrome?
When pulmonary pressure increases so much that a left to right shunt is reversed so that it is a right to left shunt
93
What is the presentation of atrial septal defects?
Dyspnoea
Stroke
Atrial fibrillation or atrial flutter
94
What can be heard on auscultation in atrial septal defect?
Mid-systolic, crescendo-decrescendo murmur which is loudest at the left sternal border with a fixed split second heart sound
95
What is the management of atrial septal defects?
Percutaneous transvenous catheter closure or open heart surgery.
Can be managed by anticoagulants if asymptomatic
96
How do VSDs present?
pansystolic murmur
Present late in adulthood
97
What are the 3 differentials for pansystolic murmur?
VSD
Mitral regurgitation
Tricuspid regurgitation
98
What is the management of VSD?
Transvenous catheter closure
Open heart surgery
99
What is coarctation of the aorta?
When there is narrowing of the aortic arch
100
Which condition is coarctation of the aorta particularly associated with?
Turner's syndrome
101
How does coarctation of the aorta present?
Systolic murmur
Left ventricular heave
102
How is coarctation of the aorta managed?
Stenting
Open surgical repair
103
What can cause a pericardial effusion?
Transudates (low protein)
Exudates (high protein)
Blood
pus
Gas
104
What is cardiac tamponade?
A pericardical effusion is large enough to raise the pericardial pressure. This squeezes the heart and impacts its ability to function
105
What might cause a transudative pericardial effusion?
Congestive heart failure
Pulmonary HTN
106
What might cause an exudative pericardial effusion?
Infection
Autoimmune
Injury
MI
Cancer
Medications
(basically anything inflammatory)
107
What is the presentation of pericardial effusion?
Chest pain
SOB
Feeling of fullness in the chest
Orthopnoea
Pulsus paradoxes (fall in patients blood pressure during inspiration)
Quiet heart sounds
Compression of phrenic nerve may cause hiccups, reccurrent laryngeal may cause hoarseness of voice, oesophagus may cause difficulty swallowing
108
How is pericardial effusion diagnosed?
Echo
Fluid analysis
109
What is the management of pericardial effusion?
Treating the underlying cause
Drainage of effusion
(needle pericardiocentesis or surgical drainage)
Inflammatory causes (pericarditis) can be treated with aspirin, NSAIDs, colchicine and steroids
110
What valve is most commonly affected by IE
Mitral Valve
111
Name some risk factors for IE
- Rheumatic valve disease
- Prostehtic valves
- Congenital heart defects
- IVDU (although this typically causes tricuspid legion)
112
What are the main 2 bacteria that can cause IE
Staphylococcus Aureus (most common)
Streptococcus viridans (most common in developing countries)
113
What is the diagnostic criteria for IE?
Modified duke criteria, IE diagnosed if:
- 2 major criteria
- 1 major and 3 minor
- 5 minor
114
What are major criteria of IE?
- Positive blood cultures
- Evidence of endocardial involvement e.g. +ve echocardiogram or new valve regurg
115
What are some minor criteria for IE?
Predisposing heart condition or IVDU
Fever >38
Vascular phenomena - major emboli, splenomegaly, clubbing, splinter haemorrhages, janeway lesions, petechiae or purpura
Immunological: glomerulonephritis, osler nodes, roth spots (white centered retinal hemorrhage)
116
What is the initial management in IE if it is a native valve
Amoxicillin (consider adding low dose gentamicin)
117
What is the initial management in IE if it is a prosthetic valve
Vancomycin + rifampicin + low-dose gentamicin
118
What drug is given in IE if staphlococci infection is confirmed
flucloxacillin (vancomycin + rifampicin if penicillin allergic)
119
What drug is given in IE if steptococci is confirmed (e.g. viridans)
Benzylpenicillin (vancomycin if allergic)
120
Who requires IE prophylaxis?
only people at risk of IE is receiving ABx because they are undergoing a gastro or genitourinary procedure
121
List some causes of pericarditis
- Viral infections (coxsackie)
- TB
- Post-MI infection (if this is weeks-months later = dressler syndrome)
- Radiotherapy
- Connective tissue disease
- Malignancy
122
What are the features of pericarditis?
Chest pain, may be pleuritic, relived by sitting forwards
May also have flu like symptoms
123
What ECG changes are seen in pericarditis
global saddle-shaped ST elevation
PR depression
124
What investigations should be done in pericarditis
ECG
Transthoracic echocardiography
Bloods: inflamm markers & toponin
125
What is the management for pericarditis
Treat underlying cause e.g. infection
NSAIDs and colchicine
126
What is the main cause of CONSTRICTIVE pericarditis
TB - mainly seen in developing countries
