Cardiology Flashcards
What are the 5 signs that appear on CXR for pulmonary oedema (CCF)?
- Cardiomegaly
- Bat wings
- Blunting of costophrenic angles
- Upper lobe venous diversion
- Curly’s B line
What are the common cardiovascular risk factors?
Hypertension
High LDL/cholesterol
Diabetes
Smoking
Obesity
Physical inactivity
High Salt intake
What is a STEMI?
ST elevation in coherent leads
High Troponin I
OR new LBB
What is a NSTEMI?
ST depression in coherent leads
High troponin
(ECG could be normal)
What is unstable angina?
NORMAL TROPONIN
ST depression in ECG
What are non-cardiac causes of high troponin?
CKD
Sepsis
PE
How do Acute Coronary Syndromes (ACS) present?
Pain radiating to jaw/arms
Nausea/vomiting
Sweating/clammy
SOB
Crushing central chest pain
What patients are at most risk of silent MIs?
Diabetics
What leads represent what area of the heart and artery?
LCA
Anterolateral
I, aVL, V3-6
LAD
Anterior
V1-V4
Circumflex
Lateral
I, aVL, V5-6
RCA
Inferior
II, III, aVF
What areas of the heart does the RCA supply?
RA
RV
Inferior LV
Posterior septal
What areas of the heart does the Circumflex artery supply?
LA
Posterior LV
What areas of the heart does the LAD supply?
Anterior LV
Anterior septum
What is the immediate management of a STEMI? What management will the cardiology team do?
ROMANCE
Reassure
O2
Morphine (10mg IV) + Anti-emetic
Aspirin (300mg chewable) (75mg for life)
Nitrate spray
Clopidogrel (300mg)
Enoxaparin (2.5g)
Then send to Cath lab for PCI (percutaneous coronary intervention)
What is PCI and when can it be given?
Putting a catheter in the radial artery and feeding it to the coronary artery.
Inject contrast to identify blockage then can use a balloon and stent to widen the artery lumen.
Has to be within 2hrs of onset of symptoms
What can be given if time has passed for PCI?
Thrombolysis
Streptokinase, Alteplase
How do we manage NSTEMI?
MATE
Morphine + anti-emetic
Aspirin (300mg)
Ticagrelor (180mg)
Enoxaprin (48hrs)
Nitrates + o2
How can we figure out whether patients with a NSTEMI need PCI?
GRACE score of 3%+
What is the pathophysiology of acute MI?
A thrombus ruptures and occludes a coronary artery leading to ischaemic death/necrosis of myocardial tissue
What does cardiac rehabilitation entail?
A programme of education, emotional sport and adapted exercise to help recovery after a MI
What are the complications of acute MI?
Arrhythmias
Heart block
CCF
Further MI
Valvular Damage
Septal Defects
What long term management is needed for a MI?
Echocardiogram (to asses the LV function)
Cardiac rehabilitation
Tony And Billy Are Silly
Ticagrelor
Aspirin
B blocker (bisoprolol)
ACEi/ARB (lisinopril/ramipril losartan/candesartan)
Statin (atorvastatin)
Need to keep an eye on hyperglycaemia (insulin if needed)
Smoking cessation/htn control
What is Dressler’s syndrome? How do we diagnose it and manage it?
Pericarditis weeks after a MI
Pleuritic chest pain
Low grade fever
Pericardial rub (auscultation)
Global ST elevation on ECG
1)NSAIDs
2)Prednisolone
3)Pericardiocentesis
What are the different types of MI? (ACDC)
ACDC
Type 1 - ACS
Type 2 - Can’t cope (increased demand of o2 or reduced supply of o2 [anaemia/tachycardiac/hypotensive]
Type 3- Dead by MI (Sudden cardiac arrest/death)
Type 4 - Caused by us (PCI, CABG,Stent)
What is Takotsubo cardiomyopathy?
High emotional/physical stress causes LV enlargement causes it to weaken
Symptoms mirror MI
What other ECG leads should you do if someone comes in with a posterior STEMI?
POSTERIOR (V7-V9)
How does an ECG change with a STEMI?
1) ST elevation
2) Pathological Q waves
What features of a patient’s presentation will support a diagnosis of heart failure?
History:
Cardiac History (IHD, AF, HTN, Valvular Disease)
Increasing SOB/Cough
Fatigue
Ankle Swelling
Orthopnoea
Paroxysmal Nocturnal Dyspnoea
Examination:
Hypertensive
Tacyhcardiac
Tachypnoea
Pitting Oedema
Raised JVP
Bilateral Basal Crackles (Pulmonary Oedema)
What does a CXR appear like in HF?
Cardiomegaly
Perihilar Shadowing
Alveolar Oedema
Air Bronchograms
Increased Vascular Pedicle Width
Possible Pleural Effusion
What are the common causes of HF?
- IHD
HTN
Valvular Heart Disease
AF
Chronic Lung Disease
Cardiomyopathy
Previous Chemotherapy
HIV
Why do patients with HF develop ankle oedema?
SEE YR 1 NOTES
What is the management for acute HF? (Sudden SOB)
1) Sit Up
2) Give o2
3) IV Diuretics (furosemide)
Monitor Fluid Balance + stop IV fluids
Cardiologist:
IV opiates/nitrates (vasodilators)
Inotropes (^CO)
Vasopressors (NA to ^BP)
Ventilation
What is the management of chronic HF? (Lifestyle and Medical)
Lifestyle Modification:
Smoking Cessation
Reduce Alcohol Intake
Salt restriction
Fluid Restriction
Medication:
1) Diuretics (furosemide)
2) ACEi/ARBs
3) B blockers (start low and go slow) Have to have BP > 100 + HR > 60bpm
What’s the ABAL pneumonic for the cascade of Chronic HF treatment?
ABAL:
A - ACEi (ramipril)
B - Beta Blocker (bisoprolol)
A - Aldosterone Antagonist (if AB not working e.g. spironolactone)
L - Loop Diuretics (furesomide)
What are some specialist medications/treatments for HF and when are they indicated?
Pacemakers (if LBBB)
Entresto (Sacubitril + Valsartan) if severe HF with ejection fraction of less than 35%
Ivabradine (good for hypotensive patients as has no effect on BP)
Nitrates (if previous IHD)
TREAT UNDERLYING CAUSE
What blood investigations are needed for HF?
Renal Function (baseline + diuretics effects)
FBC (anaemia?)
LFTs
TFTs
Lipid Profile
BNP (NT-proBNP) > 100 shows Acute HF
What investigations are needed for HF?
Echocardiogram (gold standard to diagnose)
ECG
CXR (pulmonary oedema)
What is the difference between HFwREF + HFwPEF? (in terms of EF %)
HFwREF : less then 50%
HFwPEF : more than 50% (diastolic LV dysfunction)
What is the definition of Ejection Fraction?
The percentage of blood in the left ventricle squeezed out with each ventricular contraction.
What features on an ECG will be present for AF?
Irregulary Irregular
Sawtooth wavy Baseline
Different heights of QRS complexes
Tachycardiac
What is the difference between a supraventricular tachycardia (SVT) and ventricular tachycardia (VT)?
SVT: Ectopic beat/rhythm arises in the atria
VT: Ectopic beat/rhythm arises in ventricles
What is the acute treatment for AF?
Rate Control:
B blocker (bisoprolol)
Ca Channel Blocker (verapamil)
Rhythm Control:
Flecainide
Amiodarone
3) Cardioversion
Anticoagulant (prevent stroke):
Apixaban
What would be the indications for electrical DC cardioversion in AF?
If patient is haemodynamically unstable
What are the 3 commonest causes of AF and what associated investigations would be useful to identify or exclude these common causes?
Hypertensive (BP)
Valvular Disease (Echo)
Cardiomyopathy (Echo)
Thyrotoxicosis (TFTs)
IHD (ECG)
Sepsis
Mitral valve pathology
IHD
Tyrotoxicosis
Htn
What is Wolff-Parkinson-White syndrome?
An additional pathway connecting the atria and ventricles (bundle of Kent)
(SVT)
What are the ECG changes in WPW?
Tachycardia
Short PR interval
Wide QRS complex
Delta Wave
What is the stepwise treatment for WPW?
1) Vagal Manoevure (Blow into a syringe)
1) Carotid Sinus massage
2) Adenosine
3) Verapamil or B blocker
4) Synchronised DC Cardioversion
What Scoring systems are helpful in determining whether a patient with AF should be taking long-term anticoagulation?
CHADsVASC
HAS-BLED
RFs:
Elderly
Hypertensive
Strokes
Alchohol
How can AF present?
Palpitations
SOB
Dizziness/Syncope
Stroke
What’s Paroxysmal Atrial Fibrillation and how can we diagnose it? How is it treated?
Reoccurring episodes of AF then back to sinus rhythm
24 hour ambulatory ECG
“pill in the pocket”
Flecainide when symptoms start
What is the last treatment option for AF when medication hasn’t worked?
Ablation:
Burn the cardiac muscle responsible for the ectopic activity (Cath lab)
What is a Narrow complex tachycardia and what are the different types?
Tachycardia with a narrow QRS
Sinus Tachycardia
SVT
AF
A Flutter
How does SVT appear on ECG?
QRS followed by T waves
P waves buried in T waves so can’t see them
How does Atrial flutter present on ECG? What’s it pathopysiology and management?
Atrial rate is 300bpm
Saw tooth pattern
2 atria contractions for 1 ventricular contraction so 150bpm
Re-entrant rhythm in atria causing atrial rate to be 300bpm
Treat same as AF (B blocker, Flecainide, Apaxiban)
What are the 3 different types of SVT and explain them briefly?
Atrioventricular Nodal Re-entrant Tachycardia:
Accessory Pathway goes back through AV node (most common)
Atrioventricular Re-entrant Tachycardia:
There is an accessory pathway between the atria and ventricles that isn’t the AV node e.g. WPW
Atrial Tachycardia:
Ectopic beat in atria other than the SA node
What are the 4 rhythms in a pulseless patient/cardiac arrest rhythms?
Shockable rhythms:
Ventricular Tachycardia
Ventricular Fibrillation
Non-Shockable Rhythms (defibrillator won’t help):
Pulseless Electrical Activity
Asystole
What are the 4 Narrow Complex Tachycardias and how are they treated if they’re life threatening?
Sinus Tachycardia (treat underlying cause)
SVT (vagal manoeuvres/Adenosine)
AF (B blocker)
A Flutter (B blocker)
Life threatening:
1) Synchronised DC Cardioversion
2) IV Amiodarone
What are the 4 Broad Complex Tachycardias and how are they treated if they’re life threatening?
Ventricular Tachycardia (IV amiodarone)
Polymorphic Ventricular Tachycardia e.g. torsades de pointes (IV magnesium)
AF w/ BBB (B blocker)
SVT w/ BBB vagal manoeuvres/Adenosine)
Life threatening:
1) Synchronised DC Cardioversion
2) IV Amiodarone
What does a prolonged QT interval mean?
Prolonged repolarisation of the heart (can result in spontaneous depolarisation)
Afterdepolarisations > Torsades de pointes
What are some causes of prolonged QT interval?
Long QT Syndrome (inherited)
Meds (antipsychotics, flecainide, amiodarone, ciprofloxacin, haloperidol)
Hypokalaemia, hypomagnesaemia, hypocalcaemia
How do we manage prolonged QT interval?
1) Stop meds
1) Correct electrolytes
2) B blockers
3) Pacemakers
How do we manage torsades de pointes?
Magnesium Infusion or Defib
What are some causes of bradycardia?
Sinus Bradycardia (sinus node issue):
Meds (B blockers, Ca channel blockers)
Sick Sinus Syndrome
AV Nodal Bradycardia:
Heart Blocks
How do we manage patients at risk of systole?
IV Atropine
Inhibits parasympathetics
ADRs: dry mouth, urinary retention, constipation
What are the 4 types of heart block?
First Degree:
Prolonged PR intervla
2nd Degree (type 1):
PR Interval gradually longer until QRS dropped
2nd Degree (type 2):
PR Interval stays the same but QRS complex is dropped
3rd Degree:
No relationship between P waves and QRS complex
What are some causes of 3rd Degree Heart Block? How can we treat it?
Digoxin toxicity
Hyperkalemia (IV Ca Chloride treat)
Atropine (in a haemodynamically unstable patient)
Permanent pacing needed long term
STEMI RCA
How do we treat acute SVT?
1) Vagal manoeuvres
2) IV adenosine or IV Verapamil (can’t use verapamil w/ patients on B blockers or LV dysfunction
3) IV Flecaininde
4) Synchronised Cardioversion
How do we treat SVT long term and try and prevent it?
1) B blockers or verapamil
2) Flecainide
What clinical features of a patient would indicate aortic stenosis?
Gradual decline of exercise tolerance
Chest Pain
Blackout/Syncope
Ejection Systolic murmur heard loudest over the base of heart and radiates to the neck
What are the common differential diagnoses of a systolic murmur?
HF
Pulmonary Disease
(SOB on Exertion)
Pulmonary stenosis
Atrial Septal Defect
Hypertrophic Cardiomyopathy
(Systolic murmur)
What investigations are relevant for aortic stenosis?
Echocardiogram (can diagnose and see severity
ECG
What are the common complications of severe aortic stenosis?
Sudden Death
HF
Pulmonary Hypertension
Outline the management for patients with aortic stenosis?
Valve Replacement Surgery (symptomatic patients)
TAVI (Transcatheter Aortic Valve Implantation) implanted into femoral vein (for older patients with co-morbidities)
What are the 3 classical symptoms of aortic stenosis?
Angina
HF
Syncope
What are the common causes of valvular heart disease?
Aortic Stenosis:
Idiopathic age related calcification
Congenital bicuspid valve
Rheumatic Fever
Aortic Regurgitation:
Idiopathic age related weakness
Congenital bicuspid aortic valve
Marfan’s
Mitral Stenosis:
Rheumatic Heart Disease
Infective Endocarditis
Mitral Regurgitation:
IHD
Rheumatic Heart Disease
Infective Endocarditis
Marfan’s
Tricuspid Regurgitation:
Rheumatic Heart Disease
Infective Endocarditis
Marfan’s
Pulmonary Stenosis:
Congenital (tetralogy of fallot)
What are the clinical signs of aortic regurgitation?
Exertional Dyspnoea
Thrill on palpation of aortic area
Collapsing Pulse
Wide Pulse Pressure
Early Diastolic murmur at apex (left sternal edge)
What are the clinical signs of mitral stenosis?
AF
Malar Flash
Mid-diastolic murmur (5th ICS on mid-clavicular line - left nipple)
What are the clinical signs of mitral regurgitation?
Asymptomatic for years
Thrill in the mitral area on palpation
Pan-systolic blowing murmur (5th ICS on mid-clavicular line - left nipple)
What clinical signs would you look for if a patient presented with possible infective endocarditis?
Classic Infection Symptoms
New or changing heart murmur
Splinter haemorrhages (thin brown lines along fingernails)
Petechiae
Osler’s nodes (purple nodules on fingers)
Roth Spots (haemorrhages on the retina on fundoscopy)
What are the common pathogens causing infective endocarditis?
1) Streptococci
2) Staphylococcus aureus (IVDU more common)
What key investigations are needed for a diagnosis of infective endocarditis?
Blood Cultures (x3)
Echocardiogram to look for vegetation
(Transoesophageal echo [TOE] more sensitive then Transthoracic echo)
What Abx therapy is needed if infective endocarditis is suspected?
Streptococci:
IV Benzylpenicillin (Vancomycin if penicillin allergy)
Staph:
IV Flucloxacillin
Enterococci:
IV amoxicillin
How do we assess response of abx therapy to infective endocarditis and when is surgical referral needed?
Weekly Echo
ECG
Bloods (ESR,CRP
Surgical Referral:
Heart Failure
Infection hasn’t responded to Abx
Aortic Root abscess
What criteria can be used to diagnose infective endocartitis and how does it work?
Modified Duke criteria (1 major + 3 minor or 5 minors)
Major:
+ve blood cultures
+ve echo
Minor:
Fever
IVDU
Vascular phenomenon (laneway lesions)
Immunological phenomenon (Osler’s nodes, Roth spots)
What are the risk factors for infective endocarditis?
IVDU
CKD
Immunocompromised
Structural Heart Pathology (Congenital, Prosthetic heart valves, pacemakers, valvular heart disease)
What drug treatments are available for mitral regurgitation?
Mitral Regurgitation:
1) Diuretics
ACEi (if ischaemic MR)
Bisoprolol (if LV dysfunction)
Where are murmurs best heard when auscultating?
Aortic Area:
2nd ICS R Sternal border (base of heart)
Pulmonary Area:
2nd ICS L Sternal border
Mitral Area:
5th ICS L Midclavicular line (nipple) (apex)
Tricuspid Area:
5th ICS L Sternal Border
General Heart Sounds (Erb’s Point):
3rd ICS L Sternal border
Which murmur is heard for each valvular heart disease?
AS: Ejection-systolic (crescendo-decrescendo radiating to carotids)
AR: Early diastolic
MS: Mid diastolic
MR: Pan systolic, high pitched
PS: Ejection Systolic
TR: Pan systolic
What does aortic stenosis and regurgitation do to the cardiac muscle?
AS:
LVH (LV fills less)
AR:
LV dilation (LV fills more but cardiac muscle weaker)
What clinical signs/symptoms may appear in hypertension?
Headache
Dizziness
Palpitations
Sweating (phaeocytochroma)
Muscle weakness (hyperaldosteronism)
What are the common causes of secondary hypertension?
ROPED
Renal Disease
Obesity
Pregnant induced/Pre-eclampsia
Endocrine (phaemocytochroma/hyperaldosteronism)
Drugs (alcohol, steroids,NSAIDs)
What investigations should you request for a hypertensive patient?
24 Hour ambulatory BP monitoring if haven’t already done so
Urine Dip (urine albumin:creatine ratio + heamaturia to see kidney function)
Bloods (HbA1c, U+Es, Creatinine, eGFR, Lipid profile)
ECG (echo if LVH)
Fundus Examination (hypertensive retinopathy)
What non-pharmalogical advice is there for hypertension?
Weight Reduction
Reduce salt intake
Reduce alcohol intake
Smoking Cessation
List the 3 common drug class anti-hypertensives and 1 ADR of each?
ACEi (Ramipril) - Cough
Ca Channel Blocker (Amlodopine) - Headaches
Thiazide-like diuretic (Indapemide) - Hyperglycaemia
What are the common complications of untreated hypertension?
IHD
Stroke/ICH
Vascular disease
Hypertensive retinopathy
Hypertensive nephropathy
Vascular dementia
LVH
HF
When are Flame haemorrhages seen?
Fundoscopy of hypertensive retinopathy (emergency)
What are the stages of hypertension?
Stage 1:
> 140/90 (> 135/85 at home)
Stage 2:
> 160/100 (> 150/95 at home)
Severe:
> 180 or > 110
What could you see on physical examination on a hypertensive to as the reason for there hypertension?
Cushing’s syndrome (moon face, buffalo hump, purple striae)
Renal Bruit
Enlarged Kidneys (palpable)
Radio-femoral delay (coarctation)
What are the target blood pressures for different hypertensive patients?
< 140/90
Diabetic, CKD, previous IHD/Stroke:
<135/85
What is the difference between a hypertensive emergency and hypertensive urgency?
Hypertensive Emergency:
High BP associated with a critical event (AKI, MI, Pulmonary oedema)
Hypertensive Urgency:
High BP alone without a critical event, usually associated with severe hypertensive retinopathy
Need to reduce both diastolic to below 110mmHg. Emergency within hours ideally!
How do we treat hypertensive emergency?
ALL IV
1) Sodium Nitroprusside
2) Labetalol
4) Glyceryl Trinitrate (GTN)
5) Esmolol
How do we treat hypertensive urgency?
ORAL
1) Nifedipine + Amlodipine
Amlodipine
Diltiazem
Lisonopril
How does pheochromocytoma present? How do we diagnose it? How do we treat it?
Sweating
Tachycardiac
Headaches
Sustained HTN
Dgx: 24hr urinary collection for metanephrine + CT/MRI may show adrenal tumour(s)
Tx: Resection
HTN control: Phenoxybenzamine (A + B Blocker)
How does Cushing’s present? How do we diagnose it?
Moon Face
Purple Striae
Buffalo Hump
24hr urine collection for cortisol
Dexamethasone suppresion test
Adrenal CT
Surgical Resection of lesion
How does Primary Aldosteronism present? How do we diagnose it?
HIGH BP
High Na + Low K (bloods)
High Aldosterone:renin ratio
Adrenal CT
NICE recommends HTN patients to have investigations to look for end organ damage. What are they?
Urine Dip (Kidney Function)
Bloods (HbA1c, renal function and lipids)
Fundus examination (hypertensive retinopathy)
ECG (LVH)
What HTN patients should be started on ACEi first?
Age < 55yrs
DMII
What HTN patients should be started on a CCB first?
55yrs +
Black African or African Caribbean
When should abx prophylaxis for infective endocarditis be given and who to?
Before dental surgery to:
- Valvular heart disease
- Hypertrophic cardiomyopathy
- Previous infective endocarditis
- Structural congenital heart disease
- Valve replacement (including TAVI)
How does aortic dissection present?
Sudden tearing chest pain > back
Weak/Absent distal pulses
>20mmHg systolic difference in both arms
What investigations are needed if you suspect Aortic Dissection and how do we treat it?
CT angiography of chest, abdo & pelvis
TOE (unstable patients)
CXR (widened mediastinum)
Crossmatch bloods
IV Labetalol
SURGERY
What triad is there in Cardiac Tamponade?
Beck’s triad:
1) Hypotension
2) ^JVP
3) Muffled heart sounds
What’s the management for cardiac tamponade?
1) Give O2
2) Fluids
3) Inotropes
URGENT PERICARDIOCENTESIS
What are the 6 P’s in critical limb ischemia?
Pulseless
Perishing Cold
Palor
Pain
Paralysis
Paraesthetic
How do we investigate Intermittent claudication and what it’s management?
HbA1c (rule out diabetes)
Ankle Brachial Pressure Index
Duplex USS
MR Angiography (if operating)
Smoking cessation
Clopidogrel + Statin
Exercise Programme
How do we investigate critical limb ischemia and what it’s management?
Handheld Arterial Doppler
IV Opioid (analgesia)
IV unfractrionated heparin
SURGICAL REFERRAL
What is the treatment for Takotsubo Cardiomyopathy? What are the relevant investigations findings?
ECG - potential ST elevation
Coronary Angiogram - NORMAL
Supportive (pain management)
What is Brugada Syndrome? How is it treated?
Tachycardia due to irregular electrical activity
ECG - RBBB + ST^ w/ T wave depression in V1-V3)
Implantable Cardioverter Defibrillator (ICD)
What is Dressler’s syndrome? How will it present?
Pericarditis post MI (2/3 weeks)
Fever
Pericardial rub
Widespread saddle ST elevation
How do we treat Dressler’s syndrome?
1) NSAIDs
2) Steroids
3) Periocardiocentesis
What is a bifasicular block?
- Left Axis Deviation
- R BBB
What is a trifasicular block?
- Left Axis Deviation
- R BBB
- PR Interval Elongation
What is the relevance of the M sign in the ECG?
Highest part of the M is where the ectopic beat arises
1st part of M - Atrial
2nd part of M - Ventricle
What investigations do you want to do if someone comes in with palpitations?
U+Es - CKD/hypokalaemia
TFTS - Hyperthyroidism
Echo
Ambulatory BP/ECG/HR
Overnight pulse oximetry - if OSA
