Cardiology Flashcards
One drug to prescribe patients with chronic heart failure with reduced ejection fraction to improve survival?
ACEi (or ARB air not tolerated) or Beta-blocker. Start one at a time
After MI, which drugs prescribed to reduce mortality?
Dual antiplatelet (aspirin plus clothes or ticagrelor), statin, ACEi and B blocker
New AF. CHA2DS2-VASc score = 2. What anticoagulation?
Also how to calculate CHA2DS2-VASc?
DOAC - first line. Ie Apixaban, rivaroxaban
CHA2DS2-VASc:
CHF: yes=1, no=0
HTN : yes=1, no=0
Age: <65=0, 65-74 =1, >/=75 = 2
Diabetes : yes=1, no=0
Sex: 1 for female, 0 for male
Stroke/TIA/VTE : yes=1, no=0
Offer anticoagulation tx if score is 2 or more. Consider offering to men with score of 1 taking into account bleeding risk
Appearance of venous vs arterial ulcers?
Venous: irregular margins, rolled skin edges, red granulation tissue, yellow slough at base. Surrounding skin shows characteristic changes of chronic venous insufficiency ie oedema, hyperpigmentation. Typically ankle to mid calf.
Arterial: location generally pressure points, toes/feet, lateral malleolus/tibial. Punched out and deep, unhealthy wound bed, minimal exudate unless infected. Surrounding skin thin/shiny, cool, pallor, weak/absent pulses
Aortic regurgitation murmur - description, where best to hear, causes?
Early diastolic decrescendo murmur.
Best heard at left parasternal border, 3rd/4th intercostal space
(Can present with a bounding pulse or wide pulse pressure)
Causes: bicuspid aortic valve, endocarditis, rheumatic fever, aortic root dilatation,
Score used to ascends risk of death in ACS
GRACE
Score to assess bleeding risk and what it contains
ORBIT
Older age (>/=75)
Reduced Hb (<130 for men, <120 women, or hx anaemia)
Bleeding hx ie GIB, haemorrhagic stroke
Insufficient renal function (eGFR<60)
Treatment with antiplatelets
All score 1 point except Reduced Hb/anaemia which scores 2
Superventricular tachycardia
- definition?
-management?
Narrow complex tachycardia, rate >100, QRS complex <120ms
-Vagal manoeuvres (avoid in elderly due to risk of stroke from emboli)
-Valsalva manoeuvre
-if above fails, IV adenosine/verapamil
-if above fails, DC cardioversion
Maintenance = B-blockers/verapamil
Ventricular tachycardia
- definition?
- management?
Broad complex tachycardia, faster than 120bpm, arising distal to bundle of His
- Pulseless: unsynchronised defibrillation
- pulse & unstable - synchronised cardioversion
- pulse & stable - 300mg amiodarone IV
Brugada syndrome:
-who it typically affects
-how it presents/symptoms
-signs on ECG
-treatment
-young males from SE Asia
-often asymptomatic. Syncope in 3rd-4th decade
-ECG Brugada sign: ‘coved’ STE >2mm in >1 of V1-V3 followed by negative T wave
-Implantable cardioverter-defibrillator (ICD)
Corresponding coronary arteries to these ECG leads?
1) Lateral (1, aVL, V5-V6)
2) Inferior (II, III, aVF)
3) anterior (V1-V2)
1) Circumflex
2) Right coronary artery
3) Left anterior descending (LAD)
70 y/o woman, crushing retrosternal pain which radiates to jaw. Has had on and off for 3 years, prev cardiac Ivx normal. What is the diagnosis?
What investigation can you do and what would it show?
Oesophageal spasm
Barium swallow - corkscrew oesophagus due to multiple simultaneous contractions
Patient who had cardiac catheterisation this morning via femoral artery presents with cold foot. She has a pulsatile mass over her femoral artery with loss of distal pulses. Dx?
FemoralPSEUDOaneurysm
(Haematoma, with pulsatile mass, femoral bruit and loss of distal pulses.)
Which of the following is NOT a complication of MI?
1. Heart block
2. Tachyarrhythmias
3. L ventricular failure
4. Pericarditis
5. Mitral stenosis
- Mitral stenosis
(mitral REGURGITATION happens, due to rupture/ischaemia of the papillary/chordal muscles!)
Patient with stable angina. Which drug to start?
B blocker or cardio selective CCB ie verapamil.
Also GTN spray
Most common congenital defect in Down’s syndrome?
ASD
(Others include VSD, PDA and Fallot’s tetralogy)
How does mitral stenosis present?
What type of murmur and where best to hear?
-fatigue, dyspnoea, palpitations, malar flush, AF
-rumbling mid-diastolic murmur (loudest with expiration and patient on left side)
How does mitral stenosis present?
What type of murmur and where best to hear?
-fatigue, dyspnoea, palpitations, malar flush, AF
-rumbling mid-diastolic murmur (loudest with expiration and patient on left side)
25 y/o pt with hypertension confirmed with home measurements. No evidence of diabetes/heart/renal disease or organ damage. What should you do?
Refer for further investigations for all patients below 40 with no evidence of diabetes/heart/renal disease or organ damage!! Ie renal causes, vascular or endocrine disorders
Post MI, which antiplatelet to start?
DAPT (aspirin plus P2Y12 inhibitor ie clopidogrel, prasugrel, ticagrelor)
Following an ACS, all patients should be offered?
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Hallmark characteristic of hypertrophic cardiomyopathy (HCM)?
Asymmetrical septal hypertrophy
ECG changes in hypothermia?
J-waves (small peak connecting QRS with T wave)
AF
PR elongation
QRS widening
QT elongation
HypO = lOng!!
Example of fibrin-specific and non-fibrin specific thrombolyric
Fibrin-specific:
Alteplase (and other ‘plases’)
Non-fibrin specific:
Streptokinase (and other ‘kinases’)
When is Warfarin favoured over a DOAC and when are DOACs NOT recommended?
Warfarin favoured over DOAC if:
-eGFR <30
-significant liver dysfunction
-weight over 120kg
DOAC NOT recommended if:
-antiphospholipid syndrome
-prosthetic heart valves
-pregnancy/breast feeding
-severe hepatic impairment
-dose needs to be adjusted in renal impairment. Use with caution in severe impairment and avoid if eGFR <15
When to offer CCB ie Amlodipine as first line for HTN?
-if over 55 and no T2DM
-if black African/African-Carribean (any age)
When to offer ACEi or ARB as 1st line for HTN?
-if have T2DM (as renal protective!)
-if age <55 and not African-Caribbean
What is step 2 for HTN?
Add the other agent (if CCB, add ARB or ACEi, and vice versa)
OR
Add thiazide-like diuretic
If giving African-Caribbean patients ARB vs ACEi, which to choose?
ARB in preference to ACEi
Is low potassium linked to HTN
Yes - potassium deficiency stimulates RAAS system, promoting sodium retention and vasoconstriction
What to be cautious of with spironolactone and reduced eGFR?
Hyperkalaemia
In SVT, if no signs of shock, what to do? 2nd line?
Vagal manouvres
If unsuccessful- give adenosine IV
If VT, no signs of shock, what to give
Amiodarone infusion 300mg over 10-60 min
What does ‘Lone AF’ mean?
Occurs in younger adults (<60) without any cardiac/other disease
How does pericarditis present?
Typically acute, sharp and pleuritic chest pain that gets better when sitting up or leaning forward. Worse when lying flat
Typical ECG changes in pericarditis?
Saddle shaped ST elevation
And
PR depression
(With reciprocal ST depression and PR elevation)
What is exercise testing used for ?
Evaluating the presence of obstructive coronary disease.
Uses exercise, ECG and BP
What can cause low voltage on ECG?
Increased distance:
-fluid: pericardial/pleural effusion
-fat: obesity
-air: emphysema, pneumothorax
Infiltration of heart muscle3
-myxoedema
-restrictive cardiomyopathy /pericarditis
Loss of myocardium:
-prev massive MI
-end stage dilated cardiomyopathy
Triad of findings for massive pericardial effusion?
Low voltage
Tachycardia
Electrical alternans (variation in amplitude/direction or duration of waveform that occurs from beat to beat)
When do troponin levels start to rise
When do they peak?
How long can they remain elevated for?
2-4 hours within onset of injury
Peak 18-20 hours
Remain elevated for 2 weeks post MI
Initial treatment for MI
No longer MONA - only MNA
(IV opioid, nitrate, aspirin)
Oxygen only recommended if SATs <94% or pulmonary oedema
If patient is presenting within 2 hours symptom onset for STEMI, what to decide treatment
CAN PCI BE DELIVERED WITHIN 120 mins from ECG diagnosis?
If yes - PCI
If no - fibrinolysis
What is Dressler syndrome and how/when does it present?
Secondary pericarditis that occurs as result of injury to heart/pericardium
Typical presentation is 1-6 weeks following initial damage with:
-persistent low-grade fever
-pleuritic chest pain
-pericarditis (friction rub, diffuse STE)
-may have pericardial effusion
In theory, tearing pain in the following areas is linked to which anatomical area of dissection?
-anterior chest pain
-neck/jaw pain
-intrascapular pain
-anterior - anterior arch/aortic root
Neck/ jaw - aortic arch
Intrascapular - descending aorta
How does hypertrophic cardiomyopathy (HCM) usually present?
-sudden LOC
-chest pain
-palpitations
-postural light-headedness
-fatigue
-sudden death
How is HCM inherited?
Autosomal dominant
What is HCM characterised by (which area of heart is hypertrophic?)
Asymmetric left ventricular hypertrophy
Best investigation for HCM?
Echocardiography
What is Wolff-Parkinson-White syndrome and what shows on ECG?
Accessory pathway (bundle of Kent) creates abnormal electrical connection between atria and ventricles - bypassed AV node and allows pre-excitation of ventricles
Delta waves - slurred upstroke of QRS
Therefore also SHORT PR AND LONG QRS
How does papilloedema present on fundoscopy?
Blurred optic disc
Difference between Mobitz type 1 and 2?
Type 1 - Wenkebach ‘walking back’
-progressive prolongation of PR interval, until dropped QRS and cycle repeats
Type 2 - PR interval is consistent, but some p waves don’t conduct - may be regular pattern ie 2:1 or 3:1 block
Mx difference for Mobitz type 1 & 2 ?
Type 1 - almost always benign, no specific tx
Type 2 - may progress to complete heart block, need to be referred to cardiology
How is brugada syndrome inherited?
Autosomal dominant
What is Brugada syndrome?
What shows on ECG?
Genetic disease - impaired sodium channels lead to abnormal electrical activity in heart, can lead to fatal cardiac arrhythmias
STE in right precordial leads (V1-V3) can be ‘coved’ or ‘saddleback’
Post MI (without successful angioplasty):
-when can drive again?
-when able to resume sexual intercourse?
-how long off work?
Driving - 1 month (if successful angioplasty - only 1 week!)
Sexual intercourse - 1 month
Working - 2 months (unless specific jobs ie pilot)
Difference anatomically between NSTEMI and STEMI?
STEMI = complete atherosclerotic occlusion
NSTEMI = partial occlusion of coronary artery
How does atropine work?
Increases firing of the SA node and conduction through AV node, and opposed actions of vagus nerve - thus speeding up heart rate
What is it called when blood pressure drops >10 during inspiration ?
Associated conditions?
Pulsus paradoxus
-cardiac tamponade
-constrictive pericarditis
-severe heart failure
-severe asthma/COPD
-mechanical ventilation
-massive PE
-OSA
-hypovolaemic shock
Normal length in msec and small squares?
-PR interval
-QRS
-PR = 120-200msec or 3-5 small squares
-QRS complex - 120 or 3 squares
What is cholestyramine?
Side effects?
Bile acid sequestrant (binds bile in GI tract) - treats hypercholesterolaemia
Constipation, dental problems, GALLSTONES
What is nicotinic acid used for ?
Main side effect?
Lowers both cholesterol and triglyceride concentrations
Vasodilation - FLUSHING
ECG changes in PE?
Sinus tachycardia
RAD, RBBB, R ventricular strain
S1Q3T3 (rare)
Eye Symptoms of digoxin toxicity?
ECG changes?
Visual changes - most commonly yellow-green distortion
ST depression, inverted T waves in V5-6 (reversed tick)
ECG changes with hypokalaemia?
Small flattened T waves
Prominent U waves
Prolonged PR
ST depression
Beck’s triad for cardiac tamponade?
HDD
Hypotension
Distended neck veins
Distant heart sounds
Provoked vs Unprovoked causes of DVT
Provoked = TRANSIENT risk factor ie pregnancy, surgery, trauma, COCP
Unprovoked = no RF or PERSISTENT RF is cancer or thrombophilia
If CCB not tolerated as step 1 treatment ie oedema, what is next drug of choice?
THIAZIDE-LIKE DIURETIC IE INDAPAMIDE
Hypokalaemia ECG changes?
Prolonged Pr
ST depression
Shallow T wave
Prominent U wave
Hypercalcaemia ECG changes?
Short QT (normal 360-440msec or 9-11 boxes)
J waves - step off the QRS complex, or extra little wave after QRS
Murmur in mitral stenosis
Rumbling mid-diastolic murmur (loudest in expiration, and patient on left side)
