Cardiology Flashcards
What is the pathophysiology of stable angina?
During times of high demand e.g. exercise there is insufficient supply of blood to meet the demand due to narrowing of coronary arteries
What are the 3 typical symptoms of angina?
- Precipitated by physical exertion
- Constricting pain in chest, neck, shoulder, jaws or arms
- Relieved by rest or GTN spray
What is the gold standard investigation for stable angina?
Invasive coronary angiography
What medical management should be given for short and long term symptomatic relief of stable angina?
GTN spray/sublingual tablet, beta blocker or CCB (diltiazem/verapamil)
When are angina patients considered for procedural or surgical interventions and what are they?
If still getting angina pain on two anti-anginals –> interventions
PCI = 1st line
CABG = used in those with more severe/extensive disease
What secondary prevention is required in those with angina?
Aspirin 75mg OD
Atorvastatin 80mg OD
ACE inhibitors (if co-morbidities)
How can you differentiate between STEMI, NSTEMI and unstable angina?
STEMI - ECG changes of ST elevation/new LBBB
NSTEMI = raised troponin with either normal ECG or ST depression/T wave inversion
Unstable angina = normal troponin with either normal ECG or ST depression/T wave inversion
Which coronary artery supplies which area of the heart?
Left coronary artery - anterolateral (I, aVL, V3-V6 )
LAD - anterior (V1-V4)
Circumflex - lateral (I, aVL, V5, V6)
Right coronary - inferior (II, III, aVF)
What is the initial management for all types of ACS?
ECG
Aspirin 300mg
IV morphine if required
Antiemetics if required
GTN spray (as long as BP is ok)
Oxygen - if saturations are low
When is PCI used in management of STEMI?
If presenting within 12 hours of onset and PCI is available within 2 hours of presenting - if not they use thrombolysis
If patient is having primary PCI what should they be given in addition to aspirin for dual anti-platelet therapy?
Prasugrel
If patient is having thrombolysis what should they be given in addition to aspirin for dual anti-platelet therapy?
Ticagrelor
What scoring system is used to determine management in NSTEMI/unstable angina and what results are significant?
GRACE score
3% or less is considered low risk
Above 3% is medium to high risk –> PCI within 72 hours
What secondary prevention is done in those with ACS?
Aspirin 75mg OD for life
Another antiplatelet for 12 months
Atorvastatin 80mg OD for life
Bisoprolol titrated as high as possible
ACE inhibitors titrated as high as possible
PRN GTN spray
What is Dressler’s syndrome?
Occurs 2-3 weeks after acute MI, localised immune response that results in inflammation of the pericardium
ECG will show global ST elevation
Management is with NSAIDs
What are the triggers for acute LV heart failure?
Iatrogenic (aggressive IV fluids), MI, arrhythmias, sepsis, hypertensive emergency
What symptoms/signs are common in acute LV failure?
Acute shortness of breath exacerbated by lying flat and improves on sitting up
Bilateral basal crackles on auscultation of lungs
What investigations would you do in someone with acute LV failure?
ECG, bloods (including BNP), ABG, CXR, echo
What is a normal ejection fraction?
> 50%
What is BNP blood test measuring?
BNP is released from the heart ventricles when cardiac muscle is stretched beyond normal i.e. heart is overloaded
What CXR findings are in keeping with heart failure?
Cardiomegaly
Upper lobe diversion
Bilateral pleural effusions
Fluid in interlobar fissures
Fluid in septal lines (Kerley B lines)
What is the management of someone in acute LV failure?
Sit the patient upright
Oxygen
IV furosemide
May require Inotropes/Vasopressors - initiated by specialist, may require ICU admission
What is heart failure with preserved ejection fracture a result of?
Dysfunction of diastole
What are the common causes for heart failure?
IHD, valvular heart disease, hypertension, arrhythmias, cardiomyopathy
What symptoms are associated with heart failure?
Breathlessness (worsened by exertion), cough (may be frothy white), orthopnoea, paroxysmal nocturanl dyspnoea, peripheral oedema, fatigue
What is the medical management for heart failure?
ACE-i/ARB
Beta blocker
Aldosterone antagonist (if reduced EF and not controlled on the two above)
Loop diuretics - given if symptoms of fluid overload
What are the causes of secondary hypertension?
Renal disease, obesity, pregnancy, endocrine disorder such as Conn’s, drugs such as alcohol, steroids, oestrogen
If a patient has a clinical BP of >140/90 but less than 180/120 what should you do?
24 hour ambulatory BP OR home readings
What investigations are performed to assess for end organ damage in hypertension?
Urine ACR and urine dipstick - assess for kidney damage
Bloods - HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG - for cardiac abnormalities
If under 55 and Caucasian/T2DM what is the first step in managing HTN?
ACE-inhibitor e.g. ramipril
If over 55 or black what is the first step in managing HTN?
Calcium channel blocker e.g. amlodipine
When is an ARB used over ACE inhibitor in HTN?
Black people and those who do not tolerate ACE-i due to dry cough
What is the side effect commonly associated with CCB and what is an alternative?
Ankle oedema
Thiazide diuretic e.g. indapamide
What is the second step in managing HTN?
ACE inhibitor plus CCB
What is the 3rd step in managing HTN?
ACE inhibitor plus CCB plus thiazide like diuretic
What is the 4th step in managing HTN?
ACE inhibitor plus CCB plus thiazide like diuretic plus another based on K
if serum potassium <4.5mmol consider spironolactone
If serum potassium >4.5mmol consider alpha blocker such as doxazosin
What are you aiming for when treating HTN (dependent on age)?
BP <140/90 in under 80s
BP <150/90 in over 80s
What should be done in a patient with clinic BP of >180/120
Same day referral to assess for retinal haemorrhage or papilloedema
In malignant hypertension with signs of end organ damage what should be done?
Start antihypertensive medication ASAP without waiting for results of home BP monitoring
What are the ECG signs associated with AF?
Absent P waves, chaotic baseline, narrow complex tachy, irregularly irregular ventricular rhythm
Why are patients at AF at increased risk of stroke?
The unco-ordinated atrial activity means that blood can stagnate in the atria forming a blood clot –> block cerebral artery –> ischaemic stroke
What symptoms can be assoicated with AF?
Palpitations, SOB, dizziness, syncope, reduced exercise intolerance
What investigations are done in someone with paroxysmal AF?
24 hour ambulatory ECG or cardiac event recorder
What are the principles behind managing AF with rate control?
Slowing the heart down to between 60 and 80bpm extends the time spent in diastole allowing the ventricles to fill with blood
What are the options for rate control in AF?
Beta blockers = 1st line
CCB such as Diltiazem/verapamil = 2nd line
Digoxin = 3rd line
When is rhythm control preferred to rate control in AF?
They have a reversible cause for their AF, new onset AF (within 48 hours), heart failure caused by AF or continuing symptoms despite effective rate control
What are the options for rhythm control in AF?
Cardioversion - immediate if <48 hours of AF, delayed if not for 3 weeks to anticoagulate
Electrical cardioversion - done with synchronised DC cardioversion
Pharmacologically - flecanide or amiodarone
What is the treatment for paroxysmal AF?
Pill in pocket approach with flecanide
When is ablation used in AF?
When drug treatment for rate or rhythm control is not adequate or tolerated
Where is the location of clots most commonly in AF?
Left atrial appendage
What is the 1st line anticoagulation used in AF?
DOAC
Warfarin is only used if DOACs are contraindicated
When should anticoagulation be considered in those with AF?
If score is 1 - consider anticoagulation in men
If score is 2 or more - offer anticoagulation
What is the management for acute AF?
If haemodynamically compromised DC cardioversion (regardless of length of symptoms)
If symptoms <48 hours can try cardioversion
If symptoms >48 hours or unclear rate control and consider cardioversion in 3 weeks (after anticoagulation)
Why does SVT occur?
Due to abnormal electrical signals from above the ventricles - electrical signal re-enters the atria from the ventricles where it then travels through AV node causing another ventricular contraction
What does an ECG look like in SVT?
No p waves
Tachycardia
QRS <120ms (3 small squares)
What is Wolff-Parkinson-White syndrome?
There is an additional pathway that allows electrical activity to pass between the atria and ventricles bypassing the AV node
What are the ECG features of WPW syndrome?
Short PR interval
Wide QRS complex
Delta wave - slurred upstroke in the QRS complex
What is the definitive management of WPW?
Radiofrequency ablation of accessory pathway
What is the stepwise approach to managing SVT?
- Vagal manoeuvres - valsalva manoeuvre, carotid sinus massage
- Adenosine - 6mg –> 12mg –> 18mg
- Verapamil or beta blocker
- Synchronised DC cardioversion
If a patient is in SVT and is unstable what is the 1st line management?
Synchronised DC cardioversion (under sedation)
If a patient with WPW is unstable what is the management?
Procainamide or electrical cardioversion
What causes atrial flutter
Re-entrant rhythm in either atrium, electrical signal goes round and round in self-perpetuating loop
What is the average atrial rate in atrial flutter?
300bpm (not every atrial beat goes into ventricles due to long refractory period in AV node)
What does the ECG of someone in atrial flutter look like?
Repeated P waves - sawtooth appearance on ECG
What is the treatment for atrial flutter?
Rate and/or rhythm control
Requires anticoagulation based on CHADSVASC
What are the shockable cardiac arrest rhythms?
VF and VT
What are the non-shockable cardiac arrest rhythms?
Pulseless electrical activity and asytole
What is the management of someone in VT?
If unstable immediate electrical cardioversion is needed
If stable amiodarone IV is 1st line, lidocaine and procainamide are alternatives
Which bradycardias carry a risk of asystole?
Mobitz type II, complete heart block, ventricular pauses >3 seconds
What is the acute management of unstable bradycardic patients?
IV atropine
Inotropes
Temporary cardiac pacing
What is first degree heart block and what are the signs on ECG?
Delayed conduction through the AV node
PR interval greater than 0.2 seconds (5 small squares)
What is Mobitz type I/Wenkebach phenomenon and what are the ECG findings?
Conduction through the AV node takes progressively longer until it finally fails after which the process restarts
Increasing PR interval until a P wave is not followed by QRS complex
What is Mobitz type II and what are the ECG findings?
Intermittent failure of conduction through the AV node
PR interval remains normal
P waves with an absence of QRS complexes at certain intervals e.g. 2:1
What is third degree heart block?
There is no relationship between P waves and QRS complexes
Bradycardia
What are the ECG features of LBBB?
QRS >120ms
Broad negative QRS complex in V1 (W)
Broad positive QRS complex in V6 (M)
What are the ECG findings in RBBB?
QRS >120ms
Broad positive biphasic QRS complex in V1
Deep S waves in I, aVL and V5-V6
What classifies as prolonged QT?
QTc >440ms in men or >460ms in women
What can prolonged QT progress to if it develops?
Torsades de pointes
How do you manage torsades de pointes?
IV magnesium sulphate (even if they have normal magnesium)
What is cardiac tamponade and what are the symptoms?
Fluid accumulates in the pericardial sac which is large enough to squeeze the heart and affect its ability to function
Hypotension, raised JVP, difficult to auscultate heart sounds
What is the treatment for cardiac tamponade?
Pericardiocentesis
What are the most common causes of pericarditis?
Viral infection and idiopathic
What symptoms are associated with pericarditis?
Sharp central pleuritic chest pain that is worse on lying down better on sitting forward
Low grade fever
What ECG changes are found in pericarditis?
Saddle shaped ST elevation (widespread), PR depression
What is the treatment fir pericarditis?
NSAIDs and colchicine
What is the most common valvular pathology?
Aortic stenosis
What murmur is heard in aortic stenosis?
Ejection-systolic crescendo-decresendo murmur
What other signs are associated with aortic stenosis?
Thrill in aortic area, slow rising pulse, narrow pulse pressure, exertional syncope
What murmur is associated with aortic regurgitation?
Early diastolic soft murmur
What other signs are associated with aortic regurgitation?
Collapsing pulse, wide pulse pressure, heart failure/pulmonary oedema
What murmur is heard in mitral stenosis?
Mid-diastolic low pitched rumbling murmur
What other signs are associated with mitral stenosis?
Tapping apex beat, malar flush, AF
What murmur is associated with mitral regurgitation?
Pan systolic high pitched whistling murmur
What other signs are associated with mitral regurgitation?
Murmur radiates to left axilla, 3rd heart sound, signs of heart failure and pulmonary oedema
What murmur is associated with tricuspid regurgitation?
Pan systolic murmur loudest in tricuspid region
What murmur is heard in pulmonary stenosis?
Ejection systolic murmur loudest in the pulmonary area with deep inspiration
What is hypertrophic obstructive cardiomyopathy associated with?
Sudden onset cardiac death during exertion
What is the management for HOCM?
Beta blockers, surgical myectomy, septal ablation, implantable cardioverted defibrillator
What is the next step in management of acute heart failure that is not responding to IV diuretics?
CPAP
When is warfarin used in preference to a DOAC?
If a mechnical heart valve is present - aim for INR 3-4
By what mechanism can cocaine cause an MI?
Coronary artery spasm
What is the recommended maintenance fluid for someone with cardiac disease?
20-25ml/kg/day
When is a shock given in ALS?
In VF/pulseless VT - single shock followed by 2 minutes of CPR (repeat process)
In ALS if IV access is unsuccessful what route should be used for administering drugs?
Intraosseous route (into bone)
When is adrenaline given in ALS?
Given as soon as possible for non-shockable rhythms, if shockable rhythm give after third shock, repeat every 3-5 minutes
When is amiodarone given in ALS?
Amiodarone 300mg given to patients with VF/VT after 3 shocks have been administered, further dose of 150mg after 5 shocks (lidocaine is an alternative)
When are thrombolytic drugs given in ALS?
If pulmonary embolus is suspected, if given CPR should be continued for 60-90 minutes
A patient presents with fatigue and persistent ST elevation on ECG 6 weeks after an MI - what is the diagnosis?
Left ventricular aneurysm
What is likely to be elevated in a repeat MI?
Creatine kinase
