Cardiology Flashcards
1
Q
ECG leads and relevant blood supply
A
II, III, aVF - Right coronary artery
I, aVL, V5 + V6 - Left circumflex artery
V2-V4 - Left anterior descending artery
V2-V6 - Left main stem
V1, V2, V3 (posterior view) - RCA
2
Q
How to calculate rate on an ecg
A
300 / number of large squares between two equivalent adjacent points
3
Q
Rhythm in AF
A
No discernible P waves
Irregularly Irregular
4
Q
Rhythm in Atrial flutter
A
Saw-toothed baseline
5
Q
Rhythm in nodal/junctional rhythm
A
Regular QRS but no P waves
6
Q
Normal axis deviation
A
Leads I and II +ve
7
Q
Left axis deviation
A
Lead I +ve and lead II -ve (leaving)
8
Q
Right axis deviation
A
Lead I -ve and lead II +ve (reaching)
9
Q
Causes of right axis deviation
A
- Anterolateral MI
- RVH
- PE
- Left posterior hemiblock WPW
- Atrial Septal Defect secundum
10
Q
Causes of left axis deviation
A
- Inferior MI
- LVH
- Left anterior hemiblock WPW
- Atrial septal defect primum
11
Q
Causes of absent P waves
A
AF
Sinoatrial node block
Nodal rhythm
12
Q
Cause of dissociated P waves
A
Complete heart block
13
Q
P mitrale
A
bifid P waves = Left Atrial hypertrophy
HTN, AS, MR, MS
https://ecgwaves.com/the-ecg-in-left-and-right-atrial-enlargement-abnormality-p-pulmonale-p-mitrale/
14
Q
P pulmonale
A
peaked p waves = Right Atrial hypertrophy
Pulmonary HTN, COPD
https://ecgwaves.com/the-ecg-in-left-and-right-atrial-enlargement-abnormality-p-pulmonale-p-mitrale/
15
Q
Definition and causes of wide QRS
A
> 120ms (3 small squares)
Ventricular initiation
Conduction defect
WPW
16
Q
Definition and cause of pathological Q wave
A
> 1mm wide and >2mm deep
Full thickness MI
17
Q
Signs of RVH in the QRS complexes
A
Dominant r wave in V1 + deep S wave in V6
18
Q
Signs of LVH in the QRS complexes
A
R wave in V6 >25mm
R wave in V5/V6 + S wave in V1 >35mm
19
Q
Length of normal PR interval
A
120-200ms (3-5 small square)
20
Q
Cause of long PR interval
A
Heart block
21
Q
Causes of short PR interval
A
- Accessory conduction eg WPW
- Nodal rhythm
- Hypertrophic Cardiomyopathy
22
Q
Cause of depressed PR segment
A
Pericarditis
23
Q
Normal corrected QT interval (QTc)
A
380-420ms
24
Q
Bazett’s formula
A
Used to calculate corrected QT interval
QTc = actual QT/√R-R
25
Causes of long QT interval (>420ms)
TIIMME
Toxins
- macrolides
- anti-arrhythmics: quinidine, amiodorone
- TCAs
- Histamine antagonists
Inherited eg Romano-Ward, Jervell Lange-Neilson syndrome
Ischaemia
Myocarditis
Mitral valve prolapse
Electrolytes
- ↓Mg, ↓K, ↓Ca, ↓ temp
26
Causes of short QT interval (<380ms)
Digoxin
Betablockers
Phenytoin
27
Causes of raised ST segment (>1mm in limbs; >2mm in chest)
Acute MI
Prinzmetal's variant angina
Pericarditis - saddle-shaped
Aneurysm - ventricular
28
Causes of depressed ST segments (>0.5mm)
Ischaemia - flat
Digoxin - down-sloping
29
T waves are normally inverted in which leads
aVR and V1
Also V2-V3 less so and more commonly in Afro-Caribbeans
30
Leads in which inverted T waves is abnormal and causes
I, II and V4-6
- Strain
- Ischaemia
- Ventricular hypertrophy
- BBB
- Digoxin
31
Effect of hyperkalaemia and hypokalaemia on T waves
Hyperkalaemia - tented T waves
Hypokalaemia - flattened T waves
32
U waves on ECG
Occur after T waves
Seen in hypokalaemia
33
J waves / Osbourne waves on ECG
Occur between QRS and ST segment
Causes
- Hypothermia < 32
- Subarachnoid haemorrhage
- Hypercalcaemia
34
Causes of bradycardia
DIVISIONS
- Drugs
- Ischaemia/infarction
- Vagal hypertonia
- Infection
- Sick sinus syndrome
- Infiltration
- HypO-thyroidism / kalaemia / thermia
- Neuro: ↑ ICP
- Septal defect: primum ASD
- Surgery or catherisation
35
Drugs which cause bradycardia
Antiarrythmics (type 1a, amiodarone)
Beta-blockers
Calcium channel blockers
Digoxin
36
Infections which cause bradycardia
Viral myocarditis
Rheumatic fever
Infective endocarditis
37
Infiltrative causes of bradycardia
```
Autoimmune
Sarcoid
Haemochromatosis
Amyloid
Muscular dystrophy
```
38
Definition of Narrow Complex Tachycardia
Rate >100bmp
QRS width <120ms
39
Management of SVT
see AS medicine notes, page 13
40
Definition of Broad Complex Tachycardias (VT)
Rate >100bmp
QRS width >120ms
41
Causes of VT
IM QVICK
- Infarction
- Myocarditis
- QT interval increase
- Valve abnormality - mitral prolapse, AS
- Iatrogenic - digoxin, antiarrythmics, catheter
- Cardiomegaly (esp. dilated)
- K↓, Mg↓, O2↓, acidosis
42
Management of VT
see AS medicine notes, page 14
43
Common causes of AF
IHD
Rheumatic heart disease
Thyrotoxicosis
Hypertension
44
Symptoms of AF
```
Asymptomatic
Chest pain
Palpitations
Dyspnoea
Faintness
```
45
Signs of AF
Irregualrly irregular pulse
Pulse deficit: difference between pulse and HS
Fast AF -> loss of diastolic filling -> no palpable pulse
Signs of LVF
46
CHA2-DS2-VAS Score components
- Congestive Heart Failure
- Hypertension
- Age≥75 (2 points)
- Diabetes
- Stroke or TIA (2 points)
- Vascular disease
- Age: 65-74yrs
- Sex: female
->Determines necessity of anticoagulation in AF
Score
0: aspirin 300mg
≥1: Warfarin
47
Management of Acute AF (≤48h)
Haemo unstable → emergency cardioversion
- electrical or pharmaceutical - 1st: Flecainide (if no structural heart disease) 2nd: Amiodarone
Control ventricular rate
- 1st line: diltiazem or verapamil or metoprolol
- 2nd line: digoxin or amiodarone
Start LMWH
48
Paroxysmal AF
- Self-limiting, <7d, recurs
- Anticoagulate: use CHADSVAS
- Rx “pill-in-pocket” : flecainide, propafenone
- Prevention: β-B, sotalol or amiodarone
49
Reasons to use rhythm control in persistent AF
- Symptomatic or CCF
- Younger (<65)
- Presenting first time with lone AF
- Secondary to treated precipitant
50
Rhythm control management in persistent AF
Echo first: structural abnormalities
- Anticoagulate with warfarin for ≥3wks or use echo to exclude intracardiac thrombus.
- Pre-Rx ≥4wks with sotalol or amiodarone if ↑ risk of failure
- Electrical or pharmacological cardioversion
- ≥ 4 wks anticoagulation afterwards (target INR 2.5)
Maintenance antiarrhythmic
- Not needed if successfully treated precipitant
- 1st: β-B (e.g. bisoprolol, metoprolol).
- 2nd: amiodarone
51
Rate control management in persistent AF
Target <90bpm at rest
- 1st line: β-B or rate-limiting CCB (NOT both!)
- 2nd line: add digoxin (don’t use as monotherapy)
- 3rd line: consider amiodarone
52
Management of permanent AF
RATE CONTROL
Possible reasons:
- Failed cardioversion / unlikely to succeed
- AF >1yr, valve disease, poor LV function
- Pt. doesn’t want cardioversion
53
Management of Atrial Flutter
Similar to AF, although normal drugs may not work
Try amiodarone to restore sinus and amiodarone or sotalol to maintain it
Cavotricuspid isthmus ablation (RA) is Rx of choice.
54
Acute coronary syndrome definition
ACS = unstable angina + evolving MI
Divided into:
- ST elevation or new onset LBBB
- NSTEMI
55
Modifiable risk factors for ACS
- Hypertension
- Diabetes
- Smoking
- ↑cholesterol
- Obesity
56
Non-modifiable risk factors for ACS
- Age
- Male
- Family history of MI < 55yrs
57
Typical ACS symptoms
```
Acute central/left chest pain >20min
Radiates to left jaw or arm
Nausea
Sweating
Dyspnoea
Palpitations
```
58
Symptoms of silent MI
Syncope
Delirium
Post-op oliguria / hypotension
More common in elderly and diabetics
59
Clinical signs of ACS
Anxiety
Pallor Sweating
Pulse ↑/↓
BP ↑/↓
4th heart sound
Signs of LVF (basal creps, ↑ JVP, 3rd HS)
PSM: papillary muscle dysfunction / rupture
60
ECG changes in STEMI
- Normal
- ST elevation + hyperacute (tall) T waves
- Q waves: full-thickness infarct
- Normalisation of ST segments
- T wave inversion
- (New onset LBBB also = STEMI)
61
ECG changes in NSTEMI
- ST depression
- T wave inversion
No Q waves = subendocardial infarct
62
Diagnosis of NSTEMI, STEMI and UA
STEMI / LBBB: Typical symptoms + ST elevation (/LBBB)
NSTEMI: Typical symptoms + no ST elevation + +ve trop
UA: Typical symptoms + no ST elevation + -ve trop
63
MI complications
Death Passing PRAAED st
Death
Pump failure
```
Pericarditis
Rupture - myomalacia cordis
Arrhythmias
Aneurysms - ventricular
Embolism
Dressler’s Syndrome - pleuro-pericarditis
```
64
Presentation of pericarditis post MI
Occurs early after MI
- Mild fever
- Central chest pain / change in pain
- Relieved by sitting forward
- Pericardial friction rub
Saddle-shaped ST elevation ± PR depression on ECG
65
Presentation of Dressler's syndrome post MI
2-6 weeks after
- Recurrent pericarditis
- Pleural effusions
- Fever
- Anaemia
- ↑ESR
Due to auto-antibodies vs. myocyte sarcolemma
66
STEMI management
| 10 steps
1) 12 lead ECG
2) 2-4L oxygen (aim sats 92-98)
3) Iv access, FBC, U+E, glucose, lipids
4) Brief Hx and Exam (CV risk factors, Thrombolysis Contraindications)
5) Antiplatelets - Aspirin/Clopidogrel both 300mg PO (then 75mg/d; asp = indefinite, clop = 1month)
6) Analgesia - Morphine 5-10mg IV; Metoclopramide 10mg IV
7) Anti-ischaemia - GTN 2 puffs or 1 tablet; β-B atenolol 5mg IV (CI: asthma, LVF)
8) LMWH: e.g. enoxaparin IV then SC
9) Admit to CCU for monitoring - Arrhythmias, Continue meds except CCBs
10) Primary PCI or Thrombolysis
67
ECG criteria for thrombolysis treatment of MI
- ST elevation > 1mm in 2+ limbs or > 2mm in 2+ chest leads.
- New LBBB
- Posterior: Deep ST “depression” and tall “R” waves in V1-V3
68
Contraindications to thrombolysis after MI
AGAINST
```
Aortic dissection
GI bleeding
Allergic reaction previously
Iatrogenic - recent surgery
Neuro - cerebral neoplasm or CVA history
Severe HTN >200/120
Trauma - including CPR
```
Also contraindicated beyond 24hrs from onset of pain
69
Everyday drug regime post MI
- ACEi: start w/i 24hrs of MI (e.g. lisinopril 2.5mg)
- β-blocker: e.g. bisoprolol 10mg OD (or, CCB)
- Cardiac rehabilitation (group exercise and info) / Heart Manual
- DVT prophylaxis until fully mobile -> Continue for 3mo if large anterior MI
- Statin: regardless of basal lipids (e.g. atorvastatin 80mg)
70
Lifestyle advice after MI
```
Stop smoking
Diet: oily fish, fruit, veg, ↓ sat fats
Exercise: 30min OD
Work: return in 2 months
Sex: avoid for 1 month
Driving :avoid for 1 month
```
71
CV risk scoring systems
GRACE or TIMI
72
Angina classification
-Stable: induced by effort
-Unstable: occurs at rest / minimal exertion
-Decubitus: induced by lying down
-Prinzmetal’s / variant: occurs during rest -> Due to coronary spasm; ST elevation during attack: resolves as pain
subsides.
-Syndrome X: angina pain + ST elevation on exercise
test but no evidence of coronary atherosclerosis -> Probably represents small vessel disease
73
Treatment of angina
1) Lifestyle changes
2) CV prophylaxis - low dose Aspirin, ACEi. Statins, Antihypertensives
3) GTN + either B-blocker or CCB
4) PCI
5) CABG
74
Definition of heart failure
CO is inadequate for the body’s requirements despite adequate filling pressures
75
Steps in compensatory phase of Heart failure
Reduced CO initially → compensation
- Starling effect dilates heart to enhance contractility
- Remodelling → hypertrophy
- RAS and ANP/BNP release
- Sympathetic activation
76
Steps in the decompensatory phase of heart failure
-Progressive dilatation → impaired contractility +
functional valve regurgitation
- Hypertrophy → relative myocardial ischaemia
- RAS activation → Na+
and fluid retention → ↑ venous pressure → oedema
- Sympathetic excess → ↑ afterload → ↓ CO
77
Causes of pump failure leading to low output HF
1) systolic failure (impaired contraction)
- Ischaemia/MI
- Dilated cardiomyopathy
- HTN
- Myocarditis
2) Diastolic failure (impaired filling)
- Pericardial effusion/tamponade/constriction
- Restrictive/hypertrophic cardiomyopathy
3) Arrhythmias
- Bradycaria/ Heart Block
- Tachycardias
- Anti-arrythmics (eg B-b, verapamil)
78
Causes of low output HF other than pump failure
Excessive pre-load
- AR, MR
- Fluid overload
Excessive afterload
- AS
- HTN
- HOCM
79
Causes of high output HF
Due to increased needs
- Anaemia, AVM
- Thyrotoxicosis, Thiamine deficiency (beri beri)
- Pregnancy, Paget's
80
Causes of RVF
- Secondary to LVF
- Cor pulmonale
- Tricuspid and pulmonary valve disease
81
Symptoms of RVF
Anorexia and nausea
82
Signs of RVF
Raised JVP
Tender smooth hepatomegaly
Pitting oedema
Ascites
83
Causes of LVF
1) IHD
2) idiopathic dilated cardiomyopathy
3) systemic HTN
4) Mitral and aortic valve disease
can also be caused by specific cardiomyopathies
84
Symptoms of LVF
```
Fatigue
Exertional dyspnoea
Orthopnoea and PND
Nocturnal cough (+/- pink frothy sputum)
S3 + tachycardia (gallop)
Wheeze
Bibasal creps
```
85
Acute vs Chronic HF
Acute
- New onset or decompensation of chronic
- peripheral / pulmonary oedema
- +/- peripheral hypoperfusion
Chronic
- Develops / progresses slowly
- Venous congestion common
- Arterial pressure maintained until very late
86
Criteria for defining Chronic heart failure
Framingham Criteria
2 major criteria or 1 major and two minor
87
Major criteria of the Framingham Criteria for CCF
- PND
- +ve abdominojugular reflux
- Neck vein distension
- S3
- Basal creps
- Cardiomegaly
- Acute pulmonary oedema
- ↑ CVP (>16cmH2O)
- Wt. loss >4.5kg in 5d secondary to Rx
88
Minor criteria of the Framingham Criteria for CCF
- Bilateral ankle oedema
- SOBOE
- ↑HR >120
- Nocturnal cough
- Hepatomegaly
- Pleural effusion
- 30% ↓ vital capacity
89
Signs of CCF on CXR
ABCDE
- Alveolar shadowing
- Kerley B lines
- Cardiomegaly
(cardiothoracic ratio >50%)
- Upper lobe Diversion
- Effusions
- Fluid in the fissures
90
Signs of CCF on Echo
key investigation
- Global systolic and diastolic function -> Ejection fraction normally ~60%
- Focal / global hypokinesia
- Hypertrophy
- Valve lesions
- Intracardiac shunts
91
BNP is secreted from ventricles in response to...
- Increased pressure -> stretch
- Tachycardia
- Glucocorticoids
- Thyroid hormones
92
Actions of BNP
- ↑ GFR and ↓ renal Na reabsorption
| - ↓ preload by relaxing smooth muscle
93
Level of BNP to diagnose heart failure
>100
- BNP correlates c¯ LV dysfunction -> i.e. ↑ most in decompensated heart failure
- ↑ BNP = ↑ mortality
- BNP also ↑ in RHF: cor pulmonale, PE
94
New York Hear Association Classification
1. No limitation of activity
2. Comfortable @ rest, dyspnoea on ordinary activity
3. Marked limitation of ordinary activity
4. Dyspnoea @ rest, all activity → discomfort
95
Treatable precipitants / causes of chronic heart disease
Underlying cause
- Valve disease
- Arrhythmias
- Ischaemia
Exacerbating factors
- Anaemia
- Infection
- ↑BP
96
1st line treatment for chronic heart failure
ACEi/ARB + β-B + loop diuretic
eg lisinopril or candesartan ; carvedilol or bisprolol ; frusemide or butmetanide
for β-B's, 'start low and go slow'
E.g. carvedilol 3.125mg/12h → 25-50mg/24h
- Wait ≥2wks between increments
97
Treatment of severe pulmonary oedema - 10 steps
1 - sit patient up
2 - 15L O2, target 94-98
3 - Iv access + monitor ECG (treat arrhythmias)
4 - Diamorphine 2.5-5mg IV + Metoclopramide 10 mg IV
5 - Frusemide 40-80 mg IV
6 - GTN 2 puffs
7 - CXR, ECG, ?echo
8 - if SBP >100, start nitrate IV
9 - if worsening, consider CPAP, more frusemide or ↑ nitrate infusion
10 - if SBP <100, treat as cardiogenic shock ie consider inotropes
98
Causes of severe pulmonary oedema
Cardiogenic
- MI
- Arrythmia
- Fluid overload: renal, iatrogenic
Non-cardiogenic
- ARDS: sepsis, post-op, trauma
- upper airway obstruction
- Neurogenic: head injury
99
signs of left sided or congestive heart failure
- narrow pulse pressure
- raised jvp
- displaced thrusting apex with systolic thrill
- left parasternal heave
- S3 present
- Mid-diastolic flow murmur
- Bibasal crackles
- Peripheral oedema
100
Causes of mitral regurgitation
```
Rheumatic heart disease
Ischaemic Heart disease
Endocarditis
Mitral valve disease
Papillary muscle dysfunction (due to IHD or endocarditis)
Connective tissue diseases
Congenital (ASD etc)
Collagen disorders
Hypertrophic cardiomyopathy
```
101
Signs of mitral stenosis
Malar flush
Opening snap
Giant V waves
Graham Steel murmur (high pitched brief early diastolic murmur due to secondary pulmonary regurgitation)
102
Symptoms of mitral stenosis
Dyspnoea, reduced exercise tolerance
Orthopnoea and PND
Palpitations
Dysphagia (oesophagus compressed by left atrium)
Haemoptysis secondary to pulmonary hypertension)
103
Causes of mitral stenosis
SYMPTOMS MAY BE PRECIPITATED BY CHANGES SUCH AS AF OR PREGNANCY
```
Rheumatic heart disease
Congenital
Carcinoid syndrome (increased serotonin causes increased collagen production in heart)
SLE
Mucopolysccharidoses
```
104
Causes of aortic regurgitation
Rheumatic heart disease
Bicuspid aortic valve
Infective endocarditis
Aortic root dilatation (eg in collagen disorders)
Inflammatory (eg RA, Reiter's syndrome, ank spond, syphilis)
105
Quincke's sign
capillary nail bed pulsations
106
Corrigan's sign
visible carotid pulsations
107
De Musset's sign
head nodding with each heartbeat
108
Muller's sign
pulsation of the uvula
109
Duroziez's sign
diastolic femoral bruit when compressed distally
110
Traube's sign
pistol shot femorals
111
Austin Flint murmur
mid-diastolic murmur heart at the apex.
thought to be caused by a regurgitant jet interfering with the opening of the anterior mitral valve leaflet ie mimics mitral stenosis
112
Rosenburg's sign
pulsatile liver
113
Gerhadt's sign
enlarged spleen
114
Symptoms of aortic stenosis
Chest pain
SOB
Syncope
In absence of other disease, onset of symptoms in AS is a sign of severity and requires consideration of surgery
115
Causes of aortic stenosis
Bicuspid valve
Rheumatic heart disease
Calcific
Congenital
116
Symptoms of tricuspid regurgitation
Fatigue
Abdo pain
Ankle swelling
Anorexia
117
Causes of tricuspid regurgitation
Secondary (most common):
- chronic left heart failure
- Primary pulmonary hyper tension
- cor pulmonale due to chronic cardiorespiratory disease and hypoxia
- right venticular infarction
- Eisenmenger's syndrome (pulmonary hypertension, resulting in reversal of a congenital shunt eg VSD)
Primary:
- Congenital eg Ebsten's anomaly
- Rheumatic heart disease
- right-sided endocarditis
- carcinoid syndrome
- blunt trauma
118
Long term complications of prosthetic valves
```
Thromboembolic disease
Infective endocarditis
Valve failure
Valve dehiscence
Haemolysis
Anticoagulation complications: GI haemorrhage
```
119
Small VSD
Haemodynamically insignificant
Harsh pansystolic murmur heard at left lower sternal edge (smaller the hole the larger the murmur)
120
Large VSD
Presents with cardiac failure in first few months of life
narrow pulse pressure and mid-diastolic murmur (high flow through mitral valve)
May lead to RHF and Eisenmenger's syndrome (pulmonary hypertension, resulting in reversal of a congenital shunt eg VSD)
