Cardiology Flashcards
Initial management of all ACS patients
MONA
Morphine (only if in severe pain)
Oxygen (if less than 94 sats
Nitrates (caution if hypotensive)
Aspirin 300mg
What is STEMI criteria
Symptoms of ACS for over 20mins
AND
ST elevation in 2 or more leads
Which leads are ST elevation in mm different in
V2 and V3
What is ST elevation criteria in leads V2 and V3 for men
Men under 40
- >2.5mm
Men over 40
- >2mm
What is ST elevation criteria in leads V2 and V3 in women
> 1.5mm
What is ST elevation criteria in all leads
Above 1mm
What is criteria for being eligible for percutaneous coronary intervention
Within 12 hours of onset of symptoms
Able to be delivered within 120 minutes
Where is access gained in PCI
Radial access
If present after 12 hours from onset of symptoms, what can do for STEMI
If ongoing ischaemia or HF- do PCI
What is given alongside PCI if radial access
Unfractionated heparin
Bailout Glycoprotein IIb/IIIa inhibitor ( tirofiban and eptifibatide)
Another antiplatelet- prasugrel etc
What antiplatelet is used alongisde PCI
Prasugrel- 60mg
If high risk bleeding then ticagrelor- 180mg
If on anticoagulant- clopidogrel
What give alongisde aspirin prior to PCI if patient already on an anticoagulant
Clopidogrel
What can be used as antiplatelet alongside aspirin prior to PCI if high risk of bleeding
Ticagrelor
What is counted as postural drop in BP
Sys- drop in 20
Dias- drop in 10
Systolic going under 90
How evaluate all patients with syncope
Cardiac examination
ECG
Postural BP measurement
Any other investigations depend on features of history etc
Causes of collapse
Cardiac causes
Neuro
- seizure
Reflex
- vasovagal
Orthostatic
What can cause an orthostatic syncope
Primary autonomic dysfunction
- parkinsons
- LBD
Secondary autonomic
- DM
- amyloid
- uraemia
Drug induced
- diuretics
Volume depleted
- haemorrhage
- dehydration
What is first line antiplatelet alongside aspirin prior to PCI
Prasugrel
Type A aortic dissection on CT angio
See flap in the ascending aorta
Type B aortic dissection on CT angio
See flap in descending aorta
What is gold standard investigation for aortic dissection
CT angio
What investigation do for aortic dissection
CT angio if stable
If unstable then do transoesophageal echo if needs be
Management of aortic dissection
Type A- control BP to systolic 100-120 then surgical management
Type B- conservative bed rest and IV labetalol
Complications of aortic dissection
If tear goes towards heart
- MI
- aortic regurgitation
If tear goes forward
- stroke
- renal failure
- unequal BP in arms
What happens to BP in aortic dissection
Rises due to catecholamine surge
Assesment of aortic dissection
Obs- hypertension
ECG- may show inferior MI
CXR- widened mediastinum
Next choice depends on stability of patient
- CT angio preferable
- TOE if unstable
When refer if presenting with GP >180/110
Signs of end organ damage
- papilloedema
- retinal haemorrhages
- confusion
- chest pain
What is pulsus paradoxus
A large drop in BP on inspiration
Seen in cardiac tamponade
What is cardiac tamponade vs pericardial effusion
Pericardial effusion is fluid within the pericardial space
Tamponade is when there is pressure on the heart and the output is reduced
Features of cardiac tamponade
Becks triad
Pulsus paradoxus
Electrical alternans
May see kussmauls sign
What is in becks triad
Elevated JVP
Hypotension
Muffled heart sounds
What is kussmauls sign
JVP rises on inspiration
MOA of dabigatran
Direct thrombin inhibitor
Management of NSTEMI
MONA
Assess if stable
- if severely unwell (eg hypotensive) then immediate PCI
If stable then establish GRACE risk
- if >3% then PCI within 72 hours
- if <3% then fondaparinux and ticagrelor
If doing PCI in NSTEMI/unstable angina, what give alongside
Unfractionated heparin
Prasugrel or ticagrelor
When give fondaparinux in NSTEMI/UAP
Every time unless doing PCI immediately
What are causes of dilated cardiomyopathy
Idiopathic most commonly
Drugs- doxorubicin, cocaine, alcohol
IHD
Post myocarditis
Duchenne muscular dystrophy
Infiltrative- haemochromatosis, sarcoid
What impact can have thiamine deficiency have on heart
Restrictive and obstructive cardiomyopathy
Features on examination of dilated cardiomyopathy
HF findings
S3
CXR finding of dilated cardiomyopathy
Balloon appearance
Viral causes of myocarditis
Cocksackie B
HIV
Bacterial causes of myocarditis
Diphtheria
Clostridia
Lyme disease
Causes of myocarditis
viral: coxsackie B, HIV
bacteria: diphtheria, clostridia, lyme
protozoa: Chagas’ disease, toxoplasmosis
autoimmune- SLE, RA and sarcoid
doxorubicin
Presentation of myocarditis
Recent viral illness
Chest pain
HF features
Cause of 10% of sudden cardiac death
Blood findings of myocarditis
BNP up
Inflammatory markers up
Cardiac enzymes up
Complications of myocarditis
HF
Arrythmias
May progress to dilated cardiomyopathy
Management of myocarditis
Supportive- manage arrythmias and HF
May require transplant
Treat underlying cause
What is risk of left ventricular aneurysm
Thrombus formation
Patients are anticoagulated as a result
When do ventricular wall ruptures occur
1-2 weeks after
Presentation of ventricular free wall rupture
1-2 weeks post MI
HF presentation
Raised JVP
Pulsus paradoxus
Reduced HS
Management of dresslers syndrome
Oral NSAIDS
How does ventricular septal defect present post MI
HF with pansystolic murmur
Management of ventricular septal defect post MI
Urgent surgical correction
Ejection systolic murmurs
Aortic stenosis
HOCM
Pulmonary stenosis
Atrial septal defect
Tetralogy of fallot
How differentiate ejection systolic murmurs
Louder on expiration
- aortic stenosis
- HOCM
Louder on inspiration
- pulmonary stenosis
- atrial septal defect
Causes of pansystolic murmurs
Mitral and tricuspid regurgitation
Ventricular septal defect
Differentiating the pansystolic murmurs
Regurgitation murmurs high pitched and blowing
VSD very harsh sounding
Late systolic murmur
Mitral valve prolapse
Aortic coarctation
Early diastolic murmurs
Aortic regurgitation
Pulmonary regurgitation
What is the graham steel murmur
Pulmonary regurgitation which is very high pitched and blowing
What is the austin flint murmur
Seen in severe aortic regurgitation
Rumbling mid late diastolic
What is continuous machine murmur seen in
Patent ductus arteriosus
What are the mid late diastolic murmurs
Mitral stenosis
Austin flint murmur (severe aortic regurgitation)
Electroltye causes of prolonged QT
Hypocalcaemia
Hypokalaemia
Hypomagnaesaemia
What is difference between monomorphic and polymorphic VT
Monomorphic is all 1 shape
Polymorphic is multiple shapes
What is most common cause of monomorphic VT
MI
What does prolonged QT lead to
Torsades des pointes- a subtype of polymorphic VT
Which MIs are mitral regurg seen in
Infero-posterior
What antithrombotic therapy is given with bioprosthetic valves
Warfarin initially then aspirin
What antithrombotic therapy is given with mechanical heart valves
Warfarin + aspirin
What is kussmauls sign most likely to be seen in
Constrictive pericarditis
What is constrictive pericarditis
When the pericardial sac becomes granulomatous and non-elastic
Causes of constrictive pericarditis
Any pericarditis may progress to it
Mainly TB
Presentation of mitral stenosis
SOB
Haemoptysis- pulmonary congestion
AF- from left atrial enlargement
Features of MS murmur
Mid late diastolic heard best on expiration
Loud S1
Opening snap
Signs on examination of mitral stenosis
Low volume pulse
Malar flush
Loud S1 and opening snap
Mid diastolic murmur
What is management of mitral stenosis
Asymptomatic= regular echos
Symptomatic= balloon valvotomy or surgery
If in AF anticoagulate
What is arrythmogenic right ventricular cardiomyopathy
Autosomal dominant cardiac disease where right ventricle replaced by fibrofatty tissue
What are epsilon waves seen in
arrythmogenic right ventricular cardiomyopathy
Management of arrythmogenic right ventricular cardiomyopathy
Anti-arrythmics- sotalol
Catheter ablation of tissue
ICD implanted
How manage patient who has just had fibrinolysis for STEMI
Repeat ECG in 60 minutes
If still ST elevation then transfer to centre for PCI
Which valve most commonly affected in IE
Mitral except for in IVDU where is tricuspid
What is quinckes sign
Pulsating nailbed seen in aortic regurgitation
What is de mussets sign
Head bobbing- seen in aortic regurgitation
Signs on examination of aortic regurgitation
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke’s sign
De Musset’s sign
Management of aortic regurg
medical management of any associated heart failure
surgery: aortic valve indications include
- symptomatic patients with severe AR
- asymptomatic patients with severe AR who have LV systolic dysfunction
Causes of AR
Infections- rheumatic fever, syphillis, endocarditis
Calcified valve
Connective tissue diseases- RA, SLE, ank spond
Genetic conditions- marfans, ehlers-danlos
Aortic dissection
Which drugs should patients take following an MI long term
Dual antiplatelet therapy- aspirin 75 mg plus ticagrelor, prasugrel or clopidogrel for a year
Beta-blocker
ACEi
Aldosterone antagonist if reduced LVEF
Statin
Lifestyle advice post MI
Mediterranean diet
20-30 mins exercise to become slightly SOB
Sex 4 weeks after
What is best choice of drug for reduced LVF post MI
Aldosterone antagonist- epleronone
Causes of ST elevation (non-ACS)
pericarditis/myocarditis
normal variant
left ventricular aneurysm
Prinzmetal’s angina
Takotsubo cardiomyopathy
rare: subarachnoid haemorrhage
What is prinzmetal angina
Coronary artery spasm
Which arteries may aortic dissection involve
Coronary- MI
Spinal- paraplegia
Distal aorta- limb ischaemia
SVT management
Haem stable= Valsava first line
IV adenosine 6mg
Then 12mg
Then 18mg
Then verapamil if fails
Haem unstable, MI signs or HF= synchronised DC cardioversion
What is used for SVT if asthmatic
Verapamil
Long term prevention of SVT
B blockers
Radio frequency ablation
Causes of high output HF
anaemia
Pregnancy
thyrotoxicosis
arteriovenous malformation
Paget’s disease
thiamine deficiency
ECG findings of hyperkalaemia
Tented T waves
Widened QRS
Small p waves
If over 9 then get sinusoid/sine wave
When stop beta blockers in HF
HR<50
Second or third degree HB
Shock
What do if patient presents with bradycardia
A-E
In particular looking at BP and ECG
Look for
- shock signs
- syncope
- MI
- HF
Blood gas to identify electrolyte causes
Management of bradycardia
If signs of shock, MI, HF or syncope
- atropine 500mcg first line
If no response to this consider
- atropine doses up to 3mg
- transcutaneous pacing
- adrenaline injection
If no response to these then specialist help for transvenous pacing
What are options if atropine 500mcg does not work for bradycardia
Atropine 3mg
Transcutaenous pacing
Adrenaline injection
What do if second line options for bradycardia do not work
Seek specialist help for transvenous pacing
Even if satisfactory response to atropine 500mcg what still need to do
Check for risk of asystole
- recent asystole
- Mobitz II AV block
- complete HB
- ventricular pause >3s
Even if no signs of life threatening bradycardia what need to do
Check for risk of asystole
- recent asystole
- Mobitz II AV block
- complete HB
- ventricular pause >3s
Side effects of adenosine
Chest pain
Bronchospasm
Flushing
Indications for surgery in IE
Severe incompetence
Abscess
Antibiotic resistant infections
Cardiac failure
Persistent tachycardia
What is moa of alteplase
Activates plasminogen to plasmin
What is drug of choice for thrombolysis in STEMI
Tissue plasminogen activator- alteplase or tenectoplase
What is MOA of ticagrelor and prasugrel
P2Y12-receptor antagonist same as clopidogrel
What can be normal physiological findings on ECG in athletes
Sinus bradycardia
1st degree AV block
Mobitz type 1
What needs to always be given alongside thrombolysis
Antithrombin drug like fondaparinux
What are causes of preserved ejection fraction HF
HOCM
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis
Causes of reduced ejection fraction HF
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Arrhythmias
Who does ACS present atypically in
Women
Elderly
What causes deep pointed t wave inversion
Unstable angina or NSTEMI
What valve disease is associated with a loud opening snap
Mitral stenosis
What does S3 heart sound suggest
HF
Torsades des pointes management
IV mag sulph
Causes of torsades des pointes
Causes of long QT interval
congenital
Jervell-Lange-Nielsen syndrome
Romano-Ward syndrome
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage
Poor prognostic markers in ACS
Cardiogenic shock
Cardiac arrest
Raised serum creatine
Hypotension
Age
Elevated cardiac markers
Peripheral vascular disease
What must do for ALL patients with acute HF
IV furosemide
When give oxygen in HF
Sats under 94%
What give for resp failure in HF
CPAP
If in cardiogenic shock in HF what do
Dobutamine first line
If this fails or is continuing circulatory failure use vasopressors
If these fals use mechanical circulatory assistance
If someone comes in with HF, what consider in all patients
IV furosemide in all patients
Oxygen- only if less than 94% sats
Vasodilators- avoid if hypotensive
When mainly want to use nitrates in HF
concomitant myocardial ischaemia
severe hypertension
regurgitant aortic or mitral valve disease
Management of HOCM
Beta blockers 1st line or CCB
ICD
Surgical or catheter based reduction of atrial septa
May need heart transplant
Which drugs cant give in HOCM
Nitrates
ACEi
Inotropes
Causes of tricuspid regurgitation
right ventricular infarction
pulmonary hypertension e.g. COPD
rheumatic heart disease
infective endocarditis
Ebstein’s anomaly
carcinoid syndrome
Signs on examination of tricuspid atresia
pan-systolic murmur
prominent/giant V waves in JVP
pulsatile hepatomegaly
left parasternal heave
What can cause a raised troponin
ACS
High demand for cardiac muscle
- sepsis
- anaemia
- HF
- arrythmias
What measure for a reinfarction
CK-MB
Which heart enzyme is first to rise
Myoglobin
MOA of fondaparinux
Activates anti-thrombin III
Typical vs atypical angina
Typical has 3 of the following
Atypical has 2 of;
- pain described as constricting in chest, shoulders or arms
- brought on by exercise
- relieved by GTN within 5 mins
First line investigation for angina if diagnosis uncertain
CT coronary angio
What is best investigation for dresslers syndrome
ESR
Causes of acute pericarditis
Cocksuckie
TB
Uraemia
Malignancy
Post MI
Radiotherapy
SLE, RA
Hypothyroidism
Presentation of pericarditis
Pleuritic chest pain
Relieved on sitting forward
SOB
Flu like
ECG changes for pericarditis
Saddle ST elevation
PR depression
What investigation must always do for pericarditis
Transthoracic echo
Investigations for pericarditis
ECG
- saddle shaped ST elevation
- PR depression
Bloods
- troponin may be up
- inflam markers up
What does troponin being up in pericarditis suggest
Indicates myopericarditis
What troponin measure nowadays
Troponin I/T
Management of pericarditis
NSAIDs short term and colchicine for 3 months
Minimal exercise
Inpatient if raised trop or fever over 38
Do pericarditis patients need to be treated as inpatient
Not necessarily, do if:
- fever 38>
- elevated troponin
What is point of furosemide long term in HF
Only symptomatic support
No help for mortality
First line for HF long term with reduced ejection fraction
ACEi or ARB
Beta blocker
Which beta blockers are licensed for HF in UK
Bisoprolol
Carvedilol
Second line treatment for reduced ejection fraction HF
Aldosterone antagonist
- spironolactone
- epleronome
Can add SGLT2s
Extra non-cardiac treatments for HF
SGLT2
Annual flu
One off pneumococcal
Management options for orthostatic hypotension
Conservative
- more fluid
- more salt in diet
- wean medications
Medical
- fludrocortisone
What is collapsing pulse seen in
Aortic regurg
Hyperkinetic state- anaemia, sepsis, thyrotoxic etc
What is jerky pulse seen in
HOCM
Presentation of rheumatic fever
J- arthralgia
O- carditis
N- subcut nodules
E- erythema marginatum
S- sydenams chorea
Management of rheumatic fever
If current infection- phenoxymethicillin
NSAIDS first line anti-inflammatory
What is presentation of VSD post MI
Acute HF
Pan systolic murmur
Seen in first week post MI
If have colorectal cancer, what organism is associated with endocarditis
Strep bovis
Who should be considered for anticoagulation in AF
Anyone with even paroxysmal, asymptomatic AF or atrial flutter
How interpret chadvasc scores
0= No anticoagulation
1= in men consider but not in women as 1 due to their sex
2= offer anticoagulation
What do if chadvasc=0
No anticoagulation
Need to do TTO however to exclude valvular disease
What is an absolute indication for anticoagulation in AF regardless of CHADVASC
Valvular disease
What is second line anticoagulation post DOAC for AF
Warfarin
What use in all patients with stable angina
Aspirin
Atorvastatin 80mg
Nitrates PRN
First line for stable angina
1 of CCB or beta blocker
On top of aspirin and atorvastatin
Stepped approach to stable angina
(whilst aspirin + atorvastatin already given)
1 of beta blocker or CCB
Increase dose
Add the other
If dual therapy does not work
Refer for PCI or CABG
While waiting add 1 of
- a long-acting nitrate
- ivabradine
- nicorandil
- ranolazine
If waiting for PCI or CABG in stable angina- what do in meantime
Add 1 of
- a long-acting nitrate
- ivabradine
- nicorandil
- ranolazine
What is problem of using nitrates long term in angina treatment
Tolerance and reduced efficacy
When electrically cardiovert AF patients
Haem instability
HF signs
Management of AF haemodynamically stable
Under 48 hours
- rhythm or rate control
Over 48 hours
- can rate control
- wait 3 weeks to cardiovert electrically
- anticoagulate for 3 weeks
What medications use for rate control in AF
1st line: Beta blockers
- atenolol
- bisoprolol
2nd line: CCB
- verapamil
- diltiazem
3rd: Digoxin
If asthmatic what use for rate control in AF
Verapamil (CCB)
What is best person to use digoxin in for rate control
Sedentary lifestyle
HF
What use for rate control if reduced LVF
Digoxin
If going to medically cardiovert someone, what drug use
Flecainide if no structural or ischaemic heart disease
Amiodarone if so
What do if AF unresponsive to anti-arrythmics or patient wishes to avoid antiarrythmics
Consider catheter ablation
If having catheter ablation for AF, what need to do before it
Anticoagulate for 4 weeks
What effect does ablation have on AF stroke risk
None so still need to be anticoagulated for life
ECG of hypokalaemia
Small or absent T waves
u waves
Long PR
Long QT
When refer chest pain in the GP
In last 12 hours= if ECG changes then ambulance
12-72 hours ago= refer for same day assessment
Over 72 hours= ECG and troponin measurement
If management for SVT is unsuccessful after treatment with drugs then what is most likely cause
Atrial flutter
What are the different NYHA classfications of HF
1- no symptoms even after normal exercise
2- fine at rest but ordinary activity results in symptoms
3- fine at rest but minimal activity results in symptoms
4- severe symptoms even at rest
How are stanford B dissections managed
Uncomplicated- analgesia and HTN control
Complicated- surgery
First line investigation for HF
NT-proBNP
If have one episode of paroxysmal AF, what do
Calculate CHADVASC and consider starting DOAC
Signs and symptoms of malignant HTN
Papilloedema
Retinal bleeding
Increased cranial pressure causing headache and nausea
Chest pain due to increased workload on the heart
Haematuria due to kidney failure
Nosebleeds which are difficult to stop
Rhythm controlling beta blockers
Flecainide
Sotalol
What is a double/bisferens pulse
Where feel 2 systolic peaks
What is bisferens pulse seen in
Mixed aortic disease
HOCM
What ECG changes are seen in hypothermia
J waves
ST elevation
Long QT
Bradycardia
RFs for mitral regurg
Collagen disorders- ehlers danlos, marfans
Female sex
Recent MI
Mitral stenosis
Management of broad complex tachycardia
Adverse signs- DC conversion
Regular= IV amiodarone
Irregular= cardio input
Which drugs can cause long QT
amiodarone, sotalol
SSRI
TCA
methadone
chloroquine
erythromycin
haloperidol
ondanestron
When take statins in day
Last thing in evening
Causes of aortic stenosis
Calcification
Bicuspid valve
Williams syndrome
HOCM
Rheumatic fever
Most common cause of aortic stenosis in young vs old
Old= calcfication
Young= biscupsid valve
Antibiotics chosen for IE
Native valve- IV amox initially
Prosthetic valve- rifampicin, gentamicin and vancomycin
Severely ill or pen allergic- vancomycin and low dose gentamicin
Which valve replacements are preferred
Mechanical valves as last longer
What can raise BNP falsely
CKD
What can falsely lower BNP
Diuretics
ACEi
ARB
MOA of furosemide
Inhibits Na-K-Cl transporter in ascendiging loop of henle
What are pericardial friction rubs associated with
Pericarditis
What is wolf parkinson white syndrome
Congenital syndrome caused by accessory pathway from ventricles back to atria- AV re-entry tachycardia
ECG findings of WPW
Short PR
Wide QRS with slurred upstroke- delta wave
Axid deviation depending on the location of the accessory pathway- most commonly left
What is a delta wave
Slurred upstroke on QRS
Management of WPW
Definitive management= radiofrequency ablation of accessory pathway
Long term medical tx- amiodarone and flecainide
What are the surgery options for mitral stenosis
Commissurotomy or valve replacement
Balloon valvulotomy
What do if patient has AF but chest pain
DC cardioversion
As do this in case of not only haem unstable but ACS signs too
What can cause irregular broad complex tachycardia
AF with bundle branch block
What causes a loud S2
Pulmonary HTN
What is p mitrale indicative of
Left atrial enlargement often due to mitral stenosis
How does p mitrale appear on ECG
Bifid p wave
What can be side effects of nitrates
Hypotension
Tachycardia
Flushing
Headache
If have AV block post MI, what is likely artery
Right
When assessing orthostatic drops- how long wait
3 minutes
What injection give if allergic to atropine in bradycardia
Adrenaline
Target INR for mitral vs aortic valve replacement
Aortic- 3
Mitral- 3.5
Management of brugada syndrome
Implantable cardioverter-defibrillator
Pathophysiology of brugada syndrome
Inherited defect in cardiac sodium ion channel
ECG changes which change after being given flecainide
Brugada syndrome
ECG changes in brugada
Convex ST elevation in V1-3 followed by a negative T wave
What ECG changes see in a posterior MI
Changes seen in V1-V3:
- ST depression
- dominant tall R waves
- upright T waves
What is ECG territory is covered by LAD
V1-V4
What is ECG territory of left circumflex
V5-V6
I
aVL
What is ECG territory of right coronary
Inferior part of heart
aVF
II
III
What artery occlusion causes a anteroseptal MI
Left anterior descending
What artery occlusion causes an anterolateral MI
Proximal anterior descending
What artery occlusion causes a lateral MI
Left circumflex
What artery occlusion causes an inferior MI
Right coronary
What artery occlusion causes a posterior MI
Typically left circumflex but can be right coronary
How confirm a posterior MI
Repeat ECG with leads V7-V9 which will show ST elevation and Q waves
What are U waves
Where get an upwards deflection following the T wave
Which site of ablation is most likely to be effective for atrial flutter
Tricuspid valve isthmus
How do you describe atrial flutter rate
Describe the degree of block present
Atrial rate is calculated as the number of flutters
Ventricular rate is the number of R waves
The degree of block is the atrial flutters: r waves
What accentuates atrial flutter seen
Giving adenosine or carotid sinus massage
What can do at the bedside to further identify atrial flutter
Give adenosine or carotid sinus massage
4 causes of ST depression
Ischaemia
Hypokalaemia
Digoxin
Normal variant
Pathognomic finding for digoxin therapy on ECG
Scooped ST depression in leads aVF, II, III and V5-6
ECG findings in digoxin therapy
down-sloping ST depression (‘reverse tick’, ‘scooped out’)
flattened/inverted T waves
short QT interval
What MI is most likely to cause bradyarrythmias due to AV block
Inferior
What is murmur in HOCM
ESM louder on valsalva and quieter when squatting
What foods should people on warfarin avoid
Those high in vitamin K
- spinach
- kale
- sprouts
What are stages to hypertension
1= clinic BP>140/90 or ABPM>135/85
2= clinic BP >160/100 or ABPM> 150/95
3= clinic BP >180/110
What are 3rd line options chronically for HF
Ivabradine
Hydralazine in combination with nitrate
Sacubitril-valsartan
Digoxin
Cardiac resynchronisation therapy
What is cardiac resynchronisation therapy
biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle and left ventricle. The objective is to synchronise the contractions in these chambers to optimise heart function.
When start cardiac resynchronisation therapy for HF
Widened QRS from LBBB
Always add ICD at same time
Who is hydralazine with nitrates considered in 3rd line for HF
Black people
Best management of AF in HF
Digoxin
When give digoxin for HF
No specific criteria but can help symptoms
Certainly give if coexistent AF
When give ivabradine for HF
Sinus rhythm rate above 75
LVEF under 35
When give sacubitril-valsartan (entresto)
LVEF under 35
Symptomatic on ACEi or ARB
What need to do before giving sacubitril-valsartan
ACEi/ARB washout period
What is sacubitril-valsartan
Valsartan (ARB) in combination with sacubitril a drug which inhibits neprilysin which breaks down naturietic proteins
Ivabradine MOA
Slows HR allowing for more efficient pump
If femoral access in PCI for ACS what give alongside angiography
Bivalirudin with bailout GPI
If someone having STEMI what is first thing must assess
If eligible for PCI
If not then just give dual antiplatelet with cardio review
Which antithrombin drug give in NSTEMI
Fondaparinux
UFH if creatinine over severe renal impairment
What 3 things form main part of post MI management
Echo
Cardiac rehab
Dugs- BASH
What give if beta blockers CI post MI
Verapamil or diltiazem unless reduced LVF
What would consider as high risk for bleeding when deciding which antiplatelet post ACS
If over 75
How long give antiplatelets for post ACS
Aspirin- indefinetely
Others- 12 months
How long give beta blocker for post MI
12 months unless if reduced LVF
When give second antiplatelet if doing thrombolysis
Post giving drug
MI complications
muscle damage: HF, free wall rupture, ventricular aneurysm, VSD
inflammation: pericarditis or dresslers
valvular failure: MR
arrhythmia: VF/VT
Which second antiplatelet give if fibrinolysis
Ticagrelor or clopidogrel if high bleeding risk/on anti coag
Give after administration
If NSTEMI which second antiplatelet give
If not having PCI then ticagrelor or clopi (think high risk bleeding from antithrombin drug so avoid prasugrel)
If having PCI soon offer prasugrel, ticagrelor or clopi
Do you refer from GP if angina
Only refer to chest pain clinic if unsure about diagnosis or murmur, previous MI, HF, AF
What do if stable angina diagnosis certain in GP
Investigate potential precipitating causes- lipids, HbA1c, anaemia
Give aspirin 75mg
1 of CCB or B blocker
GTN spray
How explain GTN therapy to a patient
Stop exercise when comes on and take medication
If not relieved in 5 mins take again, if after second dose no effect then call ambulance
2nd and 3rd line investigations for angina
2nd line- non invasive functional imaging- MR angio, single photon emission uptake, stress echo
3rd line- angiography
What vagal manouevers are recommended for SVT
Valsalva method of blowing into syringe
Cold stimulus to face
Carotid sinus massage- CI in history of IHD or HF
What do if adenosine fails for SVT
Verapamil- given as slower bolus over 2 minutes
Classification of SVT
AVNRT- re-entry pathway via av node
AVRT- re-entry pathway from atria to ventricles
Atrial tachycardia
What types of SVT is WPW
AVRT
Most common classification of SVT
AVNRT
Most common cardiac arrythmia
AF
What is first line for AF assuming stable
Rate control is first line unless
- onset within last 48 hours
- is causing HF
- reversible cause
If medical cardioversion is contraindicated for a patient with new onset AF starting in last 48 hours what do
Electrical cardioversion
Presentation of sick sinus syndrome
Bradycardia with episodes of arrythmias
Which chronic HF drug use with caution in valvular disease
ACEi
When use steroids for pericarditis
2nd line or NSAIDs CI
Underlying RA
Cardiomyopathy causes
Restrictive
- amyloid
- post radiation
- sarcoid
Dilated
- haemochromatosis
- alcohol
- chemo
- post myocarditis
Genetic
- HOCM
-arrythmogenic right ventricle
Takotsobu
Indications for ICD
HOCM/arrythmogenic right ventricular cardiomyopathy
Long QT
Previous VT or VF
Pacemaker vs ICD
ICD there if go into cardiac arrest
Pacemaker to initiate contractions for heart
What are the different types of pacemaker
Single chamber in either RV or RA
Dual chamber in RA and RV
Biventricular in LV, RV and RA
Indications for pacemaker
Mobitz T2
3rd degree HB
Symptomatic bradycardia
Ablation at AVN
Severe HF
Sick sinus syndrome
What is pacemaker used in severe HF
Biventricular in RA, LV and RV which synchronises contractions to maximise LVF
How to tell if dual chamber pacemaker
On ECG will see lines before p wave and r wave
Single chamber pacemaker in RA
On ECG will see line before p wave
Single chamber pacemaker in RV
On ECG will see line before R wave
