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1. Fellowship Written - SAQ > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What are three reversible precipitants of complete heart block?

Non reversible

A

reversible
* hyperkalaemia
* MI
* drugs - calcium channel blockers/beta blockers

Non
* * cardiac fibrosis
* * infiltratve disease

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2
Q

how do you manage complete heart block

A

seek and treat precipitant
medical - adrenaline 25-50mcg bolus, isoprenaline infusion 0.1-1mcg/kg/min
Surgical - transcutaneous pacing with analgesia/sedation
disposition - cardiology for pacemaker

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3
Q

What’s the criteria for Brugada

A
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4
Q

What clinic features must be present for Brugada

A
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5
Q

List 10 high risk features of chest pain

A

Prolonged or repetitive pain
Raised biomarkers
ECG changes – ST depression >0.5mm / TWI >2mm
transient ST elevation
VT
Shock
Syncope
DM
Renal failure
PCI 6/12 or CABG ever
EF <40%

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6
Q

What clinical features (5) make VT more likely than SVT

A
  • Age over 35
  • IHD
  • Structural heart disease
  • Previous MI
  • CCF
  • FH of sudden cardiac dearh
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7
Q

What old ECG make SVT with aberrance more likely than VT

A
  • previous ECGs show bundle branch with identical morphology to
  • previous ECGs show WPW (short PR, delta wave, narros QRS)
  • previous tachyarrhtymias terminated with vagal or adenosine
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8
Q

What are the 5 ECG features suggesting VT over SVT

A
  • A - Axis - northwest axis
  • B - Broad complexes over 200ms
  • C - Concordance - positive/negative concordance in leads v1 - v6
  • D - Dissociation - is there any AV dissocation - suggestive of VT
    1. * P and QRS different rates
    2. Capture beats or fusion beats
    3. RSR with tall left rabbit ear
  • E- Early part of QRS is slow - in RBBB right is taller

https://litfl.com/wp-content/uploads/2018/08/ECG-VT-Taller-left-rabbit-ear.jpg

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9
Q

describe main ECG features
What is it?

A

bradycadia
av dissociation
peaked t waves
broad complex escape

complete heart block with ventricular escape

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10
Q

In an inferior STEMI what lead placement suggest right ventricular infarct

A
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11
Q

ECG in a kid - describe it
What is it?
What is the management>

A

tachy - say rate
narrow complex
no p waves
normal R R

Supraventricular tachycardia

Management
Simple - ice park on face
Adenosine 100/200/300mcg/kg
DC cardiversion under sedation - 1 then 2 j/kg

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12
Q

What measures can be used to reduce time to PCI?

A

ambulance pre notification
immediate ECG on arrival for all those with chest pain
immediate senior doctor review
minimise transfers eg stay on trolley
on number to activate lab
transfer packs

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13
Q

chest pain
1) whats the diagnosis with supportive ECG findings
2) What is the most important complication

A

1) inferior lateral STEMI

ST elevation in 2,3 AVF
reciprical changes 1 and avl
lateral st depression
q wave in 3

2) monomophic VT

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14
Q

Treament for MI

A

Analgesia - titrated opiates
aspirin 300mg
clopidogrel (300) or ticagrelor (180mg)
Clexane
cardio input for PCI
only oxygen if sats under 90 - aim for 94-98

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15
Q

What is the pharmacological treatment for monomorphic VT?

A

Amioderone 5mg/kg
Lidocaine 1-2mg/kg
soltalol 1mg/kg

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16
Q

describe and interpret ECG
What advice would you give to ambos on the phone

A
  • hyperacute T waves anterolateral (de winters)
  • upsloping ST v3-v6
  • ST elevation 1 and avl
  • ST depression 3 and avf

Proximal LAD stenosis

Advice
give stemi meds
analgesia
sats 92-96
inform cath lab

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17
Q

in STEMI what fibrinolytics can be used?

A

Retaplase 10 units IV now and in 30 mins
Alteplase:
>65kg - 15mg IV then 50mg over 30 mins then 35mg over an hour
<65 15mg IV then 0.75mg/kg over 30 mins and 0.5mh/kg over an hour

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18
Q

what are the absolute/relative contraindicatins to fibronolytics in MI

A

Absolute
* any prior ICH
* ischaemic stroke in last 3 months
* intercranial malignancy
* suspected aortic dissection
* AV malformation
* Active bleeding
* prior streptokinase in last 6 month (if giving this)

Relative
* poorly controlled severe hypertension
* BP over 180 at presentation
* ischamic stoke over 3 months
* pregnancy
* active peptic ulcer
* surgery within last 3 weeks

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19
Q

what consitutes a failure of MI thrombolysis suggesting need for rescue PCI

A

persistant pain
failure to reduce ST elevation by 50-75% 90 mins post therapy

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20
Q

what does this show?

A

junctional rhythm - pacing come from AV node or bundle of his
no p waves or buried in QRS

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21
Q

Describe and interpret

A

inferior ST elevation
borderline upright T waves V1
St depression v2
Q waves

Inferior STEMI

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22
Q

What initial investigations may you do with ischamic ECG and why?

A

Troponins - marker of cardiac cell distress
ECHO - to show all abnormalities
CXR - any signs of failure
posterior leads ecg - any posterior signs

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23
Q

What are the clinical findings of APO?

A

bilateral crackles
widespread wheeze
raised JVP
peripheral oedema
SOB
hypoxia
tachycardia

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24
Q

What can precipitate APO?

A

hypertension
cardiac ischaemia
renal failure
stress - takutsobos
medicine non compliance
non compliance fluid restriction
inhaltion injury
drowning injury
pancreatitis
acute valve dysfunction
acure arrythmia

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25
What are the treamtents and end points for APO?
**GTN infusion **5-100mcg/min - 30% reduction in htn to reduce preload. decrease WOB and hypoxia **CPAP **Peep 5 - decrease WOB and hypoxia **Frusemide** - reduce BP and WOB
26
how does CPAP work in APO
reduced pre load by limited SVC/IVC flow to right side of heart improves gas exchange in alveolar
27
interpret and describe
Rapid Af with accessory pathway, likely WPW charecteristics: irregularly, irregular broad complex tachycardia delta waves V3
28
what is this
delta wave - WPW
29
diagnosis Three supporting features
VT broad complex tachycardia at 180 capture beats
30
What can cause VT?
1. cardiac ischaemia 2. electrolytes - hypomag/kalaemia 3. drugs - tricyclics 4. cardiomyopathes 5. sarcoid/amyloid
31
What are the mangement steps for VT with signs of failure?
1. sedate - 25mcg fent 2. pads and shock 150-200j 3. correct underlying cause
32
diagnosis and describe abnormality
rhythm irregularly irregular = AF variable ventricular rate approx 200-250 LAD 2 types of QRS delta waves V4 AF with accesory pathway
33
what is the main abnormality?
atrial flutter with 2:1 block, no ischamia
34
With AF/Flutter, what factors favour rate control v rhythm control?
**Rate** * Over 65 * asymptomatic * longstanding AF * Left atrial enlargment **Rhythm** * young * severe symptoms * short duration * HF due to AF * mild or moderate left atrial enlargement
35
what factors must you consider for long term anticoagulation for AF?
HASBLED score Hypertension abnormal liver or renal function Stroke hx bleeding hx Labile INR over 65 drugs - aspirin/steroids
36
diagnosis Why?
monomorphic VT broad complex tachycardia NW axis jeffersons notch
37
What is a DDD pacemaker and how does it function?
**Dual chamber pacemaker** Dual chamber *sensing* Dual chamber *pacing* dual response to sensing that will inhbiit or trigger pacing depending on underlying rhythm
38
Describe ECG
* broad complex tachycardia approx 120 with pacing spike before every complex * absence of p wave suggesting the pacemaker is not triggerd by atrial sensing * like of atrial spike suggestng pacemaker does not trigger atrium
39
differntials for someone with a pacemker and tachycardia and lightheadedness. Management?
1. pacemaker mediated tachycardia - reentry tachycardia created by pacemaker 2. sensor induced tachycardia - misfire eg from loud noises or vibrations 3. lead displacement dystrhymia Management: 1. urgent pacemaker interrogation 2. magnet overpacemaker to inhibit sensing and stop pacemaker mediated tachy 3. vagal/adenosine or verapamil can inhibit PMT 4. cxr for lead placement 5. check electrolytes
40
what are the key findings of ECG relevant to her presentation? Diagnosis? mangement?
findings: paced rhythm at 130 pacing spikes after qrs retrograde p in 1, v1, v5,v6 Diagnosis **likely pacemaker mediated tachycardia** Management cardiac montoring and defib pads titraite analgesa 25mcg fent fluid for MAP over 65/70 sats over 94 magnet chat to cardio
41
how does a magnet aid in pacemaker dysfunction?
converts to asynchronous pacing which turns off sensing of the pacemaker and allows pacing of atrium and ventricles asynchronously
42
what are the criteria for cardioversion in AF?
* haemodynamic instability * patient choice * onset within 48 hours * lack of known structural heart disease * non chronic AF
43
What are the choices for chemical cardioversion in AF, plus dose and contraindications
**Flecanide **2mg/kg - LV dysfinction or BBB **Amioderone** 300mg - iodine allergy, thyroid dysfunction, hypotension **Soltalol **40-80mg - asthma, hypotension
44
What are the IV rate control drugs for AF and dose? Oral
**IV:** * metoprolol 2mg aliquots * verapamil 2.5-5mg aliqots * digoxin 500mcg * magnesium 10mmol over one hour **Oral** metoprolol 25-50mg
45
What score can you use from thrombus risk in af?
CHADVAS
46
what are the causes of fast af?
coronary artery disease holiday heart COPD mitral valve disease hyperthyroid PE pericarditis hypomag/kalaemia hypertension
47
what are some differentials for ST elevation
Ischamia brugada pericarditis BER PE SAH athletes pectus excavatum
48
what is the most significant finding?
ST elevation of 2mm followed by negative T wave in V1/V2 or coved ST in V1/V2
49
What ECG features could suggest a cardiac cause of syncope?
* Prolonged QT - torsades * Short PR and delta - WPW * epsilon waves - arrythmogenic right ventricle * deep Q or T wave inversion - HOCM * RSR and St elevation in v1/v2- Brugada * ECG features of hypo or hyperkalaemia
50
causes and management of non arrythomogenic cardiogenic shock
51
Diagnosis and supportive findings
**complete heart block** ECG changes * broad complex qrs * av dissocation * different atrial and ventricular rates
52
what is the sequential treatment of complete heart block?
**Aim for BP >90 and HR>50** 1. Atropine 1mg aliquots x 3 2. Elecrical pacing pace with 1mg aliquote midaz 3. chemical pacing - ispoprenaline (0.5-2mcg a min and titrate up) or adrenaline infusion 4. collect reversible causes 5. bolus fluid
53
what does this ecg suggest and why?
triple vessel disease/proximal LAD stenosis Why ST elevation AVR and multi lead ST depression - this means subendocardial ischaemia
54
With a NSTEMI in a rural hospital what are the mangement priorities?
* Initial stabilisation including pain control * Medication for Non STEACS – aspirin, clopidogrel,heparin. * iExclusion of contraindications to fibrinolysis * Close monitoring and serial ECGs to avoid missing a STEMI * Urgent transfer out to interventional cardiology
55
What is this and why?
LBBB meeting scarbossa therefore STEMI equivalent Why: LBBB with broad QRS and LAD hyperacute T waves V2-V4 concordant ST elevation in 1 and avl Discordant ST elevation V2/V3
56
What are the possible life threatening complications of STEMI equivalents
1. arthymias - VT/VT, brady heart blocks 2. APO 3. cardiogenic shock and hypotension affectinve end organ perfusion
57
What are the STEMI mimics?
ELEVATION Electrolytes - hyperK LBBB Early repolarization Ventricular hypertrophy (Left) Aneurysm (ventricular) Thailand - brugada Inflammation Osborne waves in hypothermia Non ischamic vasospasm
58
In NSTEMI/STEMI what factors affect a patients disposition?
* is there a cath lab within 90 minutes of door time * contraindications to thrombolysis * patient choice * shock - cath only good choice * local options * allergies
59
non reproducible chest pain in young person: 1. Diagnosis 2. why 3. What further investigations are needed?
**Acute pericarditis** Why: PR depression and diffuse ST elevation no adherant to territory Investigations Trop Echo MRI
60
what are the causes of acute pericarditis plus example and relevant investigation
**Infectious **- viral/bacterial/TB - none if viral, cultures if febrile **Inflammatory** - SLE/RA - if other sx of FH - autoimmune screen **Metabolic **- uremic - renal function **malignant **- lung ca - cxr **vasculitis radiation damage**
61
what is the sgarbossa criteria for STEMI equivalent
* concordant st elevation >1mm in leads with positive QRS * concordant st depression >1mm in v1-v3 * excessively discordant st elevation in leads with negative qrs (>5mm)
62
What are the cardiac and non cardiac causes of a raised troponin?
**Cardiac:** * ACS * Aortic dissection * cardiac contusion * cardiomyopathy * CCF **Non cardiac:** * acute SAH * renal failure * sepsis * hypoxia
63
what is this? what drugs can cause it?
torsades de points Drugs: * tricyclics * organophosphates * antihistamines * antifungals * erythromycin * class 1 (Na - lidocaine) and class 3 (K - amioderonne) anti arrthtymics
64
what are the indications for initiating pacing in complete heart block?
chest pain confusion hypotension any end organ signs
65
what drugs can be used for chemical pacing in heart block
Isoprenaline Adrenaline Dopamine Dobutmaine
66
Relevant findings What can cause this?
extreme brady then polymorphic VT R on T causing TDP ventricular ectopics Causes: hypok/mag drugs causing QT prolongation cardiac ischaemia
67
what is the treatment for torsades?
10mmol IV mg over 2 mins correct electrolytes eg K over 3.5 (10-20mmol/hr) Overdrive pacing 90-120 isoprenaline infusion 0.05/1mcg/kg/min
68
list 4 abnormalities
bradycardia at 45 sinus arrhtymia LAD RBBB bifascicular 1st degree block
69
What are some reversible causes of bradycardia?
* hypokalaemia * drugs eg beta blockers, dig, clonidine * ischami * myocarditis * hypothyroidism
70
what are Dukes criteria for endocarditis?
**Major** * 2 positive blood cultures over 12 hours apart * on echo - new regurg, mobile cardiac mass, dehiscence of prosthetic valve * periannular abscess **Minor** * temp >38 * IVDU/congenital heart disease * vascular phenomena * immunological phenomena
71
What are the most common causative agents for bacterial endocarditis in IVDU? Treatment?
staph aureus, strep viridans candida Treatment: Ceftriaxone, vanc, gent
71
define hypertensive emergency
systolic over 180 or diastolic over 110 with end organ damage
72
list organ, sign and investigation of hypertensive end organ damage
73
list two classes of medictions and doses for hypertensive emergency
74
differentials for chest pain and SOB
PE pneumonia pericardial effusion pneumothorax myocardial ischamia anxiety
75
list common causes of pericardial effusion
infections eg HIV, viral, bacterial neoplastic renal failure CCT liver failure lupus mxoedema aortic dissectiomn rheumatoid
76
what are the ECG features of cardiac tamponade?
* electrical alternans * low voltage * tachy
77
what are the echo features of cardiac tampanade?
* pericardial effusion * late diastolic collapse of RV free wall * early disatolic collase of RA free wall * dilated IVC with no respiratory collapse * diastolic flow reversal in hepatic veins * abnormal septal motion
78
what is this view?
apical four chamber
79
80
What ECG features make BER more likely than perciarditis?
1. ST elevation limited to precordial leads 2. absence of PR depression 3. Prominent T waves 4. no changes over time
81
what investigations can detect pericardial effusion?
ECG - low voltage CXR - globular heart echo - fluid as black stripe
82
What are the CXR features of APO
83
differentials of a systomic murmur
* AS * PS * MR * TR * ASD * VSD * HOCM
84
what are the physical signs of severe AS?
slow rising pulse S4 SOB LVH - displace apex LVF
85
why are nitrates contraindicated in AS
affects pre load which is already reduced in AS
86
main findings
sinus PR prolongation QT prolongation no ischamiea bradycardia
87
what features of a history suggest syncope over seizure
no post ictal no tongue biting/incontinence pre syncopal no neuro sx no seizure like movements
88
89
collapse: describe abnormalities and their significance
RBBB/LAD - bifascicular block significant because complete heart block may have occured
90
What can cause bifascicular block?
IHD CCF beta blockade amyloid sarcoid RA inflammatory
91
what investigations does bifascicular block need?
Address ?HF ?Ischamia ?need to pacemaker Echo and holter
92
what are the components of the San Francisco Syncope rule?
**CHESS** * CCF * Haematocrit under 30% * Abnormal ECG * SOB * SBP below 90 low risk if none of these are met
93
collapse diagnosis What are the key questions in a history?
Long QT History * any other syncope? * syncope in stressful or exertional event * palps or CP * any FH sudden death * relative with long QT? * drugs eg TCA soltalol, abx, antohistamies
94
list 5 differentials
**Cardogenic shock causes:** ACS arrhyhtmia eg new AF pericardial tamponade MV prolapse LV rupture **non cardiogenic** PE severe anaemia - GI bleed Sepsis
95
justify some bedside investigations doesnt get better and think synptons due to CAD. Stepwise approach to management endpoints for resus
repeat ecg - dynamic changes VBG - shock (lactate) or anaemia CXR - URTI/pneumothorax US - LV rupture, tampanade, MV prolapse **management** 1. 5ml/kg small boluses 2. ionotropes - adrenanaline 0.04mcg/kg 3. Arrange PCI end points BP over 100 urine output over 0.5ml/kg/hr resolution of lactate/Hb etc
96
what can account for hypotension post cardioversion and rhythm return?
effect of sedation sepsis stunned myocardium
97
What are the differentials for broad complex tachy
VT SVT with aberrancy SVT with WPW
98
99
What are the Jones criteria for rheumatic fever?
need two major plus one Major or two minor **Major** * Carditis * Arthritis * Chroea * Erythema marginatum * subcutaneous nodules **Minor** * Fever over 38.5 * raised ESR or CRP * Prolonged PR
100
What are the management priorities in hypertensive emergency?
1. analgesia and dose 2. antiemetic and dose 3. oxygen 4. immediate reduction of BP (MAP by 25 or diastolic to 110) over first hour 5. gradual decrease over next 4-6 hours
101
list three causes of neurally mediated syncope
1. vasovagal 2. situational eg micturition or cough 3. carotid sinus syncope
102
list three causes of orthostatic hypotension
1. any cause of volume depletion 2. drug related - any vasodilator 3. autonomic eg DM
103
what ECG findings may suggest arrythmogenic syncope in a currently asymptomatic patient?
* Bifascicular block * Pre-excitation (delta waves) * Prolonged or short QT * Brugada pattern – RBBB with ST elevation V1-3 * Findings of ARVC – epsilon waves, negative T waves right precordial leads
104
what are the main complications associated with HOCM?
1. sudden death 2. ventricualr arrhytmia 3. passing to offspring 4. abnormal coronary arteries and ischaemia
105
what are the indications for emergent cath lab in OOHCA
STEMI preceeding arrest STEMI on post ROSC ecg new LBBB post ROSC ecg

1. Fellowship Written - SAQ (29 decks)

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