Cardiology Flashcards
Prominent V waves on JVP -?
Tricuspid regurg
Symptoms of tricuspid regurgitation
Pansystolic murmur
Prominent/giant V waves in JVP
Pustile hepatomegaly
Left parasternal heave
Causes of tricuspid regurg
Right ventricular infarction
Pulmonary HTN e.g. COPD
Rheumatic heart disease
IE (esp in IVDUs)
Ebsteins anomaly
Carcinoid syndrome
What dose of adrenaline is used in cardiac arrest?
1 in 10,000
What are the shockable rhythms?
VT/VF
What are the non shockable rhythms?
Asystole
PEA
Ratio of chest compressions to ventilation breaths
30:2
What should you do to VT/VF originally?
Shock
What should be given ASAP for a non-shockable rhythm?
Adrenaline 1mg in 10,000
When is adrenaline given in a VF/VT arrest?
After the third shock after compressions are restarted
When should adrenaline be repeated?
Every 3 - 5 mins
When and who should amiodarone be given to?
VF/pulseless VT
After 3 shocks have been administered
Reversible H causes of cardiac arrest
Hypoxia
Hypothermia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia
Hypovolaemia
Reversible T causes of cardiac arrest
Thrombus
Tamponade
Toxins
Tension pneumothorax
What murmur does ASD give in adults?
Ejection systolic murmur louder on inspiration
What murmur does mitral regurg give?
Pansystolic murmur
Louder on expiration
How would tertatology of fallot present?
Cyanosis in early childhood
A loud ejection systolic murmur could be what?
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
An ejection systolic murmur which is louder on inspiration?
Pulmonary stenosis
ASD
What does a pansystolic murmur indicate?
VSD
Mitral/tricuspid regurg
What does a continous machine like murmur indicate?
Patent ductus arteriosus
Definition of pulmonary aterial hypertension
Resting mean pulmonary pressure of > 25mmHg
Which gender is pulmonary arterial HTN more common in?
Female
What age does pulmonary arterial HTN present?
30-50 y/o
Causes of pulmonary arterial HTN
Secondary to chronic diseases
HIV
Cocaine
Anorexigens (e.g. fenfluramine)
10% autosomal dominant inheritance
Presentation of pulmonary arterial HTN
Progressive exertional dyspnoea
Exertional syncope
Exertional chest pain
Peripheral oedema
Cyanosis
Right ventricular heave, loud P2, raised JVP, tricuspid regurg
What is the most common cause of death in patients following cardiac arrest?
Ventricular fibrillation
What drugs should be avoided in HOCM?
ACEIs
Nitrates
Inotropes
What does HOCM stand for?
Hypertrophic obstructive cardiomyopathy
Inheritance of HOCM
Autosomal dominant
Management of HOCM
Amoidarone
Beta blockers / verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis
What is the biggest risk factor of PCI stent thrombosis?
Withdrawl of anti-platelet therapy
Which two drugs together have shown to reduce mortality in stable heart failure?
Carvedilol
Bisoprolol
Give an example of a vagal manouvre
Carotid sinus massage
Management of a narrow complex tachycardia with no adverse features
- Vagal manouvres
- IV adenosine
Doses of adenosine to try in SVT
6mg
Then 12mg (if no response)
Then 18mg (if no response)
If the SVT is not responding to IV adenosine, what diagnosis should you consider?
Atrial flutter
If you find AF < 48 hrs of onset what can you consider?
Chemical or electrical cardioversion
What are the ACSs?
STEMI
NSTEMI
unstable angina
2 main pathologies of ACS
- Artery narrowing
- Plaque rupture causing occlusion
RFs of ischaemic heart disease
Male
FH
Increasing Age
smoking
DM
HTN
Hypercholesteraemia
Obesity
Presentation of ACS
Central / left sided chest pain
Radiating to jaw or left arm
Heavy / constricting
Dyspnoea
Sweating
Vomiting
who often may not experience chest pain in ACS?
Elderly
Diabetics
Two most important Ix of ACS
ECG
Troponins
What leads indicate anterior part of heart?
V1-V4
What leads indicate inferior part of heart?
II, III, aVF
What leads indicate lateral part of the heart?
I, V5-6
Tx of STEMI
PCI
300mg aspirin
Likely 2nd antiplatelet therapy depending on guidelines
Anti=emetics/analgesia
Nitrates
If a patient presents with an NSTEMI what is used to decide on further management?
GRACE risk stratisification tool
What should be performed in a patient with an NSTEMI?
Coronary angiography
2ndry prevention of ACS
Aspirin
2nd antiplatelet if appropriate
BB
ACEI
Statin
Definition of STEMI
ST elevation on ECG
Elevated troponins
Defiintion of NSTEMI
ECG changes but no ST elevation
Elevated troponins
Who should nitrates be used in caution with?
Hypotension
STEMI criteria on ECG
Clinical Sx consistent with ACS (generally > 20 mins) and persistent ECG changes in >2 leads of
- 2.5mm (usually >2.5 squares) ST elevation in leads V2-V3 in < 40s or >2mm ST elevation in V2-V3 >40 y/o (MEN)
- 1.5mm ST elevation in women in V2-V3
- 1mm ST elevation in other leads
- new LBBB
Two types of coronary reperfusion therapy
PCI
Fibrinolysis
Tx of NSTEMI / unstable angina
aspirin 300mg
fondaparinux if no immediate PCI planned
GRACE Score
- if low risk (<3%) -> ticagrelor/conservative management
- if intermediate/high risk (>3%) -> PCI
What does the GRACE score look at?
Age
HR
BP
Kilip class
Renal function
Cardiac arrest on presentation ?
ECG changes ?
Troponins
Poor prognostic factors after ACS
Age
Development or prescence of HF
PVD
Reduced systolic BP
Kilip class
Initial serum crt elevation
elevated initial tropnonins
Cardiac arrest on admission
ST segment deviation
Kilip class
I - No clinical signs of HF
II - Lung crackles - S3
III - Frank pulmonary oedema
IV - Cardiogenic shock
Definition of acute pericarditis
Inflammation of the pericardial sac, lasting 4-6 weeks
Causes of acute pericarditis
Viral (coxsackie)
TB
Uraemia
Post MI
Radiotherapy
Connective tissue (SLE, RA)
Hypothyroid
Malignancy (breast / lung)
Trauma
What causes early post MI Acute pericardiits? (1-3 days)
Fibrinous pericarditis
What causes late (weeks - months) acute pericarditis post MI?
Dresslers syndrome (autoimmune pericarditis)
Presentation of acute pericarditis
Chest pain
- often pleuritic
- relieved by sitting forwards
Dry cough
Flu like symptoms
SOB
Pericardial rub
ECG changes in acute pericarditis
Global / widespread (rather than territories)
Saddle shaped ST elevation
PR depression
Ix for acute pericarditis
ECG
Transthoracic ECHO
Bloods (30% raised trop)
Treatment of acute pericarditis
Most can be managened as OPs
Tx underlying cause if possible
Avoid strenuous physical activity until symptom resolution and normalization of inflammatory markers
For viral pericarditis or acute idiopathic - NSAIDs and colchicine
What is adenosine used in?
To terminate supraventicular tachycardias
Who should adenosine not be used in?
Asthmatics
S/Es adenosine
Chest pain
Bronchospasm
Transient flushing
WPW syndrome
What is amiodarone used for?
Class III anti arrythmic agent used in the treatment of atrial, nodal and ventricular tachycardias
S/Es amiodarone
Thyroid dysfunction - both hypo and hyper
Corneal deposits
Pulmonary fibrosis / pneumonitis
Liver fibrosis / hepatitis
Peripheral neuropathy / myopathy
Photosensitivity
Slate grey appearance
Thrombophlebitis and injection site reactions
Bradycardia
QT prolongation
Tx of angina
Aspirin and statin
Sublingual GTN for attacks
BBs or CCBs depending on contraindications
What should beta blockers not be used in conjunction with and why?
Verapamil
Complete heart block
If in Tx for angina if a patient is taking both a CCB and a BB when should you add in a third drug?
When waiting for PCI
What is recommended to avoid nitrate tolerance?
Asymetric dosing interval (to maintain a daily nitrate free period of 10-14 hrs)
What is an aortic dissection?
Tear in the tunica intima of the wall of the aorta
RFs for aortic dissection
HTN
Trauma
Bicuspid aortic valve
Marfans syndrome / Elos danlos syndrome
Turners and noonans syndromes
Pregnancy
Syphillis
Presentation of aortic dissection
Chest / back pain
- tearing in nature, maximal pain at onset
Pulse deficit
- weak or absent carotid, brachial or femoral pulse
- variation >20mmhg in systolic BP in both arms
Aortic regurg
HTN
Other features depend on involvement of other arteries
- coronary - angina
- spinal arteries - paraplegia
- distal aorta - limb ischaemia
Non specific ECG changes
Type A stanford classiciation of aortic dissection
Ascending aorta
2/3 of cases
Type B standford classication of aortic dissection
Descending aorta, distal to left subclavian origin
1/3 of cases
Two classifcation systems of aortic dissection
Debakey
Stanford
Type 1 debakey classifcation of aortic dissection
Origins in the ascending aorta to at least the aortic arch and beyond is distally
Type II debakey classification of aortic dissection
Origins in and is confined to the ascending aorta
Type III debakey classifcation of aortic dissection
Origins in the descending aorta, rarely extends proximally but will extend distally
Ix of aortic dissection
CXR - widended mediastinum
CT angio chest abdo pelvis
Transeosophageal ECHO
Management of type A aortic dissection
Surgery
Target BP 100-120 whilst awaiting intervention
Management of type B aortic dissection
Conservative management
Bed rest
Reduce BP with IV labetolol
What is aortic regurgitation?
Leaking of the aortic valve that causes blood to flow in the reverse direction during ventricular diastole
Causes of AR
Valve
- Rheumatic disease
- calcific valve disease
- connective tissue e.g. RA/SLE
- Bicuspid aortic valve
- infective endocarditis
Aortic root
- Bicuspid aortic valve
- Spondyloarthopathies e.g. AS
- HTN
- Syphillis
- Marfans / ehler danlos syndrome
- aortic dissection
Presentation of aortic regurg
Early diastolic murmur
Collapsing pulse
Wide pulse pressure
Nailbed pulsation (quinckes sign)
Head bobbing (de mussets sign)
Investigations of aortic regurg
ECHO
Management of AR
Medical Tx of assosiated HF
Surgery in symptomatic patients or asymptomatic patients with severe LV dysfunction
Presentation of aortic stenosis
Chest pain
SOB
Syncope / pre syncope
ESM
Features of murmur in aortic stenosis
ESM
Radiates to carotids
Decreased following the valsalva manouvre
Features of severe Aortic stenosis
Slow rising pulse
Narrow pulse pressure
Delayed ESM
Soft / absent S2
S4
Thrill
Duration of murmur
LVH or LVF
Causes of aortic stenosis
Degenerative calcification
Bicuspid aortic valve
Williams syndrome (supravalvular aortic stenosis)
Post rheumatic disease
HOCM
Management of aortic stenosis
If asymptomatic then observe is general rule
Symptomatic - valve replacement
If asymptomatic but valve gradient > 40mmHg with features of LVSD then could consider surgery
Options for aortic valve replacement
Surgical
Transcatheter AVR
Balloon valvuloplasty
What is arrythmogenic right ventricular cardiomyopathy?
An inherited disease which presents with syncope or sudden death.
Right ventricular myocardium is replaced by fatty and fibrofatty tissue
Inheritance of ARVC
Autosomal dominant
Presentation of ARVC
Palpitations
Syncope
Sudden cardiac death
Ix of ARVC
ECG; TWI in V1-3 typically, epsilon waves
ECHO
MRI
Management of ARVC
Sotalol
Catheter ablation to prevent ventricular tachycardia
Implantable defib
Definition of paroxysmal AF
Recurrent episodes > 2 which terminate spontaneously
Last < 7 days (usually < 24 hrs)
Definition of persistent AF
AF that is not self terminating (usually last > 7 days)
Presentation of AF
Palpitations
SOB
CP
What pulse is felt in AF?
Irregularly irregular
Diagnosis of AF
ECG
Two key parts of management of AF
Rate/rhythm control
Reducing stroke risk
Another name for rhythm control in AF
Cardioversion
1st line tx for rate control of AF
Beta blocker
Rate limiting CCB (diltiazem)
If one doesnt work recommends combi therapy with above and possibly digoxin
Criteria for cardioversion in AF and why
When AF converted to sinus then high risk for thrombus to move and cause stroke
symptoms < 48 hrs or
anticoagulated for a period of time prior to attempting cardioversion
What scoring system is often used to determine anti-coagulation in AF?
CHASDVASC score
Score of 0 in CHADSVASC
No tx
Score of 1 in CHASVASC
Males - consider anticoagulation
Females - no Tx
Score of 2 in CHASVASC
Treat with NOAC or anticoagulation
Two scenarios where cardioversion can be used in AF
Electrical in a patient as an emergency if haemodynamically unstable
Electrical or pharmacological as an elective procedure where a rhythm control stratergy is preferred
What drugs are used for pharmacological cardioversion?
Amiodarone if structural heart disease
Flecanide or amoiodarone otherwise
If AF symptoms started > 48 hrs ago, how long should anti-cogulation be given before cardioversion?
3 weeks
If there is a high risk of cardioversion failrue what should be given prior to electical cardioversion?
4 weeks of amiodarone or soltadol
Following electrical cardioversion how long should patients be anti coagulated for?
4 weeks
After a TIA, when should anti-coag be started for AF in the absence of a haemorrhage?
Immediately
After an acute stroke in the absence of haemorrhage, when should anti - coag for AF start?
After 2 weeks
Who should NOT be offered rate control in AF?
Reversible cause
Heart failure primarily thought to be caused by AF
New onset AF < 48 hrs
atrial flutter whos condition is more suitable for suitable for an ablation strategy
Rhythm control strategy more suitable based on clinical judgement
What agents are used to maintain sinus rhythm in patient with HX OF AF?
Beta blockers
Dronedarone
Amoidarone (particularly if co exisiting HF)
