Cardiology Flashcards
How is heart rate determined on an ECG?
Count the number of big squares between two consecutive R waves.
What does “regularly irregular” on an ECG suggest?
Sinus arrhythmia, atrial flutter.
What is the normal PR interval range?
3-5 small squares (0.12-0.2s).
What does a prolonged QRS complex suggest?
Bundle branch block, hyperkalaemia.
Which electrolyte imbalance shortens the QT interval?
Hypercalcaemia.
Apart from STEMI, what can ST elevation indicate?
Pericarditis
What is the significance of inverted T waves in V5 and V6?
Digoxin effect (reversed tick).
Which artery supplies the lateral wall of the heart?
Left circumflex artery.
How is stable angina relieved?
Rest or sublingual GTN within 5 minutes.
What is the first-line medication for chronic angina?
Beta-blockers or calcium channel blockers.
What does a delta wave indicate on ECG?
Wolf Parkinson White syndrome
What are the ECG signs of hyperkalemia?
Tall tented T waves, prolonged QRS complex, absent P waves
In hypokalemia, what changes are seen in the ECG?
Long PR interval and long QT interval.
How is STEMI defined on an ECG?
ST elevation >1mm in ≥2 inferior leads (II, III, aVF) or >2mm in ≥2 adjacent anterior leads (V1-6), new LBBB, or posterior MI.
Name complications occurring within 0-24 hours of NSTEMI
Cardiac arrest (VF), AV block, acute heart failure, cardiogenic shock.
What is the ECG characteristic of Wolff-Parkinson-White syndrome?
Shortened PR interval, prolonged QRS with slurred upstroke ‘delta’ wave, axis deviation.
How is the rate controlled in atrial flutter?
Beta-blockers or non-dihydropyridine rate-limiting calcium channel blockers (diltiazem, verapamil).
How is rhythm controlled in atrial fibrillation?
Electrical cardioversion or pharmacological (flecainide IV, sotalol IV, or amiodarone IV).
How does atrial flutter present on an ECG?
Fixed block and sawtooth pattern.
What is the first-line treatment for stable narrow complex tachycardia?
Vagal maneuvers, Adenosine.
How does atrial flutter present on an ECG?
Fixed block and sawtooth pattern.
What is the first-line treatment for regular broad complex ventricular tachycardia?
Amiodarone 300mg IV over 10-20 mins, followed by 900mg over 24 hours.
What is the preferred treatment for irregular broad complex tachycardia, such as Torsade de Pointes?
Magnesium sulfate 2g IV.
What is the first-line treatment for sinus bradycardia and heart blocks?
Atropine 500mcg IV (repeat to max 3mg).
In cardiac arrest, what is the initial approach after CPR and attaching a defibrillator?
Assess the rhythm - shockable (VF or pulseless VT) or non-shockable (PEA or asystole).
In non-shockable cardiac arrest rhythms, what medication is administered after 2 minutes of CPR?
Adrenaline 1mg of 1:10,000 IV (repeat every 3-5 minutes).
What are the symptoms of left-sided heart failure?
Dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, fatigue, pulmonary oedema, pleural effusion, cyanosis, pulsus alternans.
What are the signs of right-sided heart failure?
Peripheral oedema, ascites, tender pulsatile hepatomegaly, raised JVP (with hepatojugular reflux).
What is the immediate treatment for acute pulmonary edema?
Oxygen 15L + diamorphine 1.25-2.5mg IV + furosemide 20-50mg IV + GTN.
What causes a soft S1 sound in valvular heart disease?
Mitral regurgitation due to incomplete valve closure, prolonged PR
When is a 4th heart sound heard?
Aortic stenosis, HOCM, HF, MI - always pathological
What causes a loud S1 sound in valvular heart disease
Mitral stenosis - Narrowed valve limits flow, shortened PR interval
What are the symptoms associated with mitral regurgitation?
Left-sided heart failure symptoms, atrial fibrillation, displaced apex, thrill, pansystolic murmur
What are the common causes of mitral stenosis?
Rheumatic fever
What symptoms are associated with aortic stenosis?
narrow pulse pressure, slow-rising pulse, displaced apex, heave, systolic thrill, ejection systolic murmur
What are the common causes of aortic regurgitation?
Rheumatic fever, endocarditis, ankylosing spondylitis, Marfan’s and Ehlers-Danlos syndrome.1
What are the signs indicating the severity of aortic regurgitation?
Collapsing pulse,wide pulse pressure, displaced apex, heave, diastolic thrill, early diastolic murmur (Austin Flint murmur).
What are the main differences between mechanical and prosthetic heart valves?
Mechanical valves have a longer lifespan, are suitable for younger patients, and require lifelong anticoagulation (warfarin). Prosthetic valves have a shorter lifespan, are suitable for older patients or those at high risk of bleeding or wishing to conceive, and require anticoagulation for 3 months.
What are the components of tetralogy of Fallot (TOF)?
Pulmonary stenosis (RVOT), RVH, Overriding aorta, VSD. Ejection systolic murmur
How does transposition of the great arteries typically present?
Presents at birth with severe cyanosis. Diagnosed by echo and CXR (‘egg on a string’ heart)
What are the symptoms of pericarditis?
Sharp pain worse on lying flat and better on sitting forwards, fever, pericardial rub.
What are the common causes of infective endocarditis?
Strep viridans / staph aureus in IVDU
What is the diagnostic criteria for rheumatic fever?
Jones criteria
What type of chorea can occur in rheumatic fever
Sydenhams chorea
Which types of pacing are used in bradycardia?
Pacing includes transcutaneous (temporary) pacing and transvenous (permanent) pacing
How is pericarditis diagnosed?
Diagnosed by ECG showing widespread PR depression and ST (concave) elevation. Pericardial rub
What is the pathogenesis of rheumatic fever?
Caused by strep pyogenes (2-4 weeks after pharyngeal infection)
What is the genetic basis of hypertrophic obstructive cardiomyopathy?
Autosomal dominant, mutation of the gene encoding myosin contractile proteins. Features include LV hypertrophy
What ECG finding is associated with third-degree heart block?
complete heart block, is characterized by a complete dissociation between atrial and ventricular contractions
What are the criteria for rate control in atrial fibrillation (AF)?
Rate control in AF is recommended for patients older than 65 years or those with a history of ischemic heart disease.
What is the first-line treatment for stable ventricular tachycardia?
The first-line treatment for stable ventricular tachycardia is amiodarone 300mg IV over 10-20 minutes, followed by 900mg over 24 hours.
Which individuals are at increased risk of dilated cardiomyopathy?
Alcoholics
Target INR in aortic valve mechanical replacement
3.0
Target INR in mitral valve mechanical replacement
3.5
Which cardio drug class can lead to gum swelling (gingival hyperplasia)?
CCBs e.g. amlodipine
Imaging for acute pericarditis
Transthoracic echocardiogram
Which class of medications are contraindicated in aortic stenosis?
Nitrates
How to differentiate between TRALI and TACO
TRALI = hypotension, TACO = hypertension
How is TRALI treated?
Titrate O2, IV fluids, consider escalation of care
What is a clinical sign of Takayasu’s arteritis?
Absent upper limb pulses
What is seen on ophthalmoscope in endocarditis?
Roth spots
How do you take blood cultures in infective endocarditis?
3 sets of cultures from 3 different sites on 3 different occasions before starting ABx
Which group of drugs can cause ototoxicity?
Loop diuretics
What is heard on auscultation in pulmonary hypertension?
a loud S2
Thrombophlebitis (superficial VTE) management
Analgesia + compression stockings
Which ECG sign is most specific for acute pericarditis?
PR depression
Pathogen that causes endocarditis within 2 months of valve replacement
Staphylococcus epidermidis
Pathogen that causes endocarditis > 2 months of valve replacement
Staphylococcus aureus
Symptoms of rheumatic fever
Recent sore throat, chorea (jerk, irregular movements) and polyarthralgia
Dermatological condition associated with rheumatic fever
Erythema marginatum
1st line management of acute pericarditis
Combination of NSAID and colchicine
Surgical intervention for WPW syndrome
Catheter ablation
Which drugs should be avoided in AF and atrial flutter with WPW
AV node blockers e.g. verapamil, adenosine, CCBs, beta blockers
What is heard on auscultation in cardiac tamponade?
Muffled heart sounds
Gold standard investigation in cardiac tamponade
Echocardiogram
What percentage reduction do we aim for with statins?
At least 40%
Myocarditis clinical picture
ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness
How are unstable NSTEMI patients managed?
Immediate coronary angiogram
Most common cause of death post-MI
Ventricular fibrilation
Which post-MI complication leads to mitral regurgitation
Papillary muscle rupture
Symptoms of digoxin toxicity
Yellow-green tinge to vision + lethargy
Which medications can cause torsades des pointes?
Macrolide antibiotics e.g. clarithromycin
In ACS management, which medication is contraindicated in hypotension?
Nitrates
Hypercalcaemia ECG changes
Short QT, bradycardia, widened QRS and prolonged PR
Initial management of hypercalcaemia
0.9% NaCl replacement (3-4 litres a day)
Management of hypercalcaemia if fluid replacement is unsuccessful
IV bisphosphonates / calcitonin OR loop diuretics
Which cancers can cause hypercalcaemia
Lymphoma, breast, lung, myeloma
Main ECG change in hypercalcaemia
Short QT
SVC obstruction emergency management
Dexamethasone
Symptoms of SVC
Bulging of facial veins, SOB, raised ICP signs, Pemberton’s test (cyanosis when they lift their arms)
How should GTN be taken?
Wait 5 mins between doses, take while sitting, if after 10 mins (3 doses - 999), SE = headache
Target INR for AF
2-3
Mechanism of action of beta blockers and CCBs in angina-relief
Beta blockers reduce heart rate and strength of contraction (reducing O2 and perfusion demand of myocardium)
CCBs relax coronary artery smooth muscles (increases O2 and perfusion to heart)
Which valvular lesion predisposes you to AF and why?
Mitral stenosis (increased atrial workload > LA hypertrophy > SA node disturbance)
Below which ABPI suggests some intermittent claudication / peripheral arterial disease?
< 0.9 (Leg / arm ABPI)
1st line investigation in intermittent claudication
Doppler ultrasound
Define intermittent claudication
pain in calf/leg/buttock when walking for given distance, relieved by rest.
The 6 Ps of acute limb ischaemia
Perishing cold, pale, pulseless, paraesthesia, paralysis, painful
Features of critical limb ischaemia / Buerger’s disease
Foot pain at rest, burning pain at night, relieved by hanging foot off side of bed, gangrene / ulceration
Management of critical limb ischaemia
Surgical emergency: needs revascularisation within 4-6 hours to save limb
When should you suspect emboli in critical limb ischaemia ?
No previous vessel disease. 40% cases are thrombotic, 38% are emboli. Do urgeny arteriopgraphy. May give thrombolysis if embolic.
Conservative management options for peripheral vascular disease
Antiplatelets e.g. clopidogrel, treat hypertension, smoking cessation, supervised exercise programs
- Naftidrofuryl oxalate (vasoactive drug – if don’t want revascularisation)
Surgical options for peripheral vascular disease
Endovascular stent, bypass graft, transluminal angioplasty, amputation
Imaging modalities in acute limb ischaemia / critical ischaemia
MR/CT angiogram, colour duplex USS
In terms of area of lower limb affected, how do we differentiated between peripheral arterial vs venous ulcers?
Arterial ulcers tend to be more distal
Left ventricular hypertrophy signs on ECG?
ST depression, prolonged QRS, inverted T waves, tall R waves in V5 and V6, S waves in V1 and V2, left axis deviation
Cardiac complication of aortic stenosis
LVH > L-sided heart failure
Long-term complications of untreated aortic stenosis
Two from: Sudden death, Arrhythmia such as AF or VT, Left heart failure, Angina
Right heart failure, Cerebral embolus
Clopidogrel mechanism of action
Binds to platelets’ P2Y12 receptor and inhibits platelet aggregation
Which clotting factors does heparin act on?
IIa and Xa
Which drug acts the same way as clopidogrel (binds to P2Y12 receptor on platelets), but reversibly?
Ticagrelor
Drugs used for rate control in AF
Beta blocker, rate-limiting CCBs (verapamil / diliatazem), digoxin if sedentary lifestyle
Beck’s triad of cardiac tamponade +/- pulse change
hypotension, raised JVP, muffled heart sounds +/- pulsus parodoxus (10mmHg decrease in arterial systolic pressure with inspiration)
Drugs that may cause pericarditis
Isoniazid, phenytoin, anticoags
Most common causes of pericarditis
Idiopathic or viral (coxsackie, EBV etc)
Causes of secondary hypertension
Phaeochromocytoma, conns, cushings, renal artery stenosis, hyperthyroid, acromegaly
Examination findings in infective endocarditis
- Pallor / Conjunctival Pallor
- Clubbing
- Roth Spots
- Osler’s Nodes
- Splinter Haemorrhages
- Splenomegaly
- Janeway’s Lesions
- Petechiae
- Hypotension
- Tachycardia
- Tachypnoea
Risk factors for infective endocarditis
Dental Surgery / Prosthetic Heart Valves / Thoracotomy / Valvular Disease / Rheumatic Heart Disease / Indwelling Cardiac Devices / Catheterisation / Haemodialysis / Immunosuppression
IVDU
ABCDE signs of heart failure on CXR
- Alveolar oedema
- Kerley B lines/ interstitial oedema
- Cardiomegaly
- Dilated prominent upper lobe vessels
- Pleural effusion (bilateral)
Signs of pulmonary oedema / cor pulmonale on examination
- Hypertension
- 3rd heart sound
- Raised JVP
- Peripheral oedema
- Frothy sputum
- Tachycardia
- Fine crackles
- Dyspnoea
Amiodarone monitoring requirements
TFTs and LFTs
Define atherosclerosis formation
Accumulation of lipids, macrophages, and smooth muscle cells in the intima of large and medium sized arteries.
Define 1st degree heart block
Indicated on an ECG by a prolonged PR interval
Define Mobitz I (Wenckebach) - second degree heart block
has progressive prolongation of the PR interval followed by a dropped QRS complex
Define Mobitz II - second degree heart block
AV block is a disease of the distal conduction system (His-Purkinje system). Characterised by intermittently non-conducted P waves not preceded by PR prolongation and not followed by PR shortening
Define 3rd degree heart block
Complete absence of AV conduction. E.g. atrial rate is ~100 bpm, ventricular rate ~40 bpm. 2 rates are independent.
Actions of the RAAS system
- Increased sympathetic activity
- Increased tubular reabsorption of Na and Cl. K+ excretion. H2O retention.
- Increased aldosterone secretion resulting in Na reabsorption in DCT.
- Arteriolar vasoconstriction
- ADH secretion leading to H2O reabsorption
- Overall salt and water retention and an increase in BP.
Causes of secondary hypertension
Renal artery stenosis Chronic renal disease Primary hyperaldosteronism Stress
Sleep apnea
Hyper- or hypothyroidism Pheochromocytoma Preeclampsia
Aortic coarctation
How do we define broad complex tachycardia?
QRS of more than 0.12s
