Cardiology Flashcards
What is angina?
Chest pain on exertion caused by myocardial ischaemia from coronary heart disease, usually atherothrombosis
What is the difference between stable and unstable angina?
Stable angina is induced by effort and relieved by rest/GTN spray
Unstable angina is an acute coronary syndrome with pain at rest/not relieved by GTN
List aetiology/risk factors for angina
Atherosclerosis Males Smoking, excess alcohol Poor diet, obesity Arteritis Low exercise Hypertension Diabetes
List clinical features of angina
Central chest tightness on exertion Pain may radiate to jaw/arm Dyspnoea Nausea Sweating Syncope
What investigations would you order for angina?
ECG may be normal
Exercise ECG, 24h ECG
CT catheter angiography
Outline medical treatment for angina
GTN spray when required
Secondary prevention (aspirin, statin, ACEi)
B-blockers unless contraindicated
Ivabradine/nicorandil if others not tolerated
Outline surgical treatment for angina
Coronary revascularisation (PCI, CABG) using balloon stent or graft bypass from internal mammary artery and greater saphenous vein
What are the acute coronary syndromes (ACS)?
Unstable angina
NSTEMI
STEMI
What is the pathophysiology of ACS?
Atherothrombotic plaque rupture leads to thrombosis and complete occlusion of coronary artery, causing ischaemia and potential necrosis
List risk factors/aetiology for ACS
Males Family history Smoking, excess alcohol Hypertension Diabetes High cholesterol Obesity Sedentary lifestyle
List clinical features of ACS
New onset severe crushing chest pain, radiating to arm and/or jaw Nausea, vomiting Not relieve by rest or GTN Breathlessness Syncope Confusion Pallor, sweating Palpitations, tachycardia SENSE OF IMPENDING DOOM
What investigations would you do for ACS?
Bloods: cardiac enzymes (CK, troponin), electrolytes, glucose, lipids
ECG
CXR
What is the criteria for STEMI on ECG?
ST elevation of 1mm or more in 2 adjacent limb leads
or
ST elevation of 2mm or more in 2 contiguous chest leads
List ischaemic changes on ECG
T wave inversion Q waves Tall T waves ST depression ST elevation
When do levels of troponin and CK peak in ACS?
Troponin: 3-12 h
CK: 24 h
Outline medical treatment for acute MI
Aspirin 300 mg
GTN sublingual
IV morphine
O2 if hypoxic
Outline definitive treatment for acute NSTEMI
B-blocker IV
LMW heparin
IV nitrate
Angiography if high risk
Outline definitive treatment for acute STEMI
PCI within 120 mins
Otherwise thrombolysis with streptokinase + aspirin, then reassess after 90 mins for need for PCI
What are the different stages of hypertension? (stage 1, stage 2 etc.)
Stage 1: 140-159/90-99
Stage 2: 160-179/100-109
Stage 3: 180/110 or higher
List risk factors/aetiology for hypertension
Renal disease (GN, polyarteritis, renal artery stenosis)
Endocrine disease (Cushing’s, Conn’s, phaeochromocytoma)
Pregnancy
Drugs
Alcohol excess
High salt intake
Essential hypertension (idiopathic)
List clinical features of hypertension
Asymptomatic Headache Palpitations Breathlessness Advanced disease: blurred vision, palpable kidney, RF delay
What investigations would you do for hypertension?
ECG, echo Bloods: electrolytes, endocrine markers Funduscopy Urinalysis Home/ambulatory BP monitoring
How is hypertensive retinopathy graded?
I: tortuous arteries, narrowing/sclerosis
II: AV nipping, marked sclerosis
III: haemorrhages, cotton wool spots, hard exudates
IV: III + papilloedema
Outline medical management of hypertension
If under 55yo, start with ACEi If over 55yo or black, start with Ca ch blocker If uncontrolled on these, ACEi + Ca ch blocker then add thiazide diuretic then add alpha/beta blocker
What is the BP target for diabetic patients with hypertension?
Less than 130/80
What is an arrhythmia?
Disturbance in the cardiac rhythm generated by abnormal conduction
List risk factors/aetiology for arrhythmias
Heart conditions Congenital heart disease Smoking, alcohol High caffeine intake Pneumonia Thyrotoxicosis Metabolic imbalance Drugs (amiodarone, B agonists, digoxin, levodopa, illicit drugs)
List clinical features of arrhythmias
Palpitations Abnormal pulse Chest pain Syncope Dizziness Dyspnoea Altered consciousness
What investigations would you order for arrhythmias?
ECG, 24 h ECG, event recording
Electrophysiology
FBC, U+E, glucose, Ca, Mg, thyroid function
Echocardiogram
Which drug can be used to treat bradycardia?
Atropine
Outline treatment of supraventricular tachycardias
Vagal maneuvres (breath-hold, Valsalva, ice, carotid massage)
IV adenosine/verapamil
DC shock
List class I anti-arrhythmic drugs and whether they are rhythm or rate controlling
Na channel blockers (rhythm control)
Lignocaine
Disopyramide
Flecanaide
List class II anti-arrhythmic drugs and whether they are rhythm or rate controlling
B blockers (rate control)
Atenolol
Propranolol
List class III anti-arrhythmic drugs and whether they are rhythm or rate controlling
K channel blockers (rhythm control)
Amiodarone
Sotalol
List class IV anti-arrhythmic drugs and whether they are rhythm or rate controlling
Ca ch blockers (rate control)
Verapamil
Diltiazem
List the main narrow-complex tachycardias
Sinus tachycardia Supra-ventricular tachycardia Atrial fibrillation/flutter Atrial tachycardia Junctional tachycardia (AVNRT, AVRT, BBB)
List the main broad-complex tachycardias
Ventricular tachycardia
Torsades de Pointes
SVT with aberrancy
Ventricular fibrillation
Outline treatment of narrow-complex tachycardias (except AF)
SVT: vagal maneuvres, IV adenosine/verapamil, DC shock
Junctional: ablation of accessory pathways, rhythm control
Outline treatment of ventricular tachycardia
Amiodarone/lignocaine + dextrose if stable
Correct K with calcium chloride
DC shock if pulseless or unstable
Outline treatment of ventricular fibrillation
DC shock
Mg chloride
Implantable defibrillator
Outline treatment of torsades de Pointes
Mg sulfate IV
Overdrive pacing
List aetiology/risk factors for AF
Heart failure Ischaemia, MI Hypertension Mitral valve disease Pneumonia Hyperthyroidism Caffeine, alcohol Hypokalaemia Cardiomyopathy Pericarditis Sick sinus syndrome
Outline treatment of acute AF
O2 + emergency cardioversion/amiodarone if unstable
Anticoagulation with LMW heparin
Rate control: diltiazem/verapamol/metoprolol/digoxin
AV node ablation or pacing
What is the aim for INR with warfarin on AF?
2-3
Describe 1’ heart block
Prolonged PR interval (greater than 0.22s)
Describe 2’ type 1 heart block
Progressive prolonging of PR interval with dropped QRS complex
Describe 2’ type 2 heart block
Normal PR interval with some dropped QRS complexes
Describe 3’ heart block
Dissociation of P-wave and QRS complexes
What would an ECG show in right bundle branch block?
M-wave in V1, W-wave in V6
What would an ECG show in left bundle branch block?
W-wave in V1, M-wave in V6
List risk factors/aetiology for heart blockWhat is
Normal variants Athletes Sick sinus syndrome Ischaemic heart disease Drugs (digoxin, B blockers) Congenital heart disease Calcified valves Trauma Surgery
Outline treatment of heart block
IV atropine
Pacing
How does the body try to compensate for low cardiac output in heart failure?
Retains fluid which increases preload and causes further stress on the heart, causing congestive heart failure
What is “systolic” heart failure? Give causes
Ventricles unable to contract normally, causing reduced cardiac output (ejection fraction less than 40%)
Causes: IHD, MI, cardiomyopathy
What is “diastolic” heart failure? Give causes
Ventricles unable to relax normally, causing increased preload (ejection fraction greater than 50%)
Causes: constrictive pericarditis, restrictive CM, tamponade, hypertension
List causes of right heart failure
Left ventricular failure
Pulmonary stenosis
Lung disease, cor pulmonale
List causes of left heart failure
Valve disease
Arrhythmia
Hypertension
Congenital defects
List clinical features of right heart failure
Raised JVP Peripheral oedema Epistaxis Organomegaly Ascites Nausea Anorexia
List clinical features of left heart failure
Dyspnoea Fatigue, poor exercise tolerance Pulmonary oedema Orthopnoea PND Pink frothy sputum Cold peropheries
What are major symptoms/signs of heart failure according to Framingham criteria?
PND Crepitations S3 Cardiomegaly Raised JVP Pulmonary oedema Weight loss
What are minor symptoms/signs of heart failure according to Framingham criteria?
Ankle oedema Dyspnoea Tachycardia Nocturnal cough Pleural effusion
What would you see on an XR in heart failure?
Alveolar shadowing (bat's wings) Kerley B lines Cardiomegaly Dilated upper vessels Effusion
Outline treatment of acute heart failure
Sit up High flow O2 IV diamorphine IV furosemide GTN/nitrate
Outline medical treatment of heart failure
Diuretics (furosemide, spironolactone)
ACEi if LV dysfunction
Digoxin if LV impairment
B-blocker reduces mortality long-term
What is a cardiac murmur?
Sound made due to turbulent blood flow against diseased/damaged heart valves
Systolic murmurs are in time with the carotid pulse. True/False?
True
List aetiology of mitral stenosis
Rheumatic fever
Congenital anomaly
Prosthesis
Carcinoid tumour
List notable clinical features of mitral stenosis
Mid-diastolic "rumbling" with loud opening snap Tapping apex Malar flush Low-volume pulse Atrial fibrillation