Cardiology Flashcards
What is Beck’s triad for cardiac tamponade and when is thi seen clinically?
1) Hypotension
2) Raised JVP
3) Muffled heart sounds
Seen in cardiac tamponade
What is the most important cause of ventricular tachycardia?
Hypokalaemia
Followed by hypomagnesaemia
NOTE: severe hyperkalaemia can also cause in certain circumstances e.g. in patients with structural heart disease
What are the shockable rhythms? And their drug management?
1) Ventricular fibrillation
2) Pulsess VT
Management: Amiodaraone 300mg (or lidocaine), after 3 shocks
What are the non-shockable rhythms?
1) Asystole
2) PEA
When do you give adrenaline in cardiac arrest? Also what dose
Non-shockale- ASAP
Shockable- after 3rd shock
Repeat adrenaline every 3-5mins
Adrenaline 1mg
What are the reversible causes of cardiac arrest?
Hs:
Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemi and other metabolic disorders
Ts:
Thrombosis
Tension pneumothorax
Tamponade (cardiac)
Toxins
What is the drug management of angina?
1st line: beta-blocker or rate-limiting calcium channel blocker (e.g. verapamil or diltiazem)
2nd line: both (if used in combo with BB use elongating CCP e.g. amlodipine, MR nifedipine)
3rd line: long-acting nitrate, ivabradine, nicorandil, ranolazine (and refer for PCI/CABG)
What are the ECG changes caused by hypokalaemia?
1) U waves
2) small or absent t waves
3) Prolonged PR interval
4) St depression
5) long QT interval
What ECG changes do you expect with pericarditis?
Often global/widespread changes
1)’saddle-shaped ST elevation”
2) PR depression (most specific for pericarditis)
Side effects of GTN spray
Hypotension
Tachycardia
Headache
Characterise aortic regurgitation murmur?
Early diastolic
Characterise mitral regurgitation murmur?
Pansystolic
What are the complications of MI?
1) Cardiac arrest (VF- most common cause
2) Cardiogenic shock
3) Chronic heart failure
4) Tachyarrhythmia- e.g. VF
5) AV block after Inferior MI
6) Pericarditis- normally in first 48hrs
7) Dressler’s syndrome- 2-6 weeks later (fever, pleuritic pain, pericardial effusion and raised ESR)
8) Left ventricular aneurysm (persistent ST elevation LVF)
9) Left ventricular free wall rupture
10) Ventricular septal defect
11) Acute mitral regurgitation- acute hypotension and flash pulmonary oedema
Characterise aortic stenosis
Ejection systolic murmur
Causes of RBBB
1) normal variant - more common with increasing age
2) right ventricular hypertrophy
3) chronically increased right ventricular pressure - e.g. cor pulmonale
4) pulmonary embolism
5) myocardial infarction
6) atrial septal defect (ostium secundum)
7) cardiomyopathy or myocarditis
Chronic heart failure management
1st line: ACEi and Beta-blocker
2nd: Aldosterone antagonist e.g. spironolactone or eplerenone
3rd line: Ivabradine, sacubitril-valsartan, hydralazine in combo with nitrate, digoxin and cardiac resynchronisation
Management of hypertension in patients with T2 diabetes?
ACE inhibitor or an angiotensin receptor blocker regardless of age
Characterise mitral stenosis murmur
mid-late diastolic murmur
Management of angina if there is co-existent AF and chronic heart failure?
Digoxin
Pharmacological cardioversion for AF
1) flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or
2) amiodarone if there is evidence of structural heart disease.’
ECG changes for hypercalcaemia
Shortened QT
When is PCI used?
- should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI)
When is fibrinolysis used?
should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given
What is antiplatelet therapy for patients with STEMi prior to PCI?
‘dual antiplatelet therapy’, i.e. aspirin + another drug:
- if the patient is not taking an oral anticoagulant: prasugrel
- if taking an oral anticoagulant: clopidogrel
What is antiplatelet therapy for patients with STEMi during PCI?
Radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
Femoral access:
bivalirudin with bailout GPI
What is drug therapy for patients with NSTEMi prior to PCI?
1) antithrombin treatment:
- fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately
- if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given
2) DAPT i.e. aspirin + another drug:
- if the patient is not taking an oral anticoagulant: prasugrel or ticagelor
- if taking an oral anticoagulant: clopidogrel
For PCI unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
What is the conservative management of NSTEMi/ unstable angina?
‘dual antiplatelet therapy’, i.e. aspirin + another drug)
if the patient is not at a high risk of bleeding: ticagrelor
if the patient is at a high risk of bleeding: clopidogrel
What are the two types of aortic dissection?
1) type A - ascending aorta, 2/3 of cases
2) type B - descending aorta, distal to left subclavian origin, 1/3 of cases
What are the investigations for aortic dissection?
For stable pts:
CT angiography of the chest, abdomen and pelvis- shows false lumen
For unstable pts:
Transoesophageal echocardiography (TOE)
CXR- shows widened mediastinum
What is the management of aortic dissection?
Type A
-surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type B*
- conservative management
- bed rest
- reduce blood pressure IV labetalol to prevent progression
What are the complications of aortic dissection?
Backward tear:
1) Aortic regurgitation/incompetence
2) MI (normally inferior due to RCA involvement)
Forward tear:
3) unequal arm pulses and BP
4) stroke
5) renal failure
What vessel is affected by inferior MI and where are the expected ECG changes?
Right coronary artery
II, III and aVF
What vessel is affected by posterior MI and where are the expected ECG changes?
left circumflex and right coronary artery
V1-V3
Reciprocal changes of STEMI are typically seen:
horizontal ST depression
tall, broad R waves
upright T waves
dominant R wave in V2
Posterior infarction is confirmed by ST elevation and Q waves in posterior leads (V7-9)
What vessel is affected by anterior MI and what are the expected ECG changes?
Left anterior descending
Anterolateral:
V1-6, I, aVL
Anteroseptal:
V1-V4
What vessel is affected by lateral MI and what are the expected ECG changes?
Left circumflex
I, aVL +/- V5-6
What is Brugada syndrome and its management?
A form of inherited cardiovascular disease with may present with sudden cardiac death
Autosomal dominant
Management: implantable cardioverter-defibrillator
What is the management of HOCM?
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
What drugs should you avoid in HOCM?
nitrates
ACE-inhibitors
inotropes
What are the ECG findings for Wolff-Parkinson-White?
1) Short PR (<120ms)
2) wide QRS (>110ms)
3) delta wave (slurred, slow rising QRS upstroke)
What is the management of a stable narrow complex tachycardia?
Regular: Vagal manouvres then 6,12,18mg adenosine
Irregular: probable AF- BB or rate-limiting CCB (e.g. diltiazem)
What is the management of a stable broad complex tachycardia?
irregular- prabable AF with BB->BB or rate-limiting CCB (e.g. diltiazem)
regular- probable VT-> amiodarone 300mg , if not Dc cardioversion
What is the management of smoking cessation and their contraindications?
1) Varenicline= nicotine receptor agonist
CIs: Depression/suicidal ideation.
2) Bupropion= dopamine reuptake inhibitor
CIs: Epilepsy.
What are the features of tricuspid regurgitation?
Pansystolic murmur loudest on inspiration
Left parasternal heave
JVP - large V waves.
What are the causes of tricuspid regurgitation?
Pulmonary hypertension and infective endocarditis
What is the cause of mitral stenosis?
Rheumatic fever
What are causes of mitral regurgitation?
post-MI/ischaemic heart disease
MV prolapse
Rheumatic fever
What are the different heart blocks?
1st: PR>200ms
2nd:
Mobitz I (Wenkeback) progressive PR until dropped QRS
Mobitz II- Prolonged PR interval is constant with dropped QRS complexes
3rd: Complete dissociation between P waves and QRS complexes
What are causes of canon A waves?
Regular= VT
Irregular Complete HB
What is the stage 4 management of hypertension?
- If K+ <4.5→ spironolactone
- If K+ >4.5→ A or B blocker
What is the antibiotic treatment of infective endocarditis?
Amoxicillin and gentamicin
If staph-> fluclox
If strep- benzylpenicllin
What is the management of acute pericarditis?
NSAID + colchicine
