Cardiology Flashcards
How elevated are limb and chest leads in a STEMI?
Limb = 1mm , Chest = 2mm
What will hs-TnI levels be in a STEMI?
> 100ng/L
When is Troponin I released?
By cardiac myocytes in response to necrosis ( infarction )
What changes on ECG are seen in a NSTEMI?
ST Segment depression and T wave inversion , or may be normal
What will hs-TnI levels be in a NSTEMI?
> 100ng/L
What will hs-TnI levels be in Unstable Angina?
In the normal reference range
What should be measured in STEMI patients?
Creatinine Kinase and hs-TnI
After how long do hs-TnI levels rise following myocardial damage?
3-4 hours
For how long following a STEMI/NSTEMI can hs-TnI levels stay elevated in patients?
2 weeks
What hs-TnI level suggests myocardial necrosis in males?
> 34ng/L
What hs-TnI level suggest myocardial necrosis in females?
> 16ng/L
At what times is hs-TnI levels taken ?
On arrival and an hour later , an increase of 5ng/L or higher indicates an ACS
What other conditions cause a raised hs-TnI level?
Advanved renal failure.
Aortic stenosis.
Stroke
Large pulmonary embolism
Aortic dissesction
Sepsis
Severe congestive heart failure Hypertrophic cardiomyopathy
Myocarditis
Takotsubo cardiomyopathy
Prolonged tachyarrythmias
Malignancy
What do NSTEMs or Unstable Anginas look like on ECG?
Transient ST segment depression
T wave inversion/flattening
No change
What is the Digoxin Effect?
At supratherapeutic doses , a downsloping Nike tick esque ST segement depression can appear
What conditions can mimic a STEMI on ECG?
Early repolarisation ( seen in young, athletic and some Afro-Carribeans )
Pericarditis ( Concave elevation )
Brugada Syndrome
Takotsubo Cardiomyopathy ( ‘Broken Heart Syndrome’ - severe emotional stress reaction )
What is the acute management for a STEMI?
I.V access
Morphine and Anti Emetic
Oxygenation ( Only if hypoxic , Sats >94% )
Aspirin 300mg loading dose , 75mg o.d for life
Antiplatelet- Prasugrel ( If <75 and >60kg with no prior TIA/Stroke ) OR Clopidogrel 600mg LD , 75mg o.d ( If don’t fit criteria for Prasugrel )
PCI in Cath Lab
Full biochemical screen ( FBC, Lipid Profile and Random Glucose )
MOANA mnemonic
What is the long term management plan of a STEMI?
Dual-Antiplatelet Therapy ( Aspirin 75mg + Clopidogrel )
Statin ( Atorvastatin 80mg od)
ACEi ( Ramipril 2.5mg od )
B-Blocker ( Bisoprolol 1.25mg od )
Control of diabetes - HbA1c target is >7% DMT1 and 6.5-7.5% DMT2
Control of hypertension
Smoking cessation
What is the management plan for a NSTEMI/ Unstable Angina?
Morphine and Anti-emetic
Aspirin 300mg , 75mg od
Fondaparinuex
Grace Score
If Risk >3% give Ticagrelor 180mg LD, 90mg bd and send for PCI
What is Stable Angina?
Chest pain on exertion
What are the risk factors for Coronary Artery Disease?
Modifiable-
Smoking
HTN
Diabetes
Hypercholesterolemia
Non-Modifiable-
Age
Male
Family History
What investigations do you do for Stable Angina?
FBC inc HbA1c
Full Lipid Profile
ECG
What is the treatment for Stable Angina?
B-Blocker first line
Aspirin 75mg od
Use when needed ; Sublingual GTN Spray
What is the second line for Stable Angina?
CCB
Ranolazine 375mg bd , GFR must be >30
What is Dressler’s Syndrome?
Autoimmune perdicarditis following a myocardial infarction.
Symptoms- chest pain worse on inspiration, dyspnoea, fever
Raised ESR and WCC
What is Hypertrophic Obstructive Cardiomyopathy?
A condition causing ventricular arrythmias that can lead to sudden cardiac death in young athletes, can happen at rest or when exercising
What anticoagulation is preferred after mechanical heart valve surgery ?
Warfarin
What is Beck’s triad? ( Cardiac tamponade )
Falling BP
Rising JVP
Quiet/ Muffled Heart Sounds
How does Aortic regurgitation present?
Dyspnoea
Orthopnea
Paroxysmal Nocturnal Dyspnoea
What are signs of Aortic Regurgitation on examination?
Wide Pulse Pressure
Quincke’s Sign
De Musset’s sign
Early diastolic murmur, loudest on expiration
What is Quincke’s Sign?
Nail Bed Pulsation
What is the best option for secondary prevention of a stroke with Atrial Fibrillation?
DOAC e.g Apixaban , 2 weeks following event
What is De Musset’s sign?
Head bobbing in time with heart beat
What is the most common change seen on ECG with a PE?
Sinus Tachycardia
Commonly said to be S1Q3T3 , but this is actually very rare
If a patient is in V Fib what do you do?
Call 2222 in hospital
Start CPR
Deliver shock on defibrillator , then continue CPR for 2 minutes after shock is delivered and assess again
What is the PESI score?
Pulmonary Embolism Severity Index - helps to identify if PE patient can be treated as outpatient with DOAC
What is the treatment for sinus bradycardia with haemodynamic instability?
IV Atropine 0.5 mg push every 3 to 5 minutes up to 3 mg total.
What are the non-shockable rhythms?
Pulseless Electrical Activity
Asystole
What is the treatment for PEA?
Start CPR 30:2
1mg IV Adrenaline , can repeat every 3 to 5 mins
What is the first line treatment for acute Pericarditis?
NSAID and Colchicine( anti-inflammatory)
What is a normal variant on ECG in athletes?
Mobitz Type 1 ( also known as Wenkebach phenomenon )
What are some non cardiac causes of chest pain?
GORD
Costochondritis
Pulmonary Embolism
Pneumothorax
Pneumonia
What are the clinical stages of Hypertension?
These are all clinical readings
Stage 1 > 140/90 mmHg
Stage 2 > 160/100 mmHg
Stage 3 > 180mmHg systolic or >110mmHg diastolic
What should be done if Clinical BP is >140/90 mmHg?
Ambulatory BP readings should be taken
At least 2 readings a day for 7 days , then create an average to see if hypertension should be diagnosed
What are some secondary causes of HTN ?
Cushing’s Syndrome
ADPKD
Renal Artery Stenosis
Diabetic Nephropathy
Pregnancy
What investigations should be done if a patient is diagnosed with HTN?
Check for end organ damage
Bloods -
HbA1c - check for diabetes
U&Es + GFR + Creatinine - check kidney function
LFTS - check liver
Lipid profile - check for hypercholesterolaemia
Urine sample
Albumin : Creatinine Ratio - check kidney function
Urinalysis - for haematauria
Fundoscopy - small vessel damage
ECG - check for any heart abnormalities that could be causing it
What score should be calculated following a diagnosis of HTNa and what does it predict?
QRISK - likelihood of a cardiovascular event in the next 10 years
Score of >10% should be put on a statin
What is the target blood pressure for people with low-moderate QRisk score?
<140 mmHg systolic
What is the target blood pressure if patient has diabetes, previous TIA/Stroke, Ischaemic Heart Disease or CKD?
<130/80 mmHg
What is the target blood pressure for those over 80?
<150/90 mmHg
What are some lifestyle modifications for HTN?
Weight loss
Reduce salt intake
Minimise alcohol intake
Smoking cessation
What is the first line treatment for HTN aged <55?
And 2 examples
ACEi
Ramipril
Lisinopril
What is the first line treatment for HTN for those who are over 55 or Afro-Caribbean? 2 examples
Calcium Channel Blocker
Amlodopine
Nifedipine
What are the main side effects of an ACEi ?
Dry cough
Angioedema
Hyperkalaemia
What are the main side effects of CCBs ?
Ankle swelling
Flushing
Headaches
What should a patient who can’t tolerate an ACEi be given?
ARB
Candesartan
Losartan
What should a person who is on both ACEi and CCB be given if their BP is still high?
Thiazide- Like diuretic
Bendroflumethiazide
Indapamide
What is the side effects of Thiazide-Like Diuretics?
Hypokalaemia
Hypernatremia
Gout
What can you add if ACEi, CCBs and a Thiazide don’t help control the HTN?
Spironolactone
a-blocker
b-blocker
What are the side effects of Spironolactone?
Hyperkalemia
Hypontraemia
Gynecomastia
What is an Example of an a-blocker?
Doxazosin
What is an example of a b-blocker?
Bisoprolol
Propanolol
What are side effects of b-blockers?
Vivid dreams/ nightmares
Bradycardia
Dizziness
What types of b-blockers are contraindicated in patients with asthma?
Non cardio-selective ones, e.g Propanolol
Causes bronchospasm
Bisoprolol IS safe
What is a hypertensive crisis?
An increase in blood pressure which if sustained can lead to irreversible end organ damage
What types of end organ damage can a hypertensive crisis cause ?
Encephalopathy
Left Ventricular Failure
Aortic Dissection
Unstable Angina
Renal Failure
What are the two types of hypertensive crisis?
Urgency
Emergency
What is the difference between an urgency and an emergency hypertensive crisis?
Urgency will cause end organ damage in days
Emergency will cause end organ damage in hours
What is the management for an urgency hypertensive crisis ?
Reduce diastolic to 110mmHg in 24 hours
What is the management for an emergency hypertensive crisis?
Reduce diastolic to 110mmHg in 3-12 hours
What is the treatment for hypotensive urgency?
Nifedipine 20mg MR b.d
Amlodopine 10mg o.d for 3 days
Want to gradually increase BP over 48-72 hours to 100mmHg
What does the MR abbreviation means ?
Modified Release
Drug effect is delayed after dose
What is the classic triad of Phaeochromocytoma?
Headache
Sweating
Episodic tachycardia
What type of HTN is indicative of Phaeochromocytoma?
Paroxysmal
What test confirms Phaeochromocytoma?
24 hour urine sample - test for plasma fracciones metanephrines and catecheloamines
CT/MRI to detect any adrenal tumours
What is the treatment for a Phaechromocytoma?
Alpha-adrenergic blockade ( Phenoxybenzamine 10mg o.d , increased by 10-20mg every few days as needed
Then resection of the tumour
Then Beta-adrenergic blockade 2-3 days post-op
Why must B-adrenergic blockade NEVER be started before Alpha-adrenergic blockade?
Can cause a hypertensive crisis
What is Cushing’s Syndrome?
Excess cortisol levels
What is the typical appearance with Cushing’s Syndrome?
Purple striae
Moon shaped face
Dorsal fat pad
What investigations should be done for suspected Cushing’s?
Bloods - to check for hyperglycemia
24 hour urine sample - 3x elevated cortisol levels
Low-dose Dexamethasone Suppression Test
What is the Low-Dose Dexamethasone Suppression Test?
Patient is given Dexamethasone ( mimics cortisol )
In normal people, the elevated cortisol would cause inhibition of ACTH release. In people with Cushing’s, ACTH levels will remain high, therefore cortisol levels will remain high. This is a positive Cushing’s Test
What are the possible causes for Cushing’s Syndrome ?
Adrenal Tumour (secretes cortisol)
Pituitary Tumour (Cushing’s Disease)
Ectopic ACTH Releasing Tumour ( normally SCLC or bronchial carcinoid tumour)
What is the test for Primary Aldosteronism?
Aldosterone : Renin
Renin will be low
What is the most common cause of Heart Failure?
Ischaemic Heart Disease
What are the causes of Heart Failure?
Ischaemic Heart Disease
Hypertension
Valvular disease
Atrial FIbrillation
Chronic Lung Disease
Cardiomyopathy( Hypertropic, Dilated, Tatkutsubo)
HIV
What are the two types of Heart Failure?
HFrEF (systolic problem)
HFnEF (diastolic problem)
What are bad prognostic features for heart failure?
Severe fluid overload
Very high NT-proBNP levels
Severe renal impairment
Elderly
Co-morbidity
What investigations do you do for someone with suspected Heart Failure?
Bloods - FBCs, LFTs, TFTs, RFTs
Ferritin and Transferrin ( if patient is young and haemochromatosis is suspected)
NT-proBNP- to see LV function
Below what NT-proBNP levels can you exclude heart failure?
Below 100ng/L
What are signs of heart failure on a CXR?
ABCDE
Alveolar Oedema
air Bronchograms
Cardiomegaly
perihilar shaDowing
pleural Effusion
What investigations do you do to check LV function?
Echo
Cardiac MRI
What is the pharmacological management for HF?
Loop Diuretic - Furosemide 40-500mg o.d
ACEi
ANRI (if HFrEF)
B-Blockers
What should be used if a patient can’t tolerate ACEi or ARBs
Hydralazine and Isosorbide Mononitrate
What should be used if a patient can’t tolerate b-blockers?
Ivabradine
How do Nitrates help heart failure?
They reduce preload, pulmonary oedema and ventricular size
What can be done for Heart Failure when pharmacological therapies don’t work?
Pacemaker can be fitted
What is an ICD?
Implantable Cardiac Defibrillator
They prevent sudden cardiac arrest, don’t control symptoms
What are surgical interventions for valvular disease?
Replacement
Repair
What can untreated valve disease lead to?
Ventricular dysfunction e.g heart failure, pulmonary hypertension
What is the triad of symptoms of Aortic Stenosis?
Dysopnea
Chest pain
Syncope
What are the causes of Aortic Stenosis?
Congenital Bicuspid Valve
Age related degeneration (calcified deposits)
Rheumatic fever
Chronic Kidney Disease
What is the murmur heard in aortic stenosis?
Ejection systolic radiating to the carotids, best heard in the 2nd ICS right sternal border
How is the severity of aortic stenosis assessed?
Echocardiogram
Determines mean pressure gradient, peak pressure gradient and aortic valve area (higher area is more severe as there is less space for blood to go through)
What are the indications for aortic valve replacemement?
Symptomatic
Asymptomatic w/ severe LV dysfunction
Asymptomatic w/ abnormal exercise test
Asymptomatic at the time of another cardiac surgery
What is a TAVI?
Transcatheter Aortic Valve Implantation
A replacement valve is put in through the femoral artery
Considered in very old or comorbid patients
What does aortic regurgitation lead to?
Increased LV load , leading to LV hypertrophy
Heart Failure
What is the usual presenting symptom of aortic regugitation?
Exertional dysopnea
What are the causes of aortic regurgitation?
Idiopathic dilatation of aorta ( causes the leaflets to get pulled apart)
Infective Endocarditis
Congenital abnormality ( bicuspid valve)
Calcific degeneration
Rheumatic Fever
Marfan’s Syndrome
What murmur is heard in aortic regurgitation?
Early diastolic decrescendo blowing murmur best heard at the left sternal border 2nd ICS
What are some signs associated with Aortic Regurgitation?
De Musset’s sign
Quinke’s sign
Collapsing pulse
What is De Musset’s sign?
Head bobbing
What is Quinke’s sign?
On pressing lightly on the nail bed to blanch it , visible red systolic pulsations are seen
What is the standard treatment for Aortic Regurgitation?
Afterload reduction through use of ACEi
What is the investigation for Aortic Regurgitation?
Echocardiogram
What are the indications for surgery with AR?
Symptomatic
Asymptomatic w/ early LV dysfunction
Asymptomatic w/ Aortic root dilation of >5.5cm (>4.5cm if they have Marfan’s or congenital biscuspid valve)
What are the causes of Mitral Regurgitation?
Mitral valve prolapse
Rheumatic heart disease
Ischaemic heart disease
Infective Endocarditis
Collagen Vascular Disease ( SLE, AnkSpond, RA)
Certain drugs
Secondary to LV Hypertrophy , causing annulus to dilate, pulling leaflets apart
What is the mitral valve annulus?
It’s the anatomical junction between the left atrium and left ventricle. It serves as an attachment site for the leaflets
In what type of people is Mitral Valve prolapse more common?
Marfan’s
People with Pectus Excavatum
What aeteologies are more likely to cause severe and acute MR?
Ruptured Chordae
Ruptured Papillary Muscle
Infective Endocarditis
What is the description of the Mitral regurgitation murmur?
Pansystolic blowing murmur bets heard in 5th ICS mid-clavicular line, radiates to the axilla
What investigations are used for mitral regurgitation?
Echocardiogram
When is surgery indicated in mitral regurgitation patients?
Symptomatic
Asymptomatic a/ mild-moderate LV dysfunction
What is the standard treatment for mitral regurgitation?
Diuretics
What medical treatment is used is mitral valve dysfunction is functional or Ischaemic ?
ACEi
What treatment is used if mitral valve dysfunction also presents with LV dysfunction?
ACEi and b-blockers
What predisposes people to infective endocarditis?
Mitral Valve Prolapse
Prosthetic valves
Rheumatic Heart Disease
Valvular Disease
Congenital Heart Diseases
What are the three most common causative organisms in infective endocarditis?
Viridans Streptococci (50%)
Staphylococcus Aureus (20%)
Enterococcus (10%)
What is most commonly the causative organism in IVDU with endocarditis ?
Staph Aureus
What is early post-operative IE usually caused by?
Coagulase Negative Staphylococcus
What is late post-operative IE caused by?
Viridans Streptococci, Staph Aureus, Coagulase-negative Staphylococci
What are around 2-10% of IE cases caused by?
Fungi
What organism has the highest mortality rate in IE?
Fungi
What predisposes people to fungal infective endocarditis ?
Immunosupression
IVDU
Cardiac Surgery
Antimicrobial drugs
IV feeding
What investigations are needed in IE?
At least 3 blood cultures , 6 if possible from different sites
ECHO
Why is it beneficial to delay antibiotics if patient is stable in IE?
Makes it easier to identify a causative organism on blood culture
What are the two types of ECHO?
Transthoracic Echocardiography
Transoesophageal Echocardiography ( TOE ) detects 95% of vegetations and is more sensitive
What are the major criteria to diagnose IE?
Positive blood cultures
Endocardial involvement
Postive ECHO
NEW valvular regurgitation
Dehiscence of prosthesis ( deatatchment of prothesis )
What are the minor criteria to diagnose IE?
IVDU
Predisposing Cardiac abnormality
Pyrexia
Embolotic event
Vasculitic event
Blood cultures suggestive
ECHO suggestive
What is the Antimicrobial treatment for streptococci IE?
IV Benylpenicillin and low dose Gentamicin
Vancomycin in penicillin allergy
What is the antimicrobial treatment for Enterococci?
IV Amoxicillin and low dose Gentamicin
Vancomycin if penicillin allergy
What is the antimicrobial treatment for staphylococcus?
Flucloxacillin and low dose Gentamicin
Vancomycin if Penicillin allergy
How do you monitor response to therapy? ( Infective Endocarditis )
ECHO once a week ( assess vegetation size)
ECG twice a week ( assess conduction disturbances )
Blood Test twice a week
What are indications for surgery in infective endocarditis?
Cardiac failure
Valve dehiscence
Not responding to antimicrobials
Relapse
Systemic embolism
Coxiella Burnetii or fungal infection
Para Alvar infection
Sinus of Valsava aneurysm
Valve obstruction
How are bradycardias/ tachycardias defined ?
By the pacemakers at fault e.g Sinus or AVN
What are the types of sinus node dysfunction?
Sinus bradycardia
Sick sinus syndrome
Sinus arrest
What are some causes of Sinus Bradycardia?
Medications
Hypothyroidism
Hypothermia
Sleep apnoea
Rheumatic fever
Viral myocarditis
Amyloidosis
Haemachromatosis
Pericarditis
For what reason would a pacemaker be fitted for someone with Sinus Bradycardia?
If they are symptomatic
What is first degree AVN block on an ECG?
A single PR interval >0.2s (one big box)
What drug could be the cause for First Degree AVN block?
Digoxin toxicity
What does second degree AVN block , Mobitz Type 1 look like on the ECG?
Progressive lengething of PR interval , followed by a dropped QRS
What does second degree AVN block look like on the ECG?
Constant PR interval
Failure of P wave to be conducted by ventricles
What is third degree Heart Block.?
When there is complete disassociation between P waves and QRS complexes
What is a block when it’s above the AVN called?
Narrow complex escape
What is a block called when it’s below the AVN ?
Broad complex escape
What are some causes of complete heart block?
Digoxin toxicity
Following a STEMI
Severe Hyperkalaemia
What treatment is important within the first 24 hours for patients with complete heart block?
Urgent permanent pacing wire otherwise it is unlikely they will ever recover conduction
What is the most common arrhythmia ?
Atrial fibrillation
What is the typical history of a patient with AF
Brief paroxysms of increasing duration, leading to persistent AF
Commonly have no or atypical symptoms
What are the complications of Atrial Fibrillation?
Embolic stroke
Cardiac instability
Death
If the atrial fibrillation has symptoms what can they be ?
Dysopnea
Palpitations
Syncope
Chest pain
What investigations are done for atrial fibrillation?
Manual pulse checks
ECG
What investigations is needed if paroxysmal AF is suspected?
Short term cardiac monitoring ( for 24 hours )
What are some examples of prolonged cardiac monitoring?
Prolonged Holter monitor
Implantable Loop recorder
When is an ECHO indicated for AF?
Suspected structural heart disease
When cardioversion is being considered
What are the three bases of management of atrial fibrillation ?
Anticoagulation (DOACs )
Rate control ( if LVEF < 40% b-blocker and Digoxin , if >40% add Diltiazem)
Rhythm control ( Flecainide or Electrical Cardioversion)
What is the score used to quantify the risk of bleeding with A Fib?
ORBIT score
What do the different scores of the CHAD2DS2VaSc scores indicate?
0- low risk
1- anticoagulant should be considered
2 or more - significant risk , anticoagulant offered
What does the HAS-BLED score indicate?
Likelihood of a major bleed , it’s used see the risk vs reward of offering anticoagulants
ORBIT score is now recommended instead
What is DOACs method of action?
Inhibit Factor Xa e.g ApiXAban , RivorAXaban
What is the most common types of Supraventricular Tachycardia?
AVNRT ( AV Nodal Re-Entry Tachycardia )
AVRT ( Atrio-Ventricular Re-Entry Tachycardia )
How can Supraventricular Tachycardias be treated?
By transiently blocking AV Nodal conduction
What is the first line treatment in stable patients with SVTs?
Vagal Manouvres - they slow AV node conduction
What are three examples of a Vagal Manouvre?
Valsava manoeuvre
Breath holding
Carotid massage
What is second line treatment for SVTS?
IV Adenosine
CCB
How should Adenosine be treated?
Rapid IV Bolus followed by a saline flush into the ante cubital fossa , 6mg stat , then 12mg if not working , then a further 12mg again if not working
Followed by a long flush with 0.9% sodium chloride
What are common side effects of Adenosine ?
Chest pain
Transient hypotension
Flushing
In which type of patients should Adenosine be avoided in?
Those with significant reversible airway disease
If the first and second line treatment for SVTs don’t work what is the new working diagnosis?
Atrial tachycardia
Atrial flutter
What treatment should be used in patients who are hypotensive , have pulmonary oedema, have chest pain with ischaemia have?
Synchronised Cardioversion ( 150J ) following sedation
What does Ventricular Tachycardia follow sometimes?
A STEMI
What is indicated for patients with sustained VT who are haemodynamically compromised?
Cardioversion ( 150-200j shock)
Which diuretic should be avoided in patients with gout?
Thiazide-like - as it can exacerbate this condition
What features of a tachyarrhythmia would make you perform DC cardioversion as treatment?
Shock ( systBP < 90mmHg )
Syncope
Myocardial ischaemia
Heart failure
What is first line treatment for Atrial FIbrillation? What if that drug isn’t tolerated/contraindicated in the patient?
First Line - DOACs
If contraindicated/not tolerated - Warfarin
A patient presents with acute onset of severe, tearing chest pain radiating to the back, an absent left femoral pulse and neurological deficits, what is the likely diagnosis?
Aortic dissesction
What is the treatment for Stable Angina?
First Line - B-Blocker/CCB ( Nifedipine if combined)
Sublingual GTN Spray
If not controlled by combination use
a long-acting nitrate or
ivabradine or
nicorandil or
ranolazine.
What is the first line treatment for Heart Failure?
ACEi and B-Blocker
What is the second line treatment for Heart Failure?
ACEi and B-Blocker
AND
Aldosterone Antagonist e.g Spironolactone
What is the treatment for acute pulmonary oedema?
IV Furosemide
What score must be calculated in individuals with and NSTEMI?
GRACE score
A GRACE score above what percentage means a patient requires a coronary angiography with follow up PCI if required?
Above 3%
What type of antibiotic can cause Torsades de Pointes ?
Macrolides
What are 3 examples of Macrolides?
Azithromycin
Clarithromycin
Erythromycin
What are you likely to see on ECG with a patient with Pericarditis?
Saddle-shaped ST Elevation
How does Pericarditis pain present?
Retrosternal sharp, stabbing chest pain
Pain is worse when lying flat and better on sitting up
Pain is worse on deep breaths
What does torsades de pointes look like on an ECG?
A type of polymorphic ventricular tachycardia. It looks like oscillations around the isolectric line
What are some congenital causes of prolonged QT syndrome?
Jervell-Lange-Nielson Syndrome ( affects K+ channels leads to hypokalaemia + deafness )
Romano-Ward syndrome ( same thing but no deafness )
What drugs are causes of prolonged QT syndrome?
Amiodarone
Sotalol
Tricyclic antidepressants ( Amitryptyline )
Citalopram
Haloperidol
Ondansetron
Macrolides
What are some other causes of prolonged QT syndrome?
Electrolyte disturbances - hypocalcaemia, hypokalaemia, hypomagnesaemia
Acute Myocardial Infarction
Myocarditis
Hypothermia
Sub-arachnoid Haemorrhage
What is the first line investigation for suspected coronary artery disease aetiology?
CT Coronary Angiography
What is the treatment for Torsades de Pointes?
IV Magnesium Sulphate
A PE is suspected . A 2-level PE Wells score is 3 and D-dimer is negative, what is the next step in management?
Consider and alternative diagnosis.
If a 2-level Wells Score is < 4 and a D-Dimer is negative consider an alternative diagnosis.
What should be prescribed for stable angina also if it isn’t controlled by just GTN spray and a B-Blocker?
Add Nifedipine
Which complication of Hypertrophic obstructive cardiomyopathy is most likely to cause sudden death?
Ventricular arrythmia
What is the appropriate initial dose of Aspirin for management of a NSTEMI?
300mg
What leads are affected in an inferior STEMI?
II
III
aVL
aVF
V4
In an inferior STEMI which artery is affected?
RCA ( 80% of time )
What are some common cardiovascular risk factors?
Hypertension
Smoking
Hyperlipidaemia
Male
Obesity
What is the pathophysiology of an acute MI?
An atherosclerotic plaque deposits in a coronary artery and ruptures. This causes total occlusion of the artery and death of cardiac myocytes.
What is cardiac rehabilitation?
An educational and exercise programme, which can be done at home or in hospital.
Smoking cessation
Diet management
Stress management
Weight management
Alcohol consumption
What is the difference between a STEMI and a NSTEMI?
NSTEMI - partially occluded artery
STEMI - fully occluded artery
What are the possible complications of a MI?
Death
Arrhythmia
Rupture
Tamponade
Heart Failure
Valvular disease
Aneurysm
Dressler syndrome
Embolism
Regurgitation
What are common causes of heart failure?
Ischaemic Heart Disease
Hypertension
Valvular Heart Disease
Atrial Fibrillation
Why do patients with heart failure develop ankle oedema?
The heart pumps blood less effectively, leading to decreased blood pressure. Decreased blood pressure leads to decreased renal perfusion. This activates
the RAAS system, which causes vasoconstriction, Aldosterone and ADH release. Collectively these cause increased sodium retention and therefore increased circulating volume. Therefore more fluid moves out to the interstitium It pools in the ankles due to gravity.
What is the treatment for decompensated heart failure?
Loop Diuretic - IV Furosemide or Bumetanide if particularly oedematous
Ventilation ( CPAP/ BiPAP)
What is the treatment for Chronic Heart Failure?
B-Blocker ( Bisoprolol 1.25mg )
ACEi ( Ramipril )
What does Atrial Fibrillation look like on an ECG?
Irregular Rhythm
Tachycardia
What is the difference between a SVT and a VT?
SVT - originates in SAN/AVN
VT- originates in ventricles
What is the treatment for Atrial Fibrillation acutely?
Flecainide - rhythm control
Cardioversion
What is the indication for electrical DC Cardioversion in A.Fib?
Haemodynamic Instability
Low BP
High HR
ALtered consciousness
SOB
What are the commonest causes of AF and what are the investigations that would be done for each suspected cause?
Valvular Disease - ECHO
Acute Infection - Blood culture + FBC
Post MI HF - ECG
Hyperthyroidism - TSH + T3/T4 levels
What is Wolff-Parkinson-White syndrome?
An accessory pathway between the atria and ventricles creates a re-entry loop
What is the best treatment for WPW?
Ablation of accessory pathway
Flecainide
When should Flecainide not be given in WPW?
If patient also has AF
What drugs are used in long term treatment of AF?
Rate control - B-Blocker ( Bisoprolol) , CCB, Digoxin
Rhythm control - Flecainide
Anticoagulation - DOAC ( Apixaban )
What scoring systems are used to determine if a patient with AF will require long term anticoagulation?
CHADVASC
HAS-BLED
What are clinical features of Aortic Stenosis on examination?
Narrow pulse pressure ( <25mmHg )
Crescendo-decrescendo systolic murmur that radiates to the carotid arteries , loudest on expiration
Slow rising pulse
What are common complications of severe Aortic Stenosis?
LSHF
Stroke
Arrhythmias
What is the management for aortic stenosis?
B-Blocker
If symptomatic , valve replacement ( TAVI )
What are the common causes of valvular heart disease?
Congenital ( Bicuspid valves )
Rheumatic Fever
Age related degeneration ( Calcification, Fibrosis)
What are clinical signs of Aortic Regurgitation?
Quincke’s Sign
De Musset’s Sign
Collapsing pulse
What are the clinical signs of Mitral Stenosis?
Malar Flush
Mid-diastolic rumble, best heard on expiration and when patient is turned to their left
What are the clinical signs of mitral regurgitation?
Pansystolic murmur that radiates to the axilla
Displaced Apex beat
What clinical features can be seen in Infective Endocarditis?
Splinter haemorrhages
Olster’s Nodes
Janeway lesions
Clubbing
Poor dental hygeine
New murmur
Intermittent fever
IDVU
Prosthetic Valve
What pathogens most commonly cause IE?
Staphylococcus Aureus
Viridans Streptococci
Enterococcus
What investigation must be done for IE?
TOE - will see vegetation
Blood culture
How is a diagnosis of IE made? ( Major criteria )
2 positive blood cultures
Positive ECHO ( TOE ) findings
Endocardial involvement
What initial antibiotic therapy is indicated in IE is suspected?
IV Benzylpenicillin + Low dose Gentamicin
What are the clinical signs of a raised BP?
Raised JVP ( >3cm)
Retinopathy
Radio-Femoral delay
Tar staining
What are common causes of secondary HTN?
COCP/POP
Cushing’s
CKD
Hyperaldosteronism
Renovascular Disease
Pheochromocytoma
What is the lifestyle management recommended for Hypertension?
Smoking cessation
Reduced alcohol intake
Increase aerobic exercise
Manage stressors
High potassium diet
Reduce salt intake
What are side effects of ACEi?
Dry cough
Hyperkalaemia
Headaches
What are the side effects of B-Blocker?
Bronchospasm
Cold Peripheries
Fatigue
What is a common side effect of CCB?
Ankle Swelling
What are common complications of untreated hypertension?
Retinopathy
Ischaemic Stroke
Coronary Artery Disease
Nephropathy
What can be seen on ophthalmoscope when a patient has hypertensive retinopathy?
Flame haemorrhages
What could be differentials for HTN in paeds?
Renal Artery Stenosis
Kawasaki Disease
Post-Streptococcal Glomerulonephritis
What is the diagnostic criteria for Familial Hypercholesterolaemia called?
Simon Broome
What are the categories for the Simon Broome Criteria?
Age
Total Cholesterol
LDL Cholesterol
Tendon Xanthomas
DNA-based evidence of a functional LDLR, PCSK9 and APOB mutation
Family history of premature CVD events
Family history of extremely high cholesterol
What defects are Turner’s Syndrome associated with?
Bicuspid aortic valve
Aortic root dilatation
Coarctation of the aorta
What medications should be taken following bioprosthetic valves?
Low dose Aspirin
Who are bioprosthetic valves recommended in?
Those over age 65
What medications should be taken following mechanical valves?
Low dose aspirin
Warfarin
If a patient is on LMWH for anticoagulation following a heart valve replacement and they get a new diagnosis of Atrial Fibrillation, what anticoagulation should be used?
LMWH should be continued , it is preferable than starting DOACs for these patients
What is Left Ventricular Aneurysm ?
A complication post MI
Presents with pulmonary oedema ( Bibasal fine crackles )
S3 and S4 heart sounds
This suggests the heart is larger than normal with stiff walls
A persistent V1-V6 ST Elevation will be seen weeks post MI . This is because the fibrotic tissue caused by the MI increases the size of the heart, and it makes it stiffer so it cannot expand properly.
What does S3 mean?
Larger than normal heart
Under 30 = physiological , common in athletes
Over 30 could be pathological ( LV Failure ( dilated cardiomyopathy) or Constrictive Pericarditis or Aortic Regurgitation -> LV dilation )
What does S4 mean?
Caused by atrial contraction against a stiff ventricle ( happens during P Wave)
Present in Aortic Stenosis,
HOCM and HTN
What valvular problem is associated with ADPKD?
Mitral Valve Prolapse
What is Coarctation of the Aorta?
Narrowing of the aorta at the level of the Ductus Arteriosus
What is the management of Aortic Stenosis?
Symptomatic = Aortic Valve Replacement
Otherwise , cut off is a gradient of >40 mmHg
What are the INR ranges for patients with a mechanical heart valve replacement?
Aortic - 3
Mitral - 3.5
This is because a MVR comes with a higher risk of thromboembolic disease so the target achieved with Warfarin should be higher
What cardiac condition is Acromegaly associated with?
Cardiomyopathy
What is cardiomyopathy?
Disease of the heart muscle - size, thickened, stiff
Which valvular complications are associated with IVDU?
Tricuspid Regurgitation - it’s the first one that is reached due to venous return
What is Tetralogy of Fallot?
V - VSD
O - Overriding Aorta
R - Right Ventricular Hypertrophy
P - Pulmonary Stenosis
R->L Shunt
Cyanotic
What is a valvular complication of an MI?
MI can cause papillary muscle rupture which can lead to acute mitral regurgitation
What is the first line treatment for Narrow Complex Tachycardia?
What if they’re haemodynamically unstable ( low BP, High pulse, Shock, Syncope
Regular rhythm = Vagal Manoeuvres , 2nd line = IV Adenosine 6mg bolus, then 12mg , then 18mg
Irregular rhythm = b-blockers ( probably a-fib )
Unstable - Synchronised DC cardioversion - three shocks then call for senior
What does Narrow Complex Tachycardia mean?
Any cardiac rhythm greater than 100bpm with a QRS complex of < 120ms
What is the treatment for sinus bradycardia?
Atropine
a’top’ine to increase
a’down’osine to decrease
What should be used for patients with asthma who are experiencing narrow complex tachycardia if vasovagal manoeuvres fail?
Verapamil
ADENOSINE IS CONTRAINDICATED
What kind of patients should you be careful giving quicker rates of fluid administration to?
Heart Failure patients
Should be given over 12 hours to prevent fluid overload
What are the management plans for different aortic root dilations?
> 5cm = Surgery within 2 weeks
4.5 - 5.5cm = Rescan every 3 months
3 - 4.5cm = Rescan every 12 months
<3cm = Discharge
What would warrant surgical management of Infective Endocarditis ( Valve replacement)
Heart Block
Severe valve dysfunction
Heart failure,
Resistant microbials
Persistent infection despite appropriate antibiotics.
What is Cor Pulmonale?
RIght sided heart failure caused by chronic lung disease
What are symptoms and signs of Cor Pulmonale/RSHF?
Ankle swelling
Weight gain
Abdominal swelling and discomfort
Anorexia and nausea
Ankle/sacral pitting oedema
Ascites
Tender smooth hepatomegaly
Raised JVP
What are symptoms and signs of LSHF?
Shortness of breath on exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea
Nocturnal cough (± pink frothy sputum)
Fatigue
Tachypnoea
Bibasal fine crackles on auscultation of the lungs
Cyanosis
Prolonged capillary refill time
Hypotension
Less common signs: pulsus alternans (alternating strong and weak pulse), S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle)
What is the management of Mobitz Type 2 or Third Degree heart block?
Temporary transcutaneous pacing followed by permanent pacemaker implantation
What murmurs can be heard in Hypertrophic Cardiomyopathy?
Ejection systolic murmur, loudest between lower left sternal edge and apex, louder with exercise/standing/performing valsalva, quieter when supine/squatting
Pansystolic murmur may be heard- loudest at the apex and radiating to the axilla (mitral regurgitation)
How does Digoxin toxicity present?
Nausea/vomiting
Diarrhoea
Blurred vision
Yellow/green discolouration of vision
Haloes in vision
Confusion
Fatigue
Palpitations
Syncope
What is Digoxin used for?
Digoxin is a commonly used medication for atrial fibrillation/flutter and heart failure
What sign is seen on ECG with Digoxin use?
Reverse tick sign
What type of valve disease is associated with malar flush?
Mitral Stenosis
What does an Apical to radial pulse deficit represent?
Apical to radial pulse deficit occurs as not all atrial impulses (palpable at the apex) are mechanically conducted to the ventricles (palpable as a peripheral pulse)
Sign of Atrial Fibrillation
What are the managements of the types of Heart Block?
FIrst Degree - doesn’t need treatment, any underlying pathology should be treated
Mobitz Type 1 - Generally asymptomatic and does not require any specific management as the risk of high AV block/complete heart block is low. If symtpomatic may require ECG monitoring and stopping of any causative medications
Mobitz Type 2 -Permanent pacemaker as these patients are at risk of complete heart block and at risk of becoming haemodynamically unstable
Third Degree - Permanent pacemaker requires insertion due to the risk of sudden death.
What is the BASH mnemonic?
HFrEF medications
ACE-I, BB, Spironolactone and Hydralazine.
What are side effects of Amlodopine?
Gum hypertrophy
What does a prolonged PR interval indicate in the context of IE?
A prolonged PR interval (>200ms) indicates that there is delayed conduction at the atrioventricular (AV) node. In the context of IE, this may suggest the presence of an aortic valve abscess. Myocardial abscesses are an indication for surgical intervention.
What type of patients cannot be given a DOAC , they should instead be given Warfarin for Atrial FIbrillation?
Patients with a creatinine clearance < 15/min as they are renally excreted.
What does WPW look like on ECG?
Delta wave and short PR interval
What can pericardial effusion lead to?
Pericardial effusion
Cardiac tamponade
Where is the oedema for each side of HF ?
Left = Pulmonary Oedema
Right = Peripheral Oedema
What is a sign of Pericarditis?
Pericardial friction rub - high-pitched scratching noise, best heard over the left sternal border during expiration
Whata re the causes of Cardiac Tamponade?
Severe penetrating chest trauma
Malignancy
Purulent pericarditis.
What is Cardiac Tamponade?
Cardiac tamponade occurs when pericardial fluid accumulates and intrapericardial pressure rises compressing the inferior vena cava and heart chambers compromising ventricular filling and leading to reduced cardiac output.
What is the treatment for patients with severe hypokalaemia (<2.5mmol/l) or those who are symptomatic?
0.9% sodium chloride with 40mmol potassium chloride and check the serum magnesium level ( hypokalaemia associated with hypomagnesaemia)
What is first line for chronic Atrial FIbrillation?
Rate Control - B-Blocker
When should rhythm control be offered over rate control in AF ?
Rhythm control should be offered to patients who have:
AF secondary to a reversible cause
Heart failure thought to be caused by AF
New-onset AF
Or those for whom a rhythm control strategy would be more suitable based on clinical judgement.
e.g,.
Flecainide ( Young/healthy)
Amiodarone ( Older/Sedentary)
What are the two GRACE scores ?
There is a GRACE risk score to estimate in-hospital mortality and another score to estimate mortality up to 6 months post-discharge
What are the side effects of nitrates?
Headaches
Dizziness
What is Digoxin indicated for?
Rate control in patients with atrial fibrillation and systolic heart failure
What are the doses for Atorvastatin depending on indication?
Primary Prevention - 20mg
Secondary Prevention - 80mg
What are the doses for Aspirin depending on indication?
During STEMI/NSTEMI - 300mg loading dose
Maintenance/ Secondary Prevention - 75mg
What is Kussmaul’s Sign?
Jugular venous pulse rises with inspiration.
Physiologically, the jugular venous pulsation should reduce and not rise when the intrapulmonary pressure reduces in inspiration. This is due to an inability of the right ventricle to fill with blood and instead the blood backs up into the venous system and causes a raised jugular venous pulsation
What does Kussmaul’s Sign happen in?
Severe heart failure
Constrictive Pericarditis
Cor Pulmonale
All these conditions restrict filling of the Right Ventricle
What is the most common cause of acute atrial regurgitation?
Aortic dissection
What o2 sat indicates a patient is hypoxic?
Below 94%
O2 should not be given to patients during acute MI who are not hypoxic and it increases the risk of a reperfusion injury
What is the treatment for patients with heart failure with reduced ejection fraction (HFrEF) ?
ACEi and B-Blocker
Can add Spironolactone if patient is symptomatic ( orthopnea )
What is the treatment for patients with heart failure with preserved ejection fraction (HFpEF) ?
Lifestyle modifications, including exercise training, weight loss, and sodium restriction
Low dose diuretic in patients with signs of fluid overload ( Furosemide )
ACE- inhibitor/ARB if the patient is hypertensive
What vessel is usually affected in an anterolateral STEMI?
Left Anterior Descending
What vessel is usually affected in an inferior STEMI?
Right Coronary Artery
What is Triple vessel disease?
This refers to disease in the right coronary artery, the left anterior descending and the left circumflex artery
What medications should all patients be offered following a MI ?
Dual antiplatelet therapy ( Ticagrelor/ Clopidogrel AND Aspirin )
ACE inhibitor ( Ramipril)
Beta-blocker ( Bisoprolol )
Statin ( Atorvastatin )
DABS mnemonic
What is the first line treatment for HTN in someone who is over 55 with Diabetes?
ACEi
What is Sick Sinus Syndrome?
Dysfunction of the sinus node, which may manifest as sinus bradycardia, sinus arrest, or alternating bradycardia and tachycardia
When is CABG preferred to PCI?
Patients with stable angina should be considered for revascularization (with CABG or PCI)
Better survival rate with CABG for those over 65, those with diabetes and patients with Triple Vessel Disease
When do you consider treatment for mitral stenosis?
Symptomatic
Mitral Valve Area < 1.5cm^2
What is the treatment for pulseless Torsades de Pointes?
Unsynchronized DC Shock
Unsynchronized because he has no pulse
What is the normal length of the PR interval
120-200ms
What are the treatments for these arrhythmias?
SVT Tachycardia
Ventricular Tachycardia
Sinus Bradycardia
TDP
Pulseless VT
VFib
SVT Tachycardia ( Hemodynamically Stable ) = Adenosine
SVT Tachycardia ( Hemodynamically Unstable ) = Synchronised DC Cardioversion
Ventricular Tachycardia ( Hemodynamically Stable ) = Amiodarone
Ventricular Tachycardia ( Hemodynamically Unstable ) = Synchronised DC Cardioversion
Sinus Bradycardia ( Hemodynamically Stable ) = Atropine
Sinus Bradycardia ( Hemodynamically Unstable ) = Synchronised DC Cardioversion
Torsades de Pointes (polymorphic ventricular tachycardia) = I.V Magnesium Sulphate
Pulseless Ventricular Tachycardia = 200J bi-phasic unsynchronised shock + Adrenaline + Amiodarone
Ventricular Fibrillation = 200J bi-phasice Unsynchronised Shock + Adrenaline + Amiodarone
What is the treatment for these arrhythmias?
Atrial Flutter
Atrial Fibrillation
Atrial Flutter ( Hemodynamically Stable ) = b-blocker/CCB
Atrial Flutter ( Hemodynamically Unstable ) = synchronised DC cardioversion +/- amiodarone.
What must be administered if you’re going to deliver a DC Shock?
Sedation or General Anaesthesia
What are the causes of HFrEF?
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
What are the causes of HFpEF?
Uncontrolled chronic hypertension (significant left ventricular hypertrophy reduces filling of the left ventricle)
Hypertrophic cardiomyopathy
Cardiac tamponade
Constrictive pericarditis.
How do you differentiate between Narrow Complex tachycardia ( SVT ) and Broad Complex Tachycardia ( VT ) on ECG?
A normal QRS complex is a narrow one (<100ms), this is a narrow complex tachycardia
A QRS complex is abnormal if it is broad (>100ms).
What are signs of Hypertrophic Cardiomyopathy?
Signs on examination include a “jerky” pulse, along a displaced apex beat, apical thrill and an ejection systolic murmur. ECG shows left ventricular hypertrophy
What can severe Long QT lead to?
Torsades de Pointes
What is the mechanism of action of GTN Sublingual Spray?
Activating cGMP, which is involved in vasodilation.
In the Duke’s Criteria of IE , what are the rules about diagnosis based on blood cultures?
A single positive blood culture of Coxiella burnetti meets a major criterion for infective endocarditis, can be diagnosed with a total of two major criteria.
Note that this differs from other organisms such as viridans streptococci, Staphylococcus aureus, Streptococcus bovis and the HACEK group two separate blood cultures are required
Can a NSTEMI have a normal ECG?
Yes it may be normal so cannot rule out if Troponin is high
What are the requirements of PCI for STEMIs and NSTEMIs?
PCI in STEMI:
Within 12hrs of symptom onset, within 2 hours of presentation (also used when there is residual ST elevation after treatment etc)
If not, use thrombolysis using TIMI score
PCI in NSTEMI:
Use GRACE score, if higher than 3% use PCI within 72 hours
What are the clinical signs of coarctation of the aorta?
Radio-Femoral Delay
Difference in BP of upper and lower limbs
Hypertension
What heart problem can excessive alcohol consumption lead to ?
Atrial Fibrillation - known as holiday heart
What are the classifications of Aortic Dissection?
Stanford Type A: Involves the ascending aorta, arch of the aorta ( Typically requires IV Labetalol AND surgical treatment )
Stanford Type B: Involves the descending aorta ( Typically managed conservatively with IV Labetalol )
What is the NYHA classification of Heart Failure?
Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitation or dyspnoea.
Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea.
Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).
Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.
What are the ECG changes of a posterior STEMI?
In a posterior MI the ECG will show reciprocal changes e.g. ST depression instead of elevation in leads V1-V4. You may also see upright t-waves and tall, broad R-waves.
When is there no need for Anticoagulation prior to DC CArdioversion in a patient with Atrial FIbrillation?
If they have a low CHA2DVA2SC score and no signs of left atrial thrombus ( Low embolic risk )
What is the management for Ventricular Fibrillation?
Start chest compressions at a rate of 100-120 per minute ( 30:2 ) and deliver an unsynchronised shock
What does 30:2 mean ?
30 chest compressions followed by 2 rescue breaths
What sign is seen on ECG in hypothermia?
J Waves ( Osborne wave )
What are clinical features found on ECHO of HOCM?
Septal hypertrophy
Diastolic dysfunction due to impaired relaxation of the thickened left ventricle during diastole, reduced filling. Presents with HFpEF
Which test is useful in assessing whether a patients experiences a reinfarct after PCI for a STEMI?
Creatine Kinase - MB ( Myocardium )
Troponin levels can be elevated for up to 2 weeks after the initial infarct episode, whilst CK-MB usually clear by 72 hours. A CK-MB level of more than 3 times the upper limit of normal is generally considered to be indicative of one.
Which electrolyte disturbance can precipitate DIgoxin toxicity?
Hypokalaemia
What is the treatment for Cardiac Tamponade?
Pericardiocentesis
What is the treatment for symptomatic Sick Sinus Syndrome?
Permanent Pacemaker
What are the indications for a Permanent Pacemaker
Complete heart block
Mobitz type 2 heart block
Symptomatic Mobitz type 1 heart block
Symptomatic sick sinus syndrome
Permanent bradyarrhythmias caused by a myocardial infarct
Cardiac resynchronisation therapy - biventricular pacemaker is inserted so that right and left ventricles contract simultaneously in severe heart failure (EF <35%).
What are the indications for Temporary Pacing wires
Transcutaneous - emergency situations
Bradycardic patients with adverse signs who are unresponsive to medical therapy (e.g. total atropine dose 3mg)
Post-inferior myocardial infarction
Patients unresponsive to medical management or cardioversion in SVT
Only temporary before putting in a Transvenous pacing system ( which is more effective ). It may be kept in place until a permanent pacemaker (PPM) is inserted or until pacing is no longer required.
What are the clinical signs of Aortic Sclerosis?
Ejection systolic murmur that does not radiate to the carotids, with a normal S2, pulse character and volume
What is the QT Interval defined as?
The start of the QRS complex to the end of the T-wave
What is the PR Interval defined as?
Start of P-wave to the start of the QRS complex
Adenosine is the 2nd line for SVT Tachycardias with no haemodynamic instability.
What are the contraindications of using Adenosine?
Asthma ( Bronchoconstrictor)
COPD ( Bronchoconstrictor)
2nd or 3rd Degree Heart Failure
Decompensated Heart Failure
If a patient’s CHA2DVA2SC score is low but they have valvular A FIb should they still be anticoagulated?
YES
All patients with valvular disease and atrial fibrillation should be on anti-coagulation, regardless of CHA2-DS2-VASc score
What are the rules about giving a B-Blocker and a CCB together?
When giving a combination of beta-blockers and calcium-channel blockers, it is vital that the latter is a dihyropyridine calcium channel blocker (e.g. Amlodipine )
This is due to a high risk of marked bradycardia and AV Block, they both slow APs at the AVN.
How much aerobic activity is recommended per week by the UK Chief Medical Officers’ guidelines (2019)?
150 minutes moderate intensity
75 minutes vigorous intensity
Which co-morbidity increases the risk of a silent myocardial infarction?
Diabetes
Where on the chest is the Tricuspid Area?
5th ICS , Left Sternal Border
What pulse finding is present in Aortic regurgiation?
Collapsing pulse or water hammer pulse
What is the most common indication for heart valve replacement surgery?
Aortic Stenosis
How much strength training does the UK Chief Medical Officers’ guidelines (2019) recommend?
At least 2 days per week
What JVP findings may be seen in tricuspid regurgitation?
Raised JVP
What do pathological Q waves on an ECG suggest?
Deep infarction involving the full thickness of the heart ( Transmural )
What are the features on auscultation with tricuspid regurgitation?
Pansystolic murmur
Split second heart sound
What are the causes of Mitral Regurgitation? (5)
Idiopathic age related degeneration
ischaemic Heart Disease
Infective Endocarditis
Rheumatic Heart DIsease
Connective TIssue Disorders ( Ehlers-Danlos and Marfan’s Syndrome )
How should cultures be performed before starting antibiotics in patients with IE?
Three blood culture samples taken from separate sites , separated by at least 6 hours
What scoring system assesses the risk of major bleeding in patients with atrial fibrillation taking anticoagulation?
ORBIT score
What is the most common side effect of calcium channel blockers? (1)
What is the usual alternative class of antihypertensive drug in patients who experience this side effect? (1)
Ankle Oedema
Thiazide-Like Diuretics ( Indapamide )
At what point is the QT interval considered prolonged? (2)
Men - More than 440ms
Women - More than 460ms
What valve pathology can cause left atrial dilatation?
Mitral Regurgitation
What change to the heart may occur in patients with longstanding hypertension? (1)
What examination finding may be present? (1)
Left Ventricular Hypertrophy
Forceful apex beat
What chest x-ray findings may be seen in acute left ventricular failure? (5)
Cardiomegaly
Upper lobe venous diversion
Bilateral pleural effusions
Fluid in interlobar fissures
Kerley B Lines ( Fluid in septal lines)
What causes individual, random, abnormal, broad QRS complexes on an otherwise normal ECG? (1)
Ventricular Ectopics
What abdominal findings may be seen in tricuspid regurgitation? (2)
Pulsatile Liver
Ascites
What is the name for the thin red-brown lines along the fingernails seen in patients with infective endocarditis? (1)
Splinter Haemorrhages
What options are available for lowering cholesterol other than statins?
Ezetimibe
PCSK9 Inhibitors
What ECG changes suggest a STEMI? (2)
ST Segment Elevation
New Left Bundle Branch Block
What medication is used for immediate symptomatic relief of angina? (1)
What are the main side effects? (2)
Sublingual GTN Spray
Headaches
DIzziness
What is the target INR for warfarin in patients with a metallic mechanical heart valve? (1)
2.5-3.5
What lifestyle factors can cause atrial fibrillation? (2)
Alcohol
Caffeine
What heart valve pathology is best heard with the patient positioned on their left side? (1)
Mitral Stenosis
What are the causes of aortic regurgitation? (3)
Idiopathic age related weakness
Bicuspid valve
Connective Tissue DIsorders ( Ehlers-Danlos and Marfan’s Syndrome )
What are the features of the murmur caused by mitral stenosis? (2)
Mid diastolic
Low pitched “ rumbling” murmur
What is the usual initial medication used to terminate an episode of supraventricular tachycardia? (1)
How is it given? (2)
What doses? (3)
Adenosine
Rapid I.V Bolus
into a large proximal cannula
Initially 6mg, then 12mg, then 18mg
What medications are avoided with hypertrophic obstructive cardiomyopathy? (2)
ACEi
Nitrates
What are the first-line medications for heart failure? (4)
ACEi
B-Blockers
Aldosterone Antagonist ( Spironolactone)
Loop Diuretic ( Furosemide)
Where on the chest is the mitral area? (1)
5th ICS, Mid Clavicular line
Where are the pacemaker leads sited in cardiac resynchronisation therapy (CRT)? (3)
Right Atrium
Right Ventricle
Left Ventricle
What are the features of the murmur caused by aortic regurgitation? (2)
Early diastolic
Soft murmur
What is the name for the tender red/purple nodules on the pads of the fingers and toes seen in patients with infective endocarditis? (1)
Osler’s Nodes
Which imaging investigation is first-line for assessing heart failure? (1)
Echocardiogram
Which patients are offered statins for primary prevention without calculating the QRISK3 score? (2)
CKD
Type 1 Diabetes for over 10 years and over 40
What valve pathology can cause left atrial hypertrophy? (1)
Mitral Stenosis
What is the name for treatment with a triple chamber pacemaker in severe heart failure with an ejection fraction of less than 35%? (1)
Cardiac Resynchronisation Therapy
What is the name for the painless red flat macules on the palms of the hands and soles of the feet seen in patients with infective endocarditis? (1)
Janeway lesions
What medication may be used longer-term (e.g., 3 months) in patients with pericarditis to reduce the risk of recurrence? (1)
Colchicine
What are the four differentials of a narrow complex tachycardia? (4)
Atrial fibrillation
Atrial Flutter
Sinus Tachycardia
SVT
What investigation options are available to help support a diagnosis of angina? (2)
Cardiac Stress testing
CT Coronary Angiography
What scar would be present after minimally invasive mitral valve surgery? (1)
Right sided mini-thoracotomy scar
What valve pathology can cause left ventricular dilatation? (1)
Aortic Regurgitation
What heart valve pathology is best heard with the patient sat up, leaning forward and holding exhalation? (1)
Aortic Regurgitation
What is used to treat ventricular tachycardia in haemodynamically stable patients? (1)
What about polymorphic ventricular tachycardia (e.g., torsades de pointes)? (1)
What is the treatment if either occurs with life-threatening features? (1)
IV Amiodarone
IV Magnesium Sulphate
Synchronised DC CArdioversion
What term describes the experience caused by heart failure of suddenly waking at night with a severe attack of shortness of breath, cough and wheezing? (1)
Paroxysmal Nocturnal Dyspnoea
What device is inserted into the chest and delivers a defibrillator shock if it identifies ventricular tachycardia or ventricular fibrillation? (1)
Implantable Cardioverter Defibrillator (ICD)
In patients with pericarditis, what makes the chest pain worse? (2)
What makes it better? (1)
Worse on deep inspiration
Worse on lying flat
Better on sitting forwards
What valve pathology commonly occurs with hypertrophic obstructive cardiomyopathy? (1)
Mitral regurgitation
Which arrhythmia is most associated with a prolonged QT interval? (1)
Torsades de Pointes
What imaging options establish the diagnosis of hypertrophic obstructive cardiomyopathy? (2)
ECHO
Cardiac MRI
What is the inheritance of familial hypercholesterolaemia? (1)
Autosomal dominant
What treatment can permanently resolve the problem of recurrent episodes of supraventricular tachycardia? (1)
Radiofrequency ablation
What investigation is required following acute coronary syndrome to assess the functional damage to the heart? (1)
ECHO
What short-term intervention may be used in unstable patients with bradycardia? (1)
What are the options for delivering this intervention? (2)
Temporary cardiac pacing
Transcutaneous or Transvenous
What does the term bigeminy describe on an ECG? (1)
When every other beat is a ventricular ectopic
Which ECG leads are affected when acute coronary syndrome affects the left coronary artery? (1)
I , aVL, V3-V6
Which ECG leads are affected when acute coronary syndrome affects the left anterior descending artery? (1)
V1-V4
Anterior STEMI
Which ECG leads are affected when acute coronary syndrome affects the circumflex artery? (1)
I, aVL, V5-V6
Lateral STEMI
Which ECG leads are affected when acute coronary syndrome affects the right coronary artery? (1)
II, III and aVF
Inferior STEMI
When can supraventricular tachycardia cause a broad complex tachycardia? (1)
If the patient also has a bundle branch block
What medications are used for secondary prevention of cardiovascular disease? (4)
Antiplatelet ( Aspirin )
Anti-coagulant ( Clopidogrel)
Atorvastatin 80mg
B-Blocker ( Bisoprolol )
ACEi ( Ramipril )
What are the non-shockable cardiac arrest rhythms? (2)
Pulseless Electrical Activity ( PEA)
Asystole
What clinical sign is part of the diagnostic criteria for familial hypercholesterolaemia? (1)
Tendon Xanthomata
What ambulatory or average home blood pressure results indicate stage 1 hypertension? (1)
Stage 2? (1)
135/85
150/95
What blood pressure abnormality is found in aortic stenosis? (1)
Narrow pulse pressure ( difference between SBP and DBP is low)
What are the major complications of mechanical heart valves? (3)
Thrombus formation
Infective Endocarditis
Haemolytic Anaemia
What is the name for haemorrhages on the retina seen during fundoscopy in patients with infective endocarditis? (1)
Roth spots
What is the immediate management of suspected acute coronary syndrome? (5)
Call an ambulance
Perform an ECG
Aspirin 300mg
I.V Morphine
Nitrates ( GTN)
Refer to Cath Lab for PCI
What are the shockable cardiac arrest rhythms? (2)
Ventricular Tachycardia
Ventricular FIbrillation
What follow-up blood tests should be arranged after starting statins? (2) When? (1)
Lipid Profile
LFTs
3 months after starting
What are the most common causes of atrial fibrillation? (5)
Sepsis
Mitral valve pathology ( Stenosis or Regurgitation)
Ischaemic Heart Disease
Thyrotoxicosis
Hypertension
What are the causes of mitral stenosis? (2)
Rheumatic Heart Disease
Infective Endocarditis
What are the ECG criteria for first-degree heart block? (2)
PR Interval >200ms
Every P wave is followed by a QRS
What class of antibiotics significantly interacts with statins? (1)
Macrolides
What are the secondary causes of hypertension? (6)
ROPEDD mnemonic
Renal disease
Obesity
Pregnancy
Endocrine Disease ( Hyperaldosteronism or Cushing’s )
Drugs ( Steroids )
Diabetes
What are the first-line medical options for long-term symptomatic relief of angina? (2)
B-Blockers ( Bisoprolol )
CCB ( Diltiazem )
GTN for acute relief of symptoms
What are the complications of myocardial infarction? (6)
Death
Rupture of heart septum of papillary muscles
Heart Failure
Arrhythmias
Aneurysms
Dressler’s Syndrome
Other than blood tests, what baseline investigations are required in patients with a new diagnosis of hypertension? (3)
Baseline bloods (FBC, U&Es, LFTs, clotting, lipid profile, HbA1c)
Urine- Albumin:Creatine for proteinuria
Urinalysis for microscopic haematuria
ECG
What does cardiac output refer to? (1)
The volume of blood ejected by the heart per minute
When would clopidogrel be the first-line antiplatelet for secondary prevention? (2)
Peripheral arterial disease
Ischaemic stroke
What ECG changes may occur in pericarditis? (2)
Saddle shaped ST Elevation
PR Depression
Where might the lead be sited in a patient with a single-chamber pacemaker? (2)
What would decide which of these sites are used? (2)
Right Atrium - if issue is with SAN
Right Ventricle - if issue is with AVN
What is the medical management of NSTEMI? (6)
BATMAN mnemonic
Base angiography and PCI on GRACE Score
Aspirin 300mg
Ticagrelor ( or Clopidogrel depending on circumstances)
Morphine for pain
Antithrombin therapy ( Fondaparineux)
Nitrate ( GTN)
What are the two principles of treating atrial fibrillation? (2)
Rate or rhythm control - usually rate control e.g B-BLocker
Anticoagulation ( DOAC )
Where on the chest is the pulmonary area? (1)
2nd ICS , left sternal border
What is the most common organism to cause infective endocarditis? (1)
Staph Aureus
How much fluid is normally contained within the pericardial sac? (1)
Less than 50ml
What murmur may be heard in hypertrophic obstructive cardiomyopathy? (1)
Where is it heard loudest? (1)
Ejection systolic murmur
Loudest at the lower left sternal border
Which medication may be used in the initial management of acute left ventricular failure with pulmonary oedema? (1)
Furosemide
Which class of medication may be used to improve cardiac output in patients with acute left ventricular failure after optimising the fluid status? (1)
Inotropes e.g Dobutamine
What is the typical duration of dual antiplatelet therapy following myocardial infarction?
12 months, followed by Aspirin alone indefinitely
What scar is a patient with a prosthetic heart valve most likely to have? (1)
Midline sternotomy scar
Give four rare but significant side effects of statins. (4)
Rhabdomyolysis
Myopathy
T2DM
Haemorrhagic stroke
What criteria are used for diagnosing infective endocarditis? (1)
Modified Duke Criteria
What are the features of the murmur caused by mitral regurgitation? (2)
Where does it radiate? (1)
Pan-systolic
High pitched “whistling” murmur
Radiates to axilla
What is the name for the extra electrical pathway in Wolff-Parkinson-White syndrome? (1)
Bundle of Kent
How do statins work? (2)
They reduce cholesterol production in the liver
By inhibiting HMG CoA Reductase
What examination findings suggest accelerated (or malignant) hypertension in a patient with a blood pressure above 180/120? (2)
Retinal haemorrhages
Papilloedema
What valve pathology can cause left ventricular hypertrophy? (1)
Aortic Stenosis
What are the ECG changes in Wolff-Parkinson-White syndrome? (3)
Delta wave
Short PR Interval (<120ms)
Wide QRS Complex (>120ms)
What drug is the usual pill-in-the-pocket treatment for paroxysmal atrial fibrillation? (1)
Paroxysmal AF is when your heartbeat returns to normal within 7 days, on its own or with treatment
Flecainide
What are the features of the murmur caused by aortic stenosis? (3)
Where does it radiate? (1)
Ejection-systolic
High pitched
Crescendo-Descendo
Radiates to the carotids
What are the features on auscultation with pulmonary stenosis? (2)
Ejection systolic
Loudest in pulmonary area in deep inspiration
Split second heart sound
What is an example of each class of antiarrhythmic?
Class I - Sodium Channel Inhibitor
A- PROCAINAMIDE
B- LIDOCAINE
C- FLECAINIDE
Class II - B-Blocker e.g BISOPROLOL
Class III - K channel inhibitor e.g AMIODARONE
CLass IIII - Nondihydropyridine Calcium Channel Blockers e.g VERAPAMIL
Class V - Others e.g ADENOSINE , DIGOXIN, MAGNESIUM SULPHATE, IVABRADINE
What are the indications for which P2Y12 inhibitor to use in STEMI?
If having PCI ( Presenting within 12 hours of symptoms and PCI available within 120 minutes )
Prasugrel if not already taking oral anticoagulant
Clopidogrel with aspirin if taking an oral anticoagulant ( high bleeding risk )
If having Fibrinolysis ( within 12 hours of symptoms and PCI not available )
Ticagrelor unless high bleeding risk
Clopidogrel with aspirin, or aspirin alone, for
high bleeding risk
What is the maximum dose that can be given of Atropine for Sinus Bradycardia?
3mg
Once this dose is reached there are several options including transcutaneous pacing, isoprenaline 5 micrograms per minute, adrenaline 2-10 micrograms per minute.
If these continue to fail, transvenous pacing may be attempted.
What can precipitate DIgoxin toxicity?
Hypokalaemia -> Diuretics!
Hypomagnesaemia
Hypercalcaemia
Which types of Strep are alpha-haemolytic and which type are beta-haemolytic?
Alpha-hemolytic strep eg pneumoniae, viridans, cause partial hemolysis
Beta-hemolytic strep eg Group A Strep (pyogenes), or Group B strep (agalactiae) cause complete hemolysis on agar
How do you know how quickly to reduce a Hypertensive Crisis?
Patients who have asymptomatic severe hypertension ( above 180/120 mmHg ) require assessment for end-organ damage. If this is no longer suspected, the urgency of lowering their blood pressure should be within days as this is hypertensive urgency rather than emergency
e.g if U&Es , LFTs are normal
What are the ECG changes seen in Hyperkalemia?
Peaked T waves
Widening of the QRS complex
Eventually a sine wave pattern
What are the ECG changes seen in Hypokalaemia?
Flattened T waves
U waves
ST-segment depression
What medications are contraindicated in patients with WPW that develop atrial fibrillation or flutter?
Most antiarrhythmic medications (beta blockers, calcium channel blockers, adenosine etc) increase the risk of polymorphic wide complex tachycardia by reducing conduction through the AV node and therefore promoting conduction through the accessory pathway – therefore they are contraindicated in patients with WPW that develop atrial fibrillation or flutter.
What is bundle branch block?
A bundle branch block occurs when electrical impulses to the ventricles are delayed or blocked, resulting in a widened QRS complex on ECG. It can be classified as left bundle branch block (LBBB) or right bundle branch block (RBBB)
What does LBBB look like on ECG?
In V1 if the QRS complex has the appearance of a W and in V6 the QRS has the appearance of M (due to a notched R wave) WiLLaM.
What does RBBB look like on ECG?
In V1 if there is an appearance of an M and in V6 the QRS complex usually looks normal or has a W appearance (N) MaRRoW
What drugs are contraindicated in patients with asthma?
B-Blocker
NSAIDs ( inc Aspirin)
ACEi
At what clinical BP should patients be offered ambulatory BP monitoring?
Over 140/90 mmHg
What do LAD and RAD look like on an ECG?
Normal - I = positive , II = positive , III = positive
L Axis Deviation - I = positive, II = negative , III = negative
R Axis Deviation - I = negative, II= positive, III = positive
What anticoagulation should be given to patients with permanent Atrial FIbrillation that cannot have a DOAC due to renal function ( eGFR < 30 )?
Warfarin
In which patients might rhythm control be favoured over rate control in patients with chronic Atrial FIbrillation?
If they are symptomatic ( palpitations, SOB, fatigue)
e.g flecainide ‘pill in pocket’ when episodes start
What should be noted before starting rhythm control in chronic AF patients?
Return to sinus rhythm is the most likely time to have a stroke, therefore :
Rhythm control should only be attempted if the onset of AF <48 hours, a patient has undergone 3/52 of anticoagulation or has had a TOE to exclude a mural thrombus.
How do you differentiate between acute myocarditis and acute pericarditis?
Widespread ST elevation is either Myocarditis or pericarditis. Myocarditis has a massive rise in troponin. Pericarditis has raised troponin but slightly
Above what BP would you need to refer to a specialist for same day assessment?
180/120 mmHg
If fibrinolysis is given for a MI , what investigation should be repeated within 60-90 minutes/
ECG to look for resolution of ST elevation
What drugs should be given immediately in an NSTEMI?
Aspirin
Fondaparinux ( Unless high bleeding risk)
Why might a patient recently started on an ACEi develop kidney problems?
ACEi can worsen underlying renal artery stenosis
What are the causes of secondary hypertension?
R - Renal DIsease ( e.g renal artery stenosis, CKD )
O - Obesity
P - Pregnancy/Pre-Eclampsia
E - Endocrine ( Cushing’s, Phaeochromcytoma)
What tests should all new patients diagnosed with hypertension recieve?
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities, including left ventricular hypertrophy
What should you do for a suspected PE?
Calculate a 2 level Well’s Score
If <4 , arrange a D-Dimer, if positive do CTPA and give DOAC in interim. If negative consider alternative diagnosis and stop DOAC.
If >4 do CTPA, in interim give DOAC . Positive is confirmed PE , do thrombolysis with Alteplase. If negative but DVT still suspected do a US doppler of leg
Continue DOAC for 3 months if provoked, or 6 months is unprovoked PE.
What is stage 1 hypertension?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
What is stage 2 hypertension?
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
What is Stage 3 hypertension?
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
What is the poor indicator for post MI mortality?
Cardiogenic shock
What is management of stable angina?
Aspirin - 75mg
Statin - 20mg
Sublingual GTN spray to stop attacks
1st Line - B-Blocker or CCB
2nd line - B-Blocker + CCB ( Amlodipine, Nifedipine)
If patient cannot tolerate addition of other drug or it is contraindicated then give
-a long acting nitrate ( Isosorbide Mononitrate ) OR
-Ivabradine
When is new onset Atrial Fibrillation considered for cardioversion?
If presenting within 48 hours of symptoms
What interaction with statins can increase the likelihood of myopathy and rhabdomyolysis?
Clarithromycin and Erythromycin
What is the imaging for suspected Aortic dissection?
CT Angiography CAP
What is the treatment for regular broad complex tachycardias ( Ventricular Tachycardias) with no adverse features?
IV Amiodarone
What is the treatment for regular narrow complex tachycardias ( SVT) with no adverse features?
Vasovagal maneuver
then
IV Adenosine
What are the complications of Thiazide diuretics?
Dehydration
Postural hypotension
Hyponatremia
Hypokalaemia Hypercalcaemia
Hypocalciuria ( why is prevents kidney stones)
Gout
What is the site of action of Furosemide?
Ascending loop of Henle Na/K/Cl Cotransporter
Which heart drug can cause cold peripheries?
B-Blocker
What should be done for a patient on Warfarin who experiences minor bleeding?
If INR>8
Stop Warfarin
Give I.V Vitamin K
Restart when INR is <5
What medication should be given post-stroke?
Without AF
Aspirin 300mg + life long clopidogrel 75mg post stroke
With AF
Aspirin 300mg + DOAC life long for post stroke
