Cardiology Flashcards

Question

RFs for AAA?

Answer 1

Smoking, hypertension Syphilis, Ehlers Danlos type 1 and Marfan's syndrome

Answer 2

Majority of AAA are asymptomatic Screening for AAA consists of a single abdominal ultrasound for males over 65

Answer 3

<3cm- Normal- No further action 3-4.4cm- small aneurysm- rescan every 12 months 4.5 - 5.4 cm- Medium aneurysm- rescan every 3 months > 5.5cm- Large aneurysm- refer within 2 weeks to vascular surgery for probable intervention

Answer 4

Low rupture risk- asymptomatic, aortic diameter < 5.5cm (i.e. small and medium aneurysms)- abdominal US surveillance and optimise RFs. High rupture risk- symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)- refer within 2 weeks to vascular surgery for probable intervention Treat with elective endovascular repair (EVAR)

Answer 5

Severe, central abdominal pain radiating to the back Pulsatile, expansile mass in the abdomen Patients may be shocked- hypotension, tachycardia or may have collapsed

Answer 6

Surgical emergency- immediate vascular review with a view to emergency surgical repair Haemodynamically unstable patients diagnosis is clinical- straight to theatre. Frail patients- potential for palliative therapy Patients who are haemodynamically stable may go for CT angiography when diagnosis in doubt

Answer 7

Intermittent claudication- cramping/burning after walking. Relieved by rest. Critical limb ischaemia- claudication pain at rest, typically nocturnal, relieved by hanging foot out of bed- rink of gangrene, infection, ulcers Acute limb-threatening ischaemia- sudden decrease in arterial perfusion

Answer 8

One or more of 6P's Pale Pulseless Painful Paralysed Paraesthetic Perishingly cold

Answer 9

Handheld arterial Doppler examination. If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained. Attempt usually made to determine if due to thrombus (due to rupture of atherosclerotic plaque) or embolus (secondary to atrial fibrillation) Buerger’s Test

Answer 10

Factors suggestive of thrombus: pre-existing claudication with sudden deterioration no obvious source for emboli reduced or absent pulses in contralateral limb evidence of widespread vascular disease (e.g. myocardial infarction, stroke, TIA, previous vascular surgery) Factors suggestive of embolus: sudden onset of painful leg (< 24 hour) no history of claudication clinically obvious source of embolus (e.g. atrial fibrillation, recent myocardial infarction) no evidence of peripheral vascular disease (normal pulses in contralateral limb) evidence of proximal aneurysm (e.g. abdominal or popliteal)

Answer 11

ABC approach Analgesia: IV opioids IV unfractionated heparin Vascular review Definitive management: Intra-arterial thrombolysis Surgical embolectomy Angioplasty Bypass surgery Amputation: for patients with irreversible ischaemia

Answer 12

1 or more of: Rest pain in foot for more than 2 weeks Ulceration Gangrene

Answer 13

< 0.5 is suggestive of critical limb ischaemia

Answer 14

Tear in the tunica intima of the wall of the aorta

Answer 15

Hypertension- most important factor Trauma Bicuspid aortic valve Collagens- Marfan's syndrome, Elhers-Danlos syndrome Turner's and Noonan's syndrome Pregnancy Syphilis

Answer 16

Chest/back pain- severe, sharp, tearing in nature, pain maximal at onset Chest pain more common in type A dissection and back pain in type B dissection but there is overlap Pulse defecit- weak or absent pulses, over 20 difference between the arms Aortic regurgitation Hypertension Other features may result from the involvement of specific arteries. For example: coronary arteries → angina spinal arteries → paraplegia distal aorta → limb ischaemia Majority no ECG changes, some ST elevation

Answer 17

Stanford- Type A - ascending aorta, 2/3 of cases Type B - descending aorta, distal to left subclavian origin, 1/3 of cases DeBakey classification type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally type II - originates in and is confined to the ascending aorta type III - originates in descending aorta, rarely extends proximally but will extend distally

Answer 18

Patients can present acutely and be clinically unstable so use appropriate investigation CXR- widened mediastinum CT angiography of the chest, abdomen and pelvis- investigation of choice- suitable for stable patients and planning surgery- false lumen is a key finding in aortic dissection Transoesophageal echocardiography (TOE)- more suitable for patients too high risk for CT scanner

Answer 19

Type A- surgical management, BP controlled 100-120 while waiting Type B- conservative, bed rest, IV labetalol to to prevent progression, surgery if complicated

Answer 20

Incompetent aortic valve leading to blood leaking back into ventricle from aorta during diastole

Answer 21

Rheumatic fever Calcified valve RA/SLE Bicuspid aortic valve IE

Answer 22

Bicuspid aortic valve Ankylosing spondylitis HTN Syphilis Marfan's, Ehler-Danlos Aortic dissection

Answer 23

Early diastolic murmur Collapsing pulse Wide pulse pressure Quinke's sign (nailbed pulsation) De Musset's sign (head bobbing) (SOBOE, oedema, fatigue, angina, syncope)

Answer 24

Echocardiogram

Answer 25

Medical management of HF Surgery- aortic valve replacement- symptomatic or LV systolic dysfunction

Answer 26

Narrowing of the aortic valve- most common valvular heart disease Calcification of aortic valve Congenital bicuspid valve Rheumatic heart disease – rare HOCM

Answer 27

Ejection systolic (crescendo-decrescendo) murmur ESM- radiates to the carotids Chest pain, dyspnoea, syncope/presyncope

Answer 28

Narrow pulse pressure Slow rising pulse Delayed ESM Soft/absent S2 S4

Answer 29

Investigation: echo If asymptomatic observe If symptomatic then valve replacement If asymptomatic, but valvular gradient >40mmHg + LVF, consider surgery Surgical options for aortic valve replacement: Surgical AVR (open)- low risk patients TAVI – transcatheter aortic valve implantation – for higher risk pts Balloon valvuloplasty- children or adults not fit for valve replacement

Answer 30

1-2% of population, asymptomatic in childhood, majority develop aortic stenosis or regurgitation Associated with left dominant coronary circulation and Turner's syndrome Higher risk of dissection/aneurysm

Answer 31

Most commonly replaced are the aortic and mitral Options for replacement: biological or prosthetic Biological- usually bovine. Major disadvantage is structural deterioration or calcification over time. Given to patients >65 for aortic and >70 for mechanical. Long term anticoagulation not needed. Warfarin may be given first 3 months, low dose aspirin long term. Most common mechanical valve is bileaflet valve. Mechanical valves have low failure rate. Major disadvantage is increased risk of thrombosis meaning long term anticoagulation needed. WARFARIN still used in preference to doacs in mechanical heart valves. Only add aspirin if there is another indication.

Answer 32

Blood leaking back through the mitral valve during systole Second most common valve disease after aortic stenosis Mitral valve between left atrium and ventricle You get left atrial enlargement and LVH

Answer 33

Mitral valve prolapse Post MI Infective endocarditis Rheumatic fever Congenital Connective tissue disorders – Ehlers-Danlos, Marfan

Answer 34

Pansystolic murmur- radiates to axilla SOBOE, palpitaitons, fatigue, signs of HF

Answer 35

Echocardiogram CXR- cardiomegaly ECG- LA enlargement- broad P wave- LVH in severe

Answer 36

In acute cases, nitrates, diuretics, inotropes, intra-aortic balloon pump – to increase CO HF – ACEi, BBs, spironolactone etc Surgery Repair / replacement

Answer 37

Obstruction of blood flow from LA to LV, inreased pressure in LA

Answer 38

RHEUMATIC fever- most common cause also infective endocarditis

Answer 39

Mid-diastolic murmur SOBOE, oedema, angina Haemoptysis from rupture of pulmonary vessels Loud S1 Opening snap Low volume pulse Malar flush AF

Answer 40

Echo CXR ECG

Answer 41

Asymptomatic- regular monitoring with ECHO If sx Balloon valvuloplasty Mitral valve replacement

Answer 42

Disorganised electrical activity of the atria leading to fibrillation- irregularly irregular rhythm Type of supraventricular tachycardia

Answer 43

First detected episode Recurrent episodes- 2 or more episodes of AF either: Paroxysmal AF – terminates spontaneously – tend to be <7d, typically <24hrs Persistent AF – not self-terminating – >7d Permanent AF – continuous AF, tx goals are rate control / anticoagulation

Answer 44

Palpitations SOB Chest pain Syncope Sx of associated conditions- stroke, infection Irregularly irregular pulse

Answer 45

ECG- Absent P waves Irregularly irregular pulse ECHO For paroxysmal AF: 24 hour ECG CHA2DS2VASc / ORBIT

Answer 46

Two key aspects: Rate/rhythm control Reducing stroke risk Rate control- slow the rate down to avoid negative effects on cardiac function Rhythm control- try to get patient back into and maintain sinus rhythm. Called cardioversion- using drugs or electric shocks NICE advocate rate control in specific situations such as coexistant heart failure, first onset AF or where there is a reversible cause

Answer 47

Beta blocker or rate limiting CCB (diltiazem) If one drug does not control then add either: Betablocker Diltiazem Digoxin Other one or digoxin

Answer 48

As cardioversion is attempted a clot can be pushed out on return to sinus rhythm. Therefore patient must have had symptoms less than 48 hours or be anticoagulated for a period of time prior to attempting cardioversion Can be used as electrical cardioversion emergency if the patient is haemodynamically unstable Electrical cardioversion is synced to the R wave Medical cardioversion is with amiodarone If >48 hours AF then patient should recieve anticoagulation for at least 3 weeks before cardioversion After electrical cardioversion patients should be anticoagulated for 4 weeks

Answer 49

CHA2DS2-VASc used to determine if anticoagulation needed Choice of warfarin or DOACs Should be on DOAC and discuss with patient about changing if on warfarin, warfarin second line NICE warn not to withhold anticoagulation based on solely age or falls risk. Use ORBIT system (look up).

Answer 50

Congestive heart failure- 1 Hypertension- 1 Age >75- 2 Age 65-74- 1 Diabetes- 1 Prior stroke, TIA, thromboembolism- 2 Vascular disease (ischaemic heart disease or peripheral arterial disease)- 1 Sex female- 1 Outcome- 0- no treatment 1- Males consider anticoagulation, females no treatment as only due to gender 2- Offer anticoagulation Choice of warfarin and NOACs If no need for anticoagulation make sure transthoracic echocardiogram has been done to exclude valvular heart disease which in combination with AF is an absolute indication for anticoagulation.

Answer 51

Offer as first line tx apart from the following pts: * AF has reversible cause * Have HF primarily caused by AF * New onset AF <48hrs * AFl suitable for ablation * Clinical judgement to say rhythm-control would be more suitable ▪ Beta-blocker – eg bisoprolol, metoprolol ▪ Calcium channel blocker – eg diltiazem (is a rate-limiting CCB) – not preferred in HF ▪ Digoxin

Answer 52

Offer to pts with: * Reversible cause for AF * New onset AF <48hrs * HF caused by AF * Sx despite effective rate control Aim is to induce normal sinus rhythm Elective cardioversion – electrical / pharmacological <48hrs onset AF → immediate cardioversion o Give heparin o Electrical – synchronised DC cardioversion o Pharm – flecainide / amiodarone – amiodarone if structural heart disease >48hrs onset AF → delayed cardioversion o Give >3wks anticoagulation before cardioversion o Or use trans-oesophageal echo to exclude left atrial appendage (LAA) thrombus – then can heparinise + cardiovert immediately o Electrical cardioversion preferred o Can give 4wks amiodarone / sotalol prior – esp if high risk of cardioversion failure o Anticoagulate >4wks after this

Answer 53

ORBIT score to assess risk of bleeding * 0-2 – low risk * 3 – medium risk * 4-7 – high risk

Answer 54

First line – DOAC * Apixaban, dabigatran, edoxaban, rivaroxaban Second line – warfarin – if DOAC CI’d or not tolerated

Answer 55

Catheter ablation ▪ If no response to antiarrhythmics ▪ Can ablate LA, or AVN + insert permanent pacemaker ▪ Ablate faulty electrical pathways ▪ Radiofrequency / cryotherapy can be used ▪ Anticoagulate 4wks before and during procedure

Answer 56

Abnormal atrial rhythm with atrial rate up to 300/min- if the block is 2:1 HR would be 150

Answer 57

Sawtooth appearance

Answer 58

Similar to AF althought medication not as effective More sensitive to cardioversion so lower energy can be used Radiofrequency ablation of the tricuspid valve isthmus is curative for most patients

Answer 59

QRS over 120ms Electrical activity not following the usual conduction system Ventricular tachycardia SVT with BBB Ventricular fibrillation

Answer 60

Monomorphic VT- caused by MI Polymorphic VT- subtype of polymorphic VT is torsades de pointes Management- ALS guidelines Unstable – synchronised DC cardioversion, up to 3x, IV amiodarone infusion if unsuccessful Stable – IV amiodarone, loading dose, then infusion Torsades de Pointes – Mg NO verapamil in VT

Answer 61

A polymorphic ventricular tachycardia associated with long QT

Answer 62

Congenital Antiarrythmics- amiodarone Tricyclic antidepressants Antipsychotics Erythromycin Electrolytes- hypocalcaemia, hypokalaemia, hypomagnesemua Hypothermia SAH

Answer 63

IV magnesium sulphate

Answer 64

Sinus tachycardia Atrial fibrillation- technically SVT Atrial flutter- technically SVt Supraventricular tachycardia

Answer 65

Acute management- Vagal manoeuvres- valsalva manoevre, carotid sinus massage IV adenosine- rapid IV bolus of 6mg if unsuccessful 12mg if unsuccessful further 18mg Contraindicated in asthmatics with verapamil preferable Electrical carioversion Prevention of episodes: Beta-blockers Radio-frequency ablation

Answer 66

A-E approach Assess for adverse signs- Shock- hypotension systolic <90, pallor, sweating, cold, clammy, confusion, impaired conciousness Syncope Myocardial ischemia HF No risk- observe If risk- Atropine 500mcg IV Further- Atropine up to 3mg (6x) Transcutaneous pacing Isoprenaline/adrenaline infusion Specialist help sought for transvenous pacing

Answer 67

Complete heart block with broad QRS Recent asystole Mobitz type II AV block Ventricular pause > 3 seconds

Answer 68

A-E approach Assess for life threatening features (unstable): Shock- hypotension (systolic BP less than 90), pallor, sweating, cold, clammy, confusion, impaired conciousness Syncope Myocardial ischaemia Heart failure If present give synchronised DC shocks- up to 3 If unsuccessful amiodarone 300mg IV over 10-20 minutes Repeat synchronised DC shock

Answer 69

Assume VT unlcess confirmed SVT with BBB Regular- Loading dose of amiodarone followed by 24 hour infusion Irregular- expert help Possibly: AF with BBB Torsades de pointes- magnesium

Answer 70

Likely SVT of atrial flutter Regular- vagal manouvres followed by IV adenosine If unsucessful consider atrial flutter and control rate (BBs) Irregular Probable AF if onset <48hours electrical or chemical cardioverrsion Rate control: BB first line unless CI

Answer 71

Shockable- VF, pulseless VT Non-shockable- asystole, pulseless electrical activity Chest compressions- 30:2 Defibrillation- single shock for VF/pulseless VT followed by 2 mins CPR If cardiac arrest witnessed in monitored patient then up to 3 successive rather than 1 followed by CPR Drug delivery- IV access attempted first line If IV access not possible drugs given via intraosseous route (IO), no longer tracheal tube Adrenaline- asap for non shocable rhythms VF/VT- adrenaline 1mg given after compressions restart after 3rd shock Repeat adrenaline 1mg every 3-5 mins while ALS continues Amiodarone 300mg given to patients who are in VF after 3 shocks Further 150mg given to VD after 5 shocks Lidocaine is an alternative if amiodarone not available Thrombolytic drugs- should be considered if PE suspected, if given CPR continuted for extended period of 60-90 minutes

Answer 72

Compressions- 15:2 if more than two people, 30:2 if alone Shout for help Feel for breathing 5 rescue breaths Check for signs of circulation- brachial or femoral in infants, femoral in children 15:2 compression- carried out at 100-120/min One-third of the chest- In children- compress the lower half of the sternum In infants- two-thumb encircling technique for chest compression

Answer 73

Heart unable to to pump enough blood to meet the metabolic needs of the body Cor pulmonale is the abnormal enlargement of the right side of the heart due to disease of the lungs

Answer 74

1st- N-terminal pro-B-type natriuretic peptide (NT-proBNP) blood test If levels are high- arrange a specialist assessment (including transthoracic echocardiography) within 2 weeks If raised arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks Secreted by LV in response to strain May also rise with ischaemia, valvular disease, CKD (reduced excretion) ECG CXR- ABCDE- pulmonary oedema ▪ Alveolar oedema – ‘bat’s wing shadowing’ ▪ Kerley B lines – interstitial oedema ▪ Cardiomegaly – cardiothoracic ratio >50% ▪ Dilated prominent upper lobe veins (upper lobe diversion) ▪ Pleural Effusions ▪ Also exclude lung pathology ECHO

Answer 75

1st line is ACEi and BB 2nd Aldosterone antagoist (spironolactone) 3rd- by specialist Ivabradine- sinus rhythm > 75/min and a left ventricular fraction < 35% Sacubitril-valsartan- initiated after ACEi/ARB washout period Digoxin Hydralazine- Afro-Caribbean patients Cardiac resynchronisation therapy Offer all patients: Diuretics- furosemide Flu vaccine Pneumococcal vaccine Lifestyle advice

Answer 76

New York Heart Association (NYHA) classification ▪ Class I – no symptoms on ordinary physical activity ▪ Class II – mild sx, slight limitation of physical activity ▪ Class III – moderate sx, comfortable at rest but less than ordinary activity leads to sx ▪ Class IV – severe sx, inability to carry out any activity without sx

Answer 77

SOB Cough- worse at night- pink/frothy sputum Orthopnoea PND Wheeze Weight loss- cachexia Bibasal crackles Signs of RHF- raised JVP, ankle oedema and hepatomegaly

Answer 78

De-novo HF

Answer 79

Cardiac ▪ Acute LVF, ACS, arrhythmias, valvular heart disease, HTN, cardiomyopathy, tamponade o Non-cardiac ▪ Fluid overload, high-output HF, ARDS, renal artery stenosis

Answer 80

SOB Tachycardia Cyanosis Increased RR Fatigue Displaced apex beat Raised SVP Crackles/Wheeze S3- heart sound

Answer 81

A-E ECG Bloods CXR ▪ Alveolar oedema ▪ Kerley B lines ▪ Cardiomegaly ▪ Dilated upper lobe vessels ▪ Pleural effusions ECHO

Answer 82

IV loop diuretics- furosemide Oxygen Vasodilators- nitrates but not to everyone- if severe, but not if BP low CPAP for resp failure Hypotension/ cardiogenic shock- Inotropic agents- dobutamine Vasopressor agents- noradrenaline Regular medications for HF continued- BB only stopped if patient HR less than 50