Cardiology Flashcards
An ECG shows tall R-waves in leads V1 and V2
Posterior MI
Aspirin, statins, bisoprolol - which of these are anti-anginals?
only bisoprolol
Widespread saddle-shaped ST-elevation in all leads - which Post-MI complication is this? How long after an MI would this present?
Dressler’s syndrome, 48h
If you see ST Elevation in Leads I and II, what is it unlikely/likely to be?
Unlikely: MI, it won’t cause elevations in I and II
Likely: pericarditis!
Other than MI, what else can cause rise in troponin? What else will be increased?
Sepsis (myocardial ischaemia from a supply-demand-mismatch secondary to another primary condition)
Lactate
ACS management: ________ should be used with caution if the patient is hypotensive
nitrates
“Suddenly, the patient develops worsening breathlessness. Upon cardiac auscultation, a new pan-systolic murmur is heard” - which post-MI complication is this?
flash pulmonary oedema secondary to new MR
NSTEMI conservative Mx
Aspirin + Ticagrelor + Fondaparinux
Which anti-anginal medication do patients commonly develop tolerance to?
Standard release isosorbide mononitrate
A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound.
left ventricular aneurysm
What do S3 and S4 heart sounds indicate?
The presence of an S3 heart sound suggests the left ventricle is larger than normal (as S3 represents the sloshing of blood into a large ventricle during diastole). The presents of an S4 heart sound suggest that the left ventricle is stiffer than normal (as S4 represents the forceful atrial push of blood against a hard ventricular wall)
A _______________________ will cause persistent ST elevation in V1-6 on an ECG, after PCI
left ventricular aneurysm
A patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sounds.
left ventricular free wall rupture
Angina management: if a patient has an inadequate response to verapamil then adding a ____________ is a suitable next step
long-acting nitrate
Notching of the inferior border of the ribs is present in around 70% of adults with ___________________________
coarctation of the aorta
Warfarin and INR, what will you do in:
1. Major bleeding (e.g. variceal haemorrhage, intracranial haemorrhage)
- INR > 8.0, Minor bleeding
- INR > 8.0, No bleeding
- INR 5.0-8.0, Minor bleeding
- INR 5.0-8.0, No bleeding
- INR > 8, major bleeding: stop warfarin, IV vitamin K, prothrombin complex concentrate/FFP
- INR > 8.0, Minor bleeding: stop warfarin, IV vitamin K, restart warfarin when INR < 5
- INR > 8.0, No bleeding: stop warfarin, oral vitamin K, restart when INR < 5
- INR 5.0-8.0, Minor bleeding: stop warfarin, IV vitamin K
- INR 5.0-8.0, No bleeding: withhold 1 or 2 doses of warfarin
WELLs criteria + what do the different scores mean
DVT signs: 3 pts
alternate Dx less likely than PE: 3
HR > 100: 1.5
immobilisation/surgery: 1.5
previous DVT/PE: 1.5
Haemoptysis: 1
Malignancy: 1
which valvular defect is associated with narrow pulse pressure
AS
Symptomatic bradycardia where atropine fails - next step?
transcutaneous pacing
patient with AAA presents with new diastolic murmur - what does this indicate? what is the tx?
aortic regurgitation = ascending aorta involved
type A - ascending aorta - control BP (IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
most common causative agent in IE
staph aureus
if < 2 months post-valve surgery: staph epidermis
Acute heart failure not responding to treatment - consider ____
CPAP
Massive PE + _____________- thrombolyse
hypotension
what is kussmaul’s signt?
increase in JVP on inspiration
The main ECG abnormality seen with hypercalcaemia is _________
shortening of the QT interval
A.fib that has been present for more than 48h - what is the tx?
the patient should be put on anticoagulants (such as apixaban) for at least 3 weeks and then referred for electrical cardioversion
amiodarone vs flecainide - what is the difference
both are medical cardioversion options for Afib (2nd line to electrical)
flecainide is used if there’s no structural heart disease
When to use the following
IV amiodarone:
IV: adenosine:
IV MgSO4:
IV amiodarone: broad complex tachy
IV: adenosine: narrow complex tachy (after trying vagal manoeuvres)
IV MgSO4: TDP
__________ Should be offered annually for all patients with heart failure
influenza vaccine
___________ Should be introduced first-line in patients with stable impaired left ventricular function
ACEI + BB
______________ Has only been demonstrated to improve mortality in patients with NYHA class III or IV heart failure who are already taking an ACE inhibitor
spironolactone
Concurrent use of ________and omeprazole/esomeprazole can make it less effective
clopidogrel
____________ is the preferred anticoagulant for patients with mechanical valves
warfarin
ALS, notable points
- is rhythm shockable (Vfib/Ttachy) or non-shockable (asystole/pulseless electrical activity)
- chest cimpressions to ventilation 30:2, do while defibrillator is charging
- single shock (or up to 3 successive shocks if happens in hospital) followed by 2 min of cpr
- Give adrenaline 1mg after third shock (contnue every 3-5 min)
- amiodarone 300mg after 3 shocks (give 150mg after 5 shocks)
lidocaine is an option is amiodrone is unavailable
IV amiodarone used for which type of tachycardias? Whats the other option?
broad
adenosine for narrow
IB beta-blockers if a fib
CCB for narrow-complex if adenosine not tolerated (like in asmatics)
_________presents with ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness. Troponin raised.
myocaditis
reduced contractile strength of heart–> can present as new-onset HF
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - add a
an alpha- or beta-blocker
if K+ < 4.5, add spironolactone instead
____________________is used first-line to prevent angina attacks
A beta-blocker or a calcium channel blocker
A man presents with central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated -
Dressler’s syndrome
Dressler’s syndrome (postmyocardial pericarditis) is secondary pericarditis that may occur with or without pericardial effusion. The pathophysiology is thought to be due to the detection of antibodies from damaged myocardial tissue, which causes an immune response. The patient in the vignette has chest pain, fever, a raised ESR, and ECG findings of widespread concave ST-elevation and PR depression with reciprocal ST depression and PR elevation in aVR, which is consistent with pericarditis.
cardiac tamponade - triad?
- raised JVP
- reduced blood pressure
- muffled HS
Pt has suspected NSTEMI within 6 days of another one - what marker will you check?
creatine kinase myocardial band (CKMB)
trops are elevated for up to 10 days, CKMB only for 3-4
Iron defiency anaemia vs. anaemia of chronic disease:
TIBC is high in IDA, and low/normal in anaemia of chronic disease
Infective endocarditis in intravenous drug users most commonly affects _______
the tricuspid valve
what is C/I in broad complex tachycardia?
verapamil, can precipitate arrest
A 14-year-old boy presents to the Emergency Department as he is unable to control his facial muscles and arm movements. For the last 5 weeks, following a throat infection, he has been experiencing ongoing fever, worsening shortness of breath and joint pains, mainly in his legs which have not been effectively managed. What is the most likely cause of the patient’s recent symptoms?
Sydenham’s chorea is a late complication of rheumatic fever
how does rheumatic fever come about?
it is an immunological reaction to a recent (2-4 weeks ago) strep pyogenes infection
what is the Dx criteria for RF?
evidence of recent strep infection + 2 major/1 major and 2 mino criteria
What are the major criteria for RF?
- erythema marginatum ( bright pink or red circular lesions which have sharply-defined borders and faint central clearing.)
- Sydenham’s chorea: this is often a late feature
- polyarthritis
- carditis and valvulitis (eg, pancarditis) [new regurgitant murmur]
- subcutaneous nodules
Diastolic murmur + AF → ?
mitral stenosis
The relation with atrial fibrillation lies in the fact that mitral stenosis causes an increase in left atrial pressure, leading to an increase in the size of the left atrium, which in turn leads to atrial fibrillation.
Cardiovascular disease: atorvastatin ____mg for primary prevention, ____mg for secondary prevention
20mg
80mg
If new BP >= 180/120 mmHg + no worrying signs then the first step is
urgent investigations for end-organ damage
ECG change in moitral stenosis
P mitrale
most likely cardiac sequala for hyperthyroidism?
high output cardiac failure and atrial fibrillation
acute and chronic changes in ECG after MI
Immediate changes
seen on an ECG following a STEMI are hyperacute T waves and then
ST elevation (or new-onset left-bundle branch block). T-wave inversion
and pathological Q waves develop over the next few days.
Tx pathway for tachycardias
complication of right coronay infarct?
1st degree AB block as it supplies AV node
damage to which vessel (in MI) will cause:
1. AV block
2. left ventricle wall thrombus
3. RBBB
4. ventricular free wall rupture
- AV block: RCA
- left ventricle wall thrombus: LAD
- RBBB: LAD
- ventricular free wall rupture: LAD
___________ becomes louder during inspiration, unlike mitral regurgitation
Tricuspid regurgitation
ALS
- is rhythm shockable?
- shockable rhythms: ventricular fibrillation, pulseless VT
- non-shockable rhythms: PEA, asystole - Delivering shocks
- in non-hospital setting: 1 shock + 2 min of CPR [30:2]
- in hospital setting: 3 shocks + CPR - Drugs
- adrenaline 1mg ASAP for non-shockable rhythms
- adrenaline 1mg after 3 shocks for Vtachy/Vfib
- repeat 1mg adrenaline every 3-5 min
- give 300mg amiodarone to Pts with VF/Vtachy after 3 shocks
- give a further 150mg dose after 5 shocks
- lidocaine is alternative for amiodarone
___________presents with ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness
Myocarditis
____________ is the first line investigation for stable chest pain of suspected coronary artery disease aetiology
Contrast-enhanced CT coronary angiogram
bizarre, wide, inverted T-waves can be seen in ____________
Stokes-Adams attacks
A 74-year-old man presents to the emergency department with episodes of haemoptysis, dyspnoea, and palpitations over the past month. On examination, he has an irregularly irregular heartbeat and a mid-diastolic murmur.
Given the likely diagnosis, what would indicate that the leaflets still have some mobility?
This is a two-part question. The first step is getting the diagnosis resulting in the patient’s symptoms. He has presented with haemoptysis, dyspnoea, an irregularly irregular pulse - likely secondary to atrial fibrillation, and a mid-diastolic murmur. These symptoms are all suggestive of mitral stenosis.
In mitral stenosis, an opening snap indicates the leaflets still have some mobility
Persistent ST elevation following recent MI, no chest pain -
left ventricular aneurysm
Following an ACS, all patients should be offered:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Acute heart failure with hypotension -
inotropes be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
Patient factors favouring rhythm control include:
Age <65 years
First presentation of AF
Symptomatic.
e- abnormalities that cause long qt
hypocalcaemia, hypokalaemia, hypomagnesaemia
__________ should be considered for Afro-Caribbean patients with heart failure who are not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy
Hydrazine and nitrate
to be given ivabradine as 3rd line for HF your HR must be
> 75
If new BP >= 180/120 mmHg + __________________then admit for specialist assessment
new-onset confusion, chest pain, signs of heart failure, or acute kidney injury
Atrial fibrillation with bundle branch block is the most likely cause of an irregular broad complex tachycardia in a stable patient
MS - choice of Tx?
Percutaneous mitral commissurotomy is the intervention of choice for severe mitral stenosis
Ibuprofen and diclofenac are both non-steroidal anti-inflammatory drugs that are avoided in those with ACS.
This is because they will be given an array of antiplatelet drugs, which can interact with NSAIDs to precipitate bleeding (e.g. aspirin, ticagrelor).
summarise ALS
Shockable - VF/VT (+ pVT)
Non-shockable - asystole/PEA
Witnessed - 3 stacked shocks
Non-witnessed - 1 shock
Non-shockable - adren 1mg 1:10,000 immediately, repeat every 3-5 mins (i.e. every other cycle); amiodarone does NOT play a role in non-shockable
Shockable - 1mg adren 1:10,000 after 3rd shock (and every 3-5 mins thereafter); 300mg amiodarone after 3rd shock, 150mg after 5th shock
If ?PE, thrombolyse (and you’re committing to do CPR for a minimum of 60 minutes afterwards)
bradycardia steps in Tx
- atropine 500mch IV
- atropine up to 3mg
- transcutaneous pacing
- isoprenaline/adrenaline
- transvenous pacing
It is important to consider the 8 reversible causes of cardiac arrest before calling time of death. These can be remembered by the 4Hs and 4Ts:
Hypothermia
Hypoxia
Hypovolaemia
Hypokalaemia / hyperkalaemia / hypoglycaemia
Tension pneumothorax
Toxins
Tamponade
Thrombosis
If intravenous access is difficult or impossible, consider
the intraosseous (IO) route during a cardiac arrest
systolic murmur + hypotension post MI?
mitral regurgitation
How to differentiate the different post-MI complications
most common: V.fib –> cardiac arrest
[pericarditis]
- within 48h: pericarditis
- in 2-6 weeks: dressler’s syndrome
Left ventricular aneurysm: persistent ST elevation [needs anticoagulation as thrombus can form within stroke]
Left ventricular free wall rupture: acute HF secondary to cardiac tamponade. Happens 2w after MI.
VSD: pan-systoolic murmur
MR: ischaemia/papillary muscle rupture. Acute hypotension + flash pulmonary oedema.
which anti-hypertensive drug can worsen glucose tolerance?
Thiazides can worsen glucose tolerance
Mitral stenosis patients who are asymptomatic - Mx?
are generally monitored and given medical therapy rather than having percutaneous/surgical intervention
features of patent ductus arteriosis?
- continuous machinery murmur
- heaving apex beat
- wide pulse pressure
- left subclavicular thrill
What is bisferiens pulse + what is associated with?
two strong systolic peaks separated by a midsystolic dip
aortic regurgitation and hypertrophic cardiomyopathy
Patients with MI secondary to cocaine use should be given_______as part of acute (ACS) treatment
IV benzodiazepines + glyceryl trinitrate
R waves in V4,V5 + deep S waves in V1,V2 + T-wave inversion in V5, V6 =
left ventricular hypertrophy
which NSAID is contraindicated in cardiovascular disease
Diclofenac
