Cardiology Flashcards
1
Q
Anteroseptal MI ECG leads
A
V1-4
2
Q
Anteroseptal MI coronary artery
A
Left anterior descending
3
Q
Inferior MI ECG leads
A
II, III, aVF
4
Q
Inferior MI coronary artery
A
Right coronary
5
Q
Anterolateral MI ECG leads
A
V1-6, aVL
6
Q
Anterolateral MI coronary aretery
A
Proximal left anterior descending
7
Q
Lateral MI ECG leads
A
I, aVL, +/- V5-6
8
Q
Lateral MI coronary artery
A
Left circumflex
9
Q
Posterior MI ECG leads
A
V1-3
Reciprocal changes typically seen
10
Q
Reciprocal changes in posterior MI
A
- Horizonal ST depression
- Tall, broad R waves
- Upright T waves
- Dominant R wave in V2
11
Q
Coronary artery in posterior MI
A
Usually left circumflex, also right coronary
12
Q
Use of ACEi
A
First line hypertension in under 55’s
Heart failure
Diabetic nephropathy
Secondary prevention IHD
13
Q
SEs ACEi
A
Cough
Angiodema
Hyperkalaemia
First dose hypotension (more common if on diuretics)
14
Q
Cautions ACEi
A
Pregnancy/breastfeeding - avoid
Renovascular disease
Aortic stenosis
Hereditary idiopathic angioedema
K ≥5
15
Q
Interactions ACEi
A
High dose diuretics (>80mg furosemide/day) - increased risk of hypotension
16
Q
Monitoring ACEi
A
U&E before treatment started and after increaseing dose
17
Q
Acceptable blood changes when starting ACEi
A
Serum creatinine 30% inc from baseline
Increase in K up to 5.5mmol/LWh
18
Q
When might ACEi cause significant renal impairment
A
In patients with undiagnosed bilateral renal artery stenosis
19
Q
Secondary prevention after ACS
A
Aspirin
Second antiplatelet if appropriate, aka clopidogrel
Beta blocker
ACEi
Statin
20
Q
Common management all patients ACS
A
Aspirin 300mg
Oxygen to maintain sats <94%
Morphine if severe pain
Nitrates - SL or IV
21
Q
STEMI criteria
A
Clinical symptoms of ACS ≥20mins, >20mins ECG features in ≥2 contiguous leads of:
- 2.5mm ST elevation in V2-3 in men under 40 years, or 2mm in men over 40
- 1.5mm ST elevation in V2-3 in women
- 1mm ST elevation in other leads
- New LBBB
22
Q
Criteria PCI
A
Presentation in 12 hours of onset of symptoms
PCI can be delivered in 120mins of time fibrinoysis could be given
23
Q
Criteria fibrinolysis
A
Presentation within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120mins
24
Q
Antiplatelets given prior to PCI
A
If patient not taking oral anticoagulant - prasugrel
If patient taking oral anticoagulant - clopidogrel
25
Drug therapy used for PCI
If radial access - unfractionated heparin
If femoral access - bivalirudin
Both give glycoprotein IIb/IIIa inhibitor if inadequate response
26
Other procedures during PCI
Thrombus aspiration
Complete revascularisation if multivessel CAD without cardiogenic shock
27
Assessment of success of fibrinolysis
ECG repeated 60-90 min after. If persistent myocardial ischaemia, consider PCI
28
Risk assessment NSTEMI patients
GRACE
29
What factors included in GRACE score
- Age
- HR and BP
- Cardiac and renal function (creatinine)
- Arrest on presentation
- ECG findings
- Troponin levels
30
Categories of risk based on predicted 6 month mortality
1.5% or below - lowest
> 1.5 - 3% - low
> 3 - 6% - intermediate
> 6 - 9% - high
over 9% - highesthi
31
Which patients with NSTEMI/unstable angina should have immediate coronary angiography?
Clinically unstable patients
32
Which patients with NSTEMI/unstable angina should have coronary angio within 73 hours
GRACE score >3% aka intermediate, high, or highest risk
33
What antithrombin treatment NSTEMI/unstable angina
Fondaparinux if not high risk of bleeding and not having immediate angio
Unfractionated heparin if immediate angio planned or Cr >265
34
Drug therapy prior to PCI in patients with NSTEMI/unstable angina
If not taking oral anticoagulant, prasugrel or ticagrelor
If taking oral anticoagulant, clopidogrel
35
Drug therapy PCI in NSTEMI/unstable angina
Unfractionated heparin
36
Conservative management NSTEMI/unstable angina
If patient at high risk of bleeding, clopidogrel
If patient not at high risk of bleeding, ticagrelor
37
Role of adenosine
Terminate SVT
38
Adverse effects adenosine
Chest pain
Bronchospasm (avoid in asthmatics)
Transient flushing
Can enhance conduction down accessory pathways, resulting in increased ventricular rate e.g. in WPW
39
What drug enhances effect of adenosine
Dipyridamole
40
What drug inhibits affects of adenosine
Theophyllines
41
When to give adrenaline ALS
ASAP non-shockable
Once chest compressions restarted after 3rd shock in VF/VT
Every 3-5 mins whilst ALS continues
42
Dose adrenaline ALS
1mg
43
When to give amiodarone ALS
VF/pulseless VT after 3 shocks
Further dose after 5 shocks
44
Dose amiodarone ALS
After 3 shocks - 300mg
After 5 shocks - 150mg
45
Alternative to adenosine ALS
Lidocaine
46
Role of thrombolytic drugs ALS
Should be given if PE suspected
If given, CPR continued for 60-90 minutes
47
Reversible causes cardiac arrest
Hypoxia
Hypovolaemia
Hyper/hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia
Hypothermia
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade
Toxins
48
Monitoring amiodarone
TFT, LFT, U&E, CXR prior to treatment
TFT and LFT every 6 months
49
Adverse effects amiodarone
Thyroid dysfunction
Corneal deposits
Pulmonary fibrosis/pneumonitis
Liver fibrosis/hepatitis
Peripheral neuropathy, myopathy
Photosensitivity
'Slate grey' appearance
Thrombophlebitis and injection site reactions
Bradycardia
Lengthens QT interval
50
First line treatment angina
Aspirin and statin
Sublingual GTN as needed
Beta blocker or calcium channel blocker
51
What calcium channel blocker angina
If monotherapy, rate limiting e.g. verapamil or diltizem
If in combo with beta blocker, dihydropyridine e.g. amlodipine, MR nifedipine
52
Second line treatment angina
If on beta blocker add CCB and vice versa
53
Options if patient cannot tolerate addition of beta blocker/CCB in angina
Long acting nitrate
Ivabradine
Nicorandil
Ranolazine
54
When to add third drug angina
Only whilst awaiting assessment for PCI
55
How to avoid nitrate tolerance
If taking SR ISMN, asymmetric dosing interval to maintain daily nitrate free time of 10-14 hours
56
Use of ARBs
Generally when ACEi not tolerated usually due to cough
57
Examples ARBs
Candesartan
Losartan
Irbesartan
58
SEs ARBs
Hypotension
Hyperkalaemia
59
1st line antiplatelet ACS (medially treated)
Aspirin (lifelong) and ticagrelor (12 months)
60
What if aspirin contraindicated in ACS (medically treated)
Lifelong clopi
61
1st line antiplatelet after PCI
Asprin (lifelong) and prasurgrel or ticagrelor (12 months)
62
What if aspirin contraindicated after PCI
Clopidogrel (lifelong)
63
1st line antiplatelet after TIA
Clopidogrel
64
2nd line antiplatelet after TIA/stroke
Aspirin and dipyridamole lifelong
65
1st line antiplatelet peripheral arterial disease
Clopidogrel (lifelong)
66
2nd line antiplatelet peripheral arterial disease
Aspirin (lifelong)
67
Risk factors aortic dissection
Hypertension
Trauma
Bicuspid aortic valve
Marfans and Ehlers-Danlos syndrome
Turner's and Noonan's sydnrome
Pregnancy
Syphilis
68
Features aortic dissection
Chest/back pain
Pulse deficit - weak/absent pulse, variation >20mmHg between arms
Aortic regurgitation
Hypertension
69
Features aortic dissection involving coronary arteries
Angina
70
Features aortic dissection involving spinal arteries
Paraplegia
71
Features aortic dissection involving distal aorta
Limb ischaemia
72
ECG changes aortic dissection
Majority have no or non-specific ECG changes
In minority, ST elevation in inferior leads
73
Classification aortic dissection
Type A - ascending aorta (more likely chest pain)
Type B - descending aorta (more likely back pain)
74
CXR aortic dissection
Widened mediastinum
75
Investigation of choice aortic dissection
CT angio CAP (suitable for stable patients and planning surgery)
76
CT angio CAP findings aortic dissection
False lumen
77
Management type A aortic dissection
Surgical management
BP control systolic 100-120mmHg whilst awaiting intervention
78
Management type B aortic dissection
Conservative management
Bed rest
IV labetalol
79
Complications backwards aortic dissection
Aortic incompetence/regurgitation
MI - inferior pattern
80
Complications forward aortic dissection
Stroke
Renal failure
81
Causes of chronic presentation of aortic regurgitation due to valve disease
Rheumatic fever
Calcific valve disease
Connective tissue disease, e.g. RA, SLE
Bicuspid aortic valve
82
Causes of acute presentation aortic regurgitation due to valve disease
Infective endocarditis
83
Causes of chronic presentation aortic regurgitation due to aortic root disease
Bicuspid aortic valve
Spondyloarthropathies, e.g. ankylosing spondylitis
Hypertension
Syphilis
Marfans, Erlers Danlos
84
Causes of acute presentation of aortic regurgitation due to aortic root disease
Aortic dissection
85
Features aortic regurgitation
Early diastolic murmur, increased by handgrip
Collapsing pulse
Wide pulse pressure
Quincke's sign
De Musset's sign
86
What is Quincke's sign
Nailbed pulsation
87
What is De Musset's sign
Head bobbing
88
Aortic regurg surgery indications
Symptomatic with severe AR
Asymptomatic with severe AR and LV dysfunction
89
Features aortic stenosis
ESM, radiates to carotids, decreased following Valsalva
Narrow pulse prsesure
Slow rising pulse
Delayed ESM
Soft/absent S2
S4
Thrill
90
Causes aortic stenosis
Degenerative calcification (most common >65)
Bicuspid aortic valve (most common <65)
Williams syndrome
Post-rheumatic disease
HOCM
91
Management aortic stenosis
If asymptomatic, observe
If symptomatic or valvular gradient >40mmHg and features of LV dysfunction, consider surgeryS
92
Surgical options aortic stenosis
Surgical AVR for young, low/medium risk patients
Transcatheter AVR for high operative risk
93
Role of balloon valvuloplasty aortic stenosis
Children with no aortic valve calcification
Adults with critical AS who not fit for valve replacement
94
Inheritence pattern arrythomogenic right ventricular cardiomyopathy (ARVC)
Autosomal dominant
95
Pathology ARVC
Right ventricular myocardium replaced with fibrous/fatty tissue
96
ECG ARVC
Abnormalities in V1-3, typically T wave inversion
Epsilon wave in 50% - terminal notch in QRS complex
97
Echo ARVC
Often subtle changes in early stages
Enlarged, hypokinetic right ventricle with thin free wall
98
Management ARVC
Sotalol
Catheter ablation
ICD
99
What is Naxos disease
Autosomal recessive variant of ARVC
ARVC, palmoplantar keratosis, woolly hair
100
First line rate control AF
Beta blocker or rate limiting CCB (e.g. diltiazem)
101
Second line rate control AF
Combination therapy with any 2 of:
Beta blocker
Diltiazem
Digoxin
102
CHADVASC score
Congestive HF - 1
Hypertension - 1
Age ≥75 - 2
Age 65-74 - 1
Diabete - 1
Prior stroke, TIA, or thromboembolism - 2
Vascular disease - 1
Female - 1
103
Anticoagulation based on CHADVASC
0 - no treatment
1 - consider anticoagulation if male
2 - offer anticoagulation
104
HASBLED score
Hb <130 males, <120 for females - 2
Age >74 - 1
Bleeding history (GI, intracranial) - 2
GFR <60 - 1
Antiplatelets - 1
105
Interpretation HASBLED
0-2 low risk
3 medium risk
4-7 high risk
106
First line anticoagulant AF
DOACs
107
Indications for cardioversion AF
If haemodynamically unstable (emergency)
If rhythm control strategy preferred (elective)
108
Anticoagulation prior to cardioversion
If definitely less than 48 hours, patients should be heparinised
If more than 48 hours, needs anticoagulation for at least 3 weeks prior to cardioversion (or TOE to exclude left atrial appendage thrombus - if neg, treat as less than 48h)
109
Cardioversion options when onset AF <48 hours
Electrical cardioversion
Chemical cardioversion
110
Drugs used for chemical cardioversion
Amiodarone if structural heart disease
Flecainide or amiodarone if no structural heart disease
111
Cardioversion options AF onset >48 hours
Electrical cardioversion
112
Management of AF with high risk of cardioversion failure
At least 4 weeks of amiodarone or sotalol prior to electrical cardioversion
113
Management post electrical cardioversion
If AF was <48 hours duration, no anticoagulation necessary
If AF >48 hours, at least 4 weeks of anticoagulation
114
Anticoagulation in AF post stroke
Warfarin or direct thrombin (rivaroxaban, apixaban, edoxaban) or factor Xa inhibitor (dabigatran)
115
When should anticoagulation for AF be started in TIA patients
Immediately (once haemorrhage excluded)
116
When should anticoagulation for AF be started in acute stroke patients
After 2 weeks (antiplatelets in intervening period)
Delayed if imaging shows very large cerebral infarction
117
When should rhythm control strategy be employed in AF
AF has reversible cause
Heart failure thought to be primarily caused by AF
New onset AF (<48hours)
Flutter suitable for ablation
More suitable based on clinical judgement
118
Role of digoxin rate control for AF
Not first line as less effective at controlling heart rate during exercise, only considered if person does no or very little exercise and other rate-limiting drugs ruled out due to co-morbidities
Good if co-existent heart failure
119
What drugs can be used to maintain sinus rhythm in patients with history of AF
Beta blockers
Dronedarone
Amiodarone
120
When is catheter ablation used in AF
If have not responded to or wish to avoid anti-arrhythmic medication
121
Anticoagulation around catheter ablation for AF
4 weeks before and during procedure
122
Limitation of catheter ablation for AF
Does not reduce stroke risk, even if patients remain in sinus rhythm, so still need anticoagulation based on chadvasc
123
Complications catheter ablation AF
Cardiac tamponade
Stroke
Pulmonary vein stenosis
124
Features first degre heart block
PR interval >0.2s
Often asymptomatic - if so doesnt need treatment
125
Features second degree heart block type 1
Progressive prolongation of PR interval until dropped beat occurs
126
Features second degree heart block type 2
PR interval constant, but P wave often not followed by QRS
127
Features third degree heart block
No association between P waves and QRS complexes
128
Causes raised BNP
Heart failure
Left ventricular hypertrophy
Ischaemia
Tachycardia
RV overload
Hypoxaemia
GFR <60
Sepsis
COPD
Diabetes
Age >70
Cirrhosis
129
Factors reducing BNP (false lows)
Obesity
Diuretics
Drugs
130
Drugs reducing BNP
ACEi
Beta blockers
ARBs
Aldosterone antagonists
131
What is bivalirudin
Reversible direct thrombin inhibitor used as anticoagulant in management of ACS
132
Inheritance Brugada syndrome
Autosomal dominant
133
ECG changes Brugada syndrome
Convex ST segment elevation >2mm in >1 of V1-3, followed by negative T wave
Partial RBBB
134
Investigation of choice Brugada syndrome
Give flecainide or ajmaline - ECG changes become more pronounced
135
Management Brugada syndrome
ICD
136
What is Buerger's disease
Small and medium vessel vasculitis, strongly associated with smoking
137
Features Buerger's disease
Extremity ischaemia - intermittent claudication, ischaemic ulcers
Superficial thrombophlebitis
Raynaud's phenomenon
138
Features cardiac tamponade
Hypotension
Raised JVP
Muffled heart sounds
Dyspnoea
Tachycardia
Pulses paradoxus
Absent Y descent on JVP
139
ECG cardiac tamponade
Electrical alternans
140
Causes restrictive cardiomyopathy
Amyloidosis
Post-radiotherapy
Loeffler's endocarditis
141
When does peripartum cardiomyopathy occur
Last month of preg - 5 months PP
142
Risk factors peripartum cardiomyopathy
Older women
Greater parity
Multiple gestations
143
Features Takotsubo cardiomyopathy
Stress induced
Transient, apical ballooning of myocardium
Supportive treatment
144
Infective causes of cardiomyopathy
Coxsackie B
Chagas disease
145
Infiltrative causes of cardiomyopathy
Amyloidosis
146
Storage causes of cardiomyopathy
Haemochromotosis
147
Toxic causes of cardiomyopathy
Doxorubicin
Alcoholic
148
Inflammatory causes of cardiomyopathy
Sarcoidosis
149
Endocrine causes of cardiomyopathy
Diabetes mellitus
Thyrotoxicosis
Acromegaly
150
Neuromuscular causes of cardiomyopathy
Friedreich's ataxia
Duchenne/Beckers muscular dystrophy
Myotonic dystrophy
151
Nutritional causes of cardiomyopathy
Beriberi (thiamine)
152
Autoimmune causes of cardiomyopathy
SLE
153
What is Boerhaaves syndrome
Spontaneous rupture of oesophagus occurring as result of repeated episodes of vomiting
154
Presentation Boerhaaves syndrome
Sudden onset severe chest pain with severe vomiting
Severe sepsis secondary to mediastinitis
155
Diagnosis Boerhaaves syndrome
CT contrast swallow
156
Treatment Boerhaaves syndrome
Thoracotomy and lavage
If less than 12 hours from onset, primary repair feasible. If more, insertion of T tube to create controlled fistula between oesophagus and skin
157
First line investigation suspected heart failure
BNP
158
Interpretation BNP as first line in suspected heart failure
If >400, specialist assessment inc transthoracic echo within 2 weeks
If 100-400, specialist assessment including transthoracic echo within 6 weeks
159
BNP → NTproBNP conversion
BNP >400 = NTproBNP >2000
BNP 100-400 = NTproBNP 400-2000
160
First line treatment heart failure
ACEi and beta blocker
Start one at a time, judgement to decide which
161
Second line treatment heart failure
Aldosterone antagonist, e.g. spironolactone and eplerenone
162
Role of SGLT-2 inhibitors in heart failure
Reduce hospitalisation and cardiovascular death
Add dapagliflozin to optimised standard care
163
Third line treatment heart failure
Should be initiated by specialist
Options:
- Ivabradine
- Sacubitril-valsartan
- Hydralazine with nitrate
- Digoxin
- Cardiac resync therapy
164
Criteria ivabradine heart failure
Sinus rhythm >75/min
LV fraction <35%
165
Criteria sacubitril-valsartan heart failure
LV fraction <35
Symptomatic on ACEi/ARB
Initiated following ACEi/ARB wash out period
166
Use of digoxin in heart failure
- Improves symptoms due to inotropic properties
- Strongly indicated if co-existent AF
167
Who is hydralazine with nitrate useful for in heart failure
Afro-Caribbean patients
168
Indications cardiac resync therapy in heart failure
Widened QRS (LBBB)
169
Vaccinations in heart failure
Annual flu
One of pneumococcal
170
Who needs 5 yearly pneumococcal vaccine
Asplenia or splenic dysfunction
CKD
171
NYHA class I heart failure
No symptoms, no limitation on ordinary physicla exercise
172
NYHA class II heart failure
Mild symptoms, slight limitations of physical activity, comfortable at rest but ordinary activity results in fatigue, palpitations, or dyspnoea
173
NYHA class III heart failure
Moderate symptoms
Marked limitation of physical activity, comfortable at rest but less than ordinary activity results in symptoms
174
NYHA class IV heart failure
Severe symptoms, unable to carry out any physical activity without discomfort, symptoms present at rest
175
Associations coarctation of aorta
Turner's syndrome
Bicuspid aortic valve
Berry aneurysms
Neurofibromatosis
176
Features coarctation of aorta
In infancy, heart failure
In adults, hypertension
Radiofemoral delay
Mid-systolic murmur, maximal over back
Apical blick from aortic valve
Notching of inferior border of ribs (due to collateral vessels)
177
Features complete heart block
Syncope
Heart failure
Regular bradycardia (30-50)
Wide pulse pressure
JVP - cannon waves in neck
Variable intensity S1
178
First line anti-hypertensive in diabetics
ACEi
179
Considerations anti-hypertensives diabetics
Autonomic neuropathy may result in more postural symptoms
Routine use of beta blockers should be avoided as can cause insulin resistance, impair insulin secretion, and alter autonomic response to hypoglycaemia
180
Causes dilated cardiomyopathy
Idiopathic (most common)
Myocarditis
IHD
Peripartum
Hypertension
Iatrogenic
Substance abuse
Inherited
Infiltrative
181
Causes of myocarditis → dilated cardiomyopathy
Coxsackie B
HIV
Diptheria
Chagas
182
Drugs causing dilated cardiomyopathy
Doxorubicin
183
Substance abuse causing dilated cardiomyopathy
Alcohol
Cocaine
184
Infiltrative causes dilated cardiomyopathy
Haemochromatosis
Sarcoidosis
185
Features dilated cardiomyopathy
Classic features of heart failure
Systolic murmur
S3
186
CXR dilated cardiomyopathy
Balloon appearance of heart
187
DVLA hypertension
Can drive unless treatment causes unacceptable side effects, no need to notify DVLA
If group 2, can't drive if BP consistently over 180mmHg systolic or 100mmHg diastolic
188
Angiography (elective) DVLA
1 week off driving
189
CABG DVLA
4 weeks off driving
190
ACS DVLA
4 weeks off driving, 1 week if successfully treated by angioplasty
191
Angina DVLA
Can't drive if symptoms at rest/at the wheel
192
Pacemaker insertion DVLA
1 week off driving
193
ICD DVLA
If implanted for sustained ventricular arrhyhtmia - 6 months off
If prophylactic - 1 month
Permanent ban for group 2
194
Successful catheter ablation for arrhythmia DVLA
2 days off
195
Aortic aneurysm DVLA
If 6cm or more, notify DVLA - yearly review of licensw
If over 6.5cm, can't drive
196
Heart transplant DVLA
Can't drive 6 weeks, no need to notify DVLA
197
Causes left axis deviation
Left anterior hemiblock or left bundle branch block
Inferior MI
WPW (right sided pathway) - majority of cases
Hyperkalaemia
Congenital - ostium primum ASD, tricuspid atresia
Minor in obese
198
Causes of right axis deviation
Right ventricular hypertrophy
Left posterior hemiblock
Lateral MI
Chronic lung disease → cor pulmonale
Pulmonary embolism
Ostium secundum ASD
WPW (left sided pathway)
Minor in tall
Normal in <1yo
199
ECG digoxin toxicity
Down-sloping ST depression
Flattened/inverted T waves
Short QT
Arrhythmias, e.g. AV block, bradycardia
200
ECG hypokalaemia
U waves
Small or absent T waves
Prolong PR
ST depression
Long QT
201
ECG hypothermia
Bradycardia
J wave
First degree heart block
Long QT interval
Atrial and ventricular arrhythmias
202
ECG LBBB
W in V1, M in V6
203
ECG RBBB
M in V1, W in V6
204
Causes LBBB
MI
Hypertension
Aortic stenosis
Cardiomyopathy
Idiopathic fibrosis
Digoxin toxicity
Hyperkalaemia
205
ECG normal variants in athlete
Sinus bradycardia
Junctional rhythm
First degree heart block
Mobitz type 1
206
Causes of increased P wave amplitude
Cor pulmonale
207
Causes of bifid (broad, notced) P waves
Left atrial enlargement, classically due to mitral stenosis
208
Causes prolonged PR interval
Idiopathic
Ischaemic heart disease
Digoxin toxicity
Hypokalaemia
Rheumatic fever
Aortic root pathology, e.g. abscess secondary to endocarditis
Lyme disease
Sarcoidosis
Myotonic dystrophy
209
Causes short PR interval
Wolff-Parkinson-White syndrome
210
Causes of right bundle branch block
Normal variant
Right ventricular hypertrophy
Chronically increased right ventricular pressure, e.g. cor pulmonale
Pulmonary embolism
Myocardial infarction
Atrial septal defect
Cardiomyopathy or myocarditis
211
Causes ST depression
Secondary to abnormal QRS (LVH, LBBB, RBBB)
Ischaemia
Digoxin
Hypokalaemia
Syndrome X
212
Causes ST elevation
Myocardial infarction
Pericarditis/myocarditis
Normal variant (high take off)
Left ventricular aneurysm
Prinzmetal's angina (coronary artery spasm)
Takotsubo cardiomyopathy
Subarachnoid haemorrhage
213
Causes peaked T waves
Hyperkalaemia
Myocardial ischaemia
214
Causes inverted T waves
Myocardial ischaemia
Digoxin toxicity
Subarachnoid haemorrhage
Arrythmogenic right ventricular cardiomyopathy
Pulmonary embolism
Brugada syndrome
215
Acute heart failure treatment for all patients
IV loop diuretics, e.g. furosemide or bumetanide
216
Role of vasodilators (nitrates) in acute heart failure
May be used if concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease
217
Treatment of acute heart failure patients with resp failure
CPAP
218
Treatment of hypotension/cardiogenic shock in acute heart failure
Inotropic agents, e.g. dobutamine
Vasopressor agents, e.g. norepinephrine
Mechanical circulatory assistance, e.g. intra-aortic balloon counterpulsation
219
Role of inotropic agents in acute heart failure
Should be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
220
Role of vasopressor agents in acute heart failure
Normally only used if insufficient response to inotropes and evidence of end-organ hypoperfusion
221
Should regular medications for heart failure be continued in acute heart failure
Yes
Beta blockers should be stopped if HR under 50, 2nd or 3rd degree block, or shock
222
Causes of soft S1
Prolonged PR
Mitral regurgitation
223
Causes of loud S1
Mitral stensois
224
Causes of soft S2
Aortic stenosis
225
Causes of S3
Normal if <30
LVF
Constrictive pericarditis
Mitral regurgitation
226
Causes of S4
Aortic stenosis
HOCM
Hypertension
227
What is remnant hyperlipidaemia
Also called type 3 hyperlipoproteinaemia
Rare inherited condition causing high levels of cholesterol and triglycerides in the blood
228
Causes palmar xanthoma
Remnant hyperlipidaemia
Less commonly, familial hypercholesterolaemia
229
What are eruptive xanthomas
Multiple red/yellow vesicles on extensor surfaces, e.g. elbows, knees
230
Causes of eruptive xanthomas
Familial hypertriglyceridaemia
Lipoprotein lipase deficiency
231
Causes of tendon xanthoma, xanthelasma
Familial hypercholesterolaemia
Remnant hyperlipidaemia
232
What are xanthelasma
Yellowish papules and plaques caused by localised accumulation of lipid deposits commonly seen on eyelid
233
Management options xanthelasma
Surgical excision
Topical tricholoroacetic acid
Laser therapy
Electrodesiccation
234
Stage 1 hypertension criteria
Clinic BP ≥140/90 and ABPM/HBPM ≥135/85
235
Stage 2 hypertension criteria
Clinic BP ≥160/100 and ABPM/HBPM ≥150/95
236
Severe hypertension criteria
Clinic BP systolic ≥180 or diastolic ≥120
237
When should ABPM/HBPM be offered
Any BP ≥140/90
238
Management BP ≥180/120
Consider need for urgent referral
Urgent investigation for end-organ damage - bloods, urine, ACR, ECG
239
Who needs urgent referral BP ≥180/120
Signs of retinal haemorrhage or papilloedema
Life threatening symptoms, e.g. new onset confusion, chest pain, signs of heart failure, AKI
If phaeochromocytoma suspected
240
What to do if BP ≥180/120 and target organ damage identified on investigation
Consider starting anti-hypertensive drugs immediately, wtihout waiting for results of ABPM/HBPM
241
What to do if BP ≥180/120 and target organ damage not identified on investigation
Repeat clinic BP within 7 days
242
How is ABPM carried out
At least 2 measurements per hour during persons usual waking hours, average value of at least 14 measurements
243
When is HBPM offered
If ABPM not tolerated or declined
244
How is HBPM carried out
For each BP recording, 2 consecutive measurements, at least 1 min apart and with patient seated
Record BP BD, ideally morning and evening
Recorded for at least 4 days, ideally 7 days.
Discard all measurements from first day, and use average of all remaining measurements
245
When to defo offer drug treatment in stage 1 hypertension
Age under 80 and:
- Target organ damage
- CVD
- Renal disease
- Diabetes
- 10 year CVD risk ≥10%
246
When to consider offering drug treatment in stage 1 hypertension
Age over 80 and clinic BP >150/90
Age under 60 and 10 year CVD risk <10%
247
What to do stage 1 hypertension in under 40's
Consider specialist evaluation of secondary causes
248
How to manage stage 2 hypertension
Lifestyle advice and drug treatment
249
Causes secondary hypertension
Primary hyperaldosteronism (5-10% of cases of hypertension
Renal disease
Endocrine disorders
Drugs
Pregnancy
Coarctation of aorta
250
Drugs causing hypertension
Steroids
MAOI
COCP
NSAIDs
Leflunomide
251
Inheritance HOCM
Autosomal dominant
252
Features HOCM
Often asymptomatic
Exertional dyspnoea
Angina
Syncope, typically following exercise
Sudden death
Jerky pulse, large A waves, double apex beat
Systolic murmur - ESM or pansystolic
253
Conditions associated with HOCM
Friedreich's ataxia
Wolff-Parkinson White
254
Echo findings HOCM
Mitral regurgitation
Systolic anterior motion of anterior mitral valve leaflet
Asymmetric hypertrophy
255
ECG HOCM
Left ventricular hypertrophy
Non-specific ST segment and T wave abnormalities, progressive T wave inversion
Deep Q waves
Occasionally AF
256
Drugs to avoid HOCM
Nitrates
ACE-i
Inotropes
256
Management HOCM
Amiodarone
Beta blockers or verapamil
Cardioverter defib
Dual chamber pacemarker
Endocarditis prophylaxis
257
Most common pathogen infective endocarditis
Staphylococcus aureus
258
Streptococcus viridans endocarditis associated with...
Developing countries (most common cause)
Poor dental hygiene or following dental procedure
259
Most common organism causing endocarditis after valve surgery/indwelling lines
Coag neg Staphylococci, e.g. staphylococcus epidermidis
After 2 months, staph aureus most common cause again
260
Infective endocarditis caused by Streptococcus bovis associated with...
Colorectal cancer
261
Causes non-infective endocarditis
SLE
Malignancy (marantic endocarditis
262
Culture negative causes of endocarditis
Prior ABx therapy
Coxiella burnetii
Bartonella
Brucella
HACEK (haemophilus, actinobacillus, cardiobacterium, eikenella, kingella)
263
Ivabradine use
Anti-anginal
264
Adverse effects ivabradine
Visual effects, particularly luminous phenomena
Headache
Bradycardia, heart block
265
Cause non-pulsatile JVP
Superior vena cava obstruction
266
What is Kussmaul's sign, and when seen
Paradoxical rise in JVP during inspiration
Seen in constrictive pericarditis
267
What forms the a wave of JVP
Atrial contraction
268
Cause of large A waves
Atrial pressure - tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
269
Cause of absent A waves
AF
270
What are Cannon a waves, and what causes?
Atrial contraction against closed tricuspid valve
Seen in:
- Complete heart block
- Ventricular tachycardia/ectopics
- Nodal rhythm
- Single chamber ventricular pacing
271
Cause of V wave JVP, and when abnormal
Due to passive filling of blood into atrium against closed tricuspid valve
Giant V waves in tricuspid regurgitation
272
How does long QT cause death
May lead to ventricular tachycardia/torsades de pointes → collapse and sudden death
273
Congenital causes long QT
Jervell-Lange-Nielsen syndrome (deafness)
Romano-Ward syndrome (no deafness)
274
Drugs causing long QT
Amiodarone, sotalol
TCAs, SSRIs (esp citalopram)
Methadone
Chloroquine
Terfenadine
Erythromycin
Haloperidol
Ondansetron
275
Electrolyte disturbances causing long QT
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
276
Other causes long QT
Acute MI
Myocarditis
Hypothermia
SAH
277
Feaetures long QT1
Usually associated with exertional syncope, often swimming
278
Features long QT2
Often assocaited with syncope occurring following emotional stress, exercise, or auditory stimuli
279
Features long QT3
Events often occur at night or rest
280
Management long QT
Avoid drugs that prolong QT interval and other precipitants as appropriate
Beta blockers
Implantable cardioverter defib in high risk cases
281
Examples loop diuretics
Furosemide
Bumetanide
282
Indications loop diuretics
Herat failure
Resistant hypertension
283
Adverse effects loop diuretics
Hypotension
Hyponatraemia, hypokalaemia, hypomagnesaemia, hypocalcemia, hypochloraemic alkalosis
Ototoxicity
Renal impairment
Hyperglycaemia
Gout
284
Risk factors mitral regurgitation
Female
Low BMI
Age
Renal dysfunction
Prior MI
Prior mitral stenosis or valve prolapse
Collagen disorders, e.g. Marfans, Ehlers-Danlos
285
Causes mitral regurgitation
Papillary muscle or chordae tendinae damage after cardiac insult
Mitral valve prolapse
Infective endocarditis
Rheumatic fever
Congenital
286
Symptoms MR
Most asymptomatic
Symtptoms of:
- Left ventricular failure
- Arrhythmias
- Pulmonary hypertension
287
Signs MR
Pansystolic murmur described as blowing - best heard at apex and radiates to axilla
S1 quiet
Severe MR - widely split S2
288
ECG findings MR
Broad P wave
289
CXR findings MR
Cardiomegaly, enlarged LA and ventricle
290
Medical management MR
Nitrates
Diuretics
Positive inotropes
Intra-aortic balloon pump
291
Indications for surgery MR
Acute, severe regurgitation
292
Surgical options MR
Repair > replacement in degenerative
When not possible, valve replacement - artificial or pig
293
Causes mitral stenosis
Rheumatic fever (most common)
Mucopolysaccharoidoses
Carcinoid
Endocardial fibroelastosis
294
Symptoms mitral stenosis
Dyspnoea
Haemoptysis
295
Cause of dyspnoea and haemoptysis in mitral stenosis
Increased left atrial pressure → pulmonary venous hypertension
This can lead to rupture of thin walled and dilated bronchial veins
296
Signs mitral stenosis
Mid-late diastolic murmur, best heard in expiration
Loud S1
Opening snap
Low volume pulse
Malar flush
AF
297
Change in murmur in severe mitral stenosis
Length of murmur increases
Opening snap becomes close to S2
298
CXR mitral stenosis
Left atrial enlargement
299
Management asymptomatic mitral stenosis
Regular echo monitoring
300
Management symptomatic mitral stenosis
Percutaneous mitral balloon valvotomy or mitral valve surgery (commissurotomy or valve replacement)
301
Management AF in mitral stenosis
Warfarin
302
Associations mitral valve prolapse
CHD - PDA, ASD
Cardiomyopathy
Turners syndrome
Marfans syndrome
Fragile X
Osteogenesis imperfecta
WPW
Long-QT
Ehlers Danlos
PKD
303
Festures mitral valve prolapse
Mid-systolic click
Late systolic murmur, longer if patient standing
304
Cause of ESM louder on expiration
Aortic stenosis
HOCMC
305
Cause of ESM louder on inspiration
Pulmonary stenosis
ASD
306
Cause of pansystolic murmur
Mitral/tricuspid regurgitation (louder during inspiration in tricuspid)
VSD (harsh)
307
Cause of late systolic murmur
Mitral valve prolapse
Coarctation of aorta
308
Cause of early diastolic murmur
Aortic regurgitation
Pulmonary regurgitation
309
Cause of mid-late diastolic murmur
Mitral stenosis (rumbling)
Severe aortic regurgitation
310
Cause of continuous machine like murmur
PDA
311
Most common cause of death after MI
Cardiac arrest
312
Management cardiogenic shock after MI
- Inotropic support
- Intra-aortic balloon pump
313
What kind of MI is bradycardia more common following
Inferior MI (AV block)
314
Time frame pericarditis after MI
- First 48 hours
- Dresslers syndrome occurs 4-6 weeks after
315
Features pericarditis after MI
Common after transmural MI
Typical pericarditis pain
Pericardial rub
Pericardial effusion on echo
316
Cause Dresslers syndrome
Autoimmune reaction against antigenic proteins formed as myocardium recovers
317
Features Dresslers syndrome
Fever
Pleuritic pain
Pericardial effusion
Raised ESR
318
Treatment Dresslers syndrome
NSAIDs
319
Features left ventricular aneurysm following MI
Persistent ST elevation
Left ventricular failure
320
Treatment left ventricular aneurysm following MI
Anticoagulation (thrombus may form → stroke)
321
Timeframe left ventricular free wall rupture post MI
1-2 weeks after
322
Presentation left ventricular free wall rupture post MI
Acute heart failure secondary to tamponade - raised JVP, pulsus paradoxus, diminished heart sounds
323
Treatment left ventricular free wall rupture
Urgent pericardiocentesis and thoracotomy
324
Timeframe VSD post MI
First week
325
Features VSD post MI
Acute heart failure
Pansystolic murmur
326
Treatment VSD post MI
Urgent surgical correction
327
What kind of MI is acute mitral regurg more common with
Infero-posterior
328
Presentation acute mitral regurg post MI
Acute hypotension
Pulmonary oedema
Early to mid systolic murmur
329
Treatment acute mitral regurgitation post MI
Vasodilator therapy
Often need emergency surgical repair
330
Secondary prevention drugs after MI
DAPT
ACEi
Beta blocker
Statin
331
Lifestyle recommendations post MI
Mediterranean style diet, switch butter and cheese for plant based products
Exercise 20-30 min/day until slightly breathless
332
Sexual activity post MI
May resume 4 weeks post uncomplicated MI
333
Use of PDE5 inhibitors (e.g. sildenafil) post MI
Can be used 6 months post MI
Avoid if on nitrates or nicorandil
334
DAPT choice post medically managed ACS
Aspirin (lifelong) + ticagrelor (12 months)
335
DAPT choice post PCI
Aspirin (lifelong) + prasugrel or ticagrelor (12 months)D
336
Role of aldosterone antagonists post MI
In patients acute MI with symptom/signs of heart failure and LV systolic dysfunction, start eplerenone within 3-14 days of MI, pref after ACEi
337
Use of oxygen therapy in COPD patients with MI
If at risk of hypercapnic respiratory failure, aim 88-92% until ABG available
338
Agent of choice in thrombolysis
Tissue plasminogen activator (tPA)
339
Glycaemic control in MI
Use dose-adjusted insulin infusion with regular monitor of blood glucose aiming under 11
340
Nicorandil use
Angina
341
Adverse effects nicorandil
Headache
Flushing
Skin, mucosal, and eye ulceration (GI ulcers including anal)
342
Contraindications nicorandil
Left ventricular failure
343
Nicotinic acid use
Hyperlipidaemia
344
Adverse effects nicotinic acid
Flushing
Impaired glucose tolerance
Myositis
345
Use nitrates
Angina
Acute treatment of heart failure
346
SEs nitrates
Hypotension
Tachycardia
Headaches
Flushing
347
Adverse signs with bradycardia
- Shock - hypotension, pallor, sweating, cold/clammy extremities, confusion, impaired consciousness
- Syncope
- Myocardial ischaemia
- Heart failure
348
First line treatment bradycardia with adverse features
Atropine 500mcg IV
349
Second line treatments bradycardia with adverse features
Atropine, up to 3mg
Transcutaneous pacing
Isoprenaline/adrenaline infusion titrated to response
350
Third line treatment bradycardia with adverse features
Specialist advice for consideration of transvenous pacing
351
Risk factors for asystole in bradycardia (need to consider transvenous pacing)
Complete heart block with broad complex QRS
Recent asystole
Mobitz type II AV block
Ventricular pause >3 seconds
352
Management tachycardia with adverse features
Up to 3 synchronised DC shocks
353
What is considered broad QRS in tachycardia
<0.12s
354
Cause regular broad complex tachycardia
Ventricular tachycardia
355
Treatment regular broad complex tachycardia
Loading dose amiodarone followed by 24 hour infusion
356
Treatment irregular broad complex tachycardia
Expert help
357
Cause irregular broad complex tachycardia
AF with bundle branch block (most likely in stable patient)
AF with ventricular pre-excitation
Torsades de pointes
358
Treatment regular narrow complex tachycardia
1. Vagal manoeuvres
2. IV adenosine
If unsuccessful, consider diagnosis of atrial flutter - control rate (e.g. beta blockers)
359
Treatment irregular narrow complex tachycardia
Probably AF - if onset <48h, consider cardioversion. If not, rate control - beta blockers first line
360
Who usually gets bioprosthetic heart valves
Older patients (>65 in aortic, >70 in mitral)
361
Advantage bioprosthetic valves
Long-term anticoagulation not needed - warfarin for 3 months, then low-dose aspirin
362
Disadvantage bioprosthetic valve
Structural deterioration and calcification over time
363
Anticoagulation mechanical heart valves
Warfarin
Aspirin if additional indication, e.g. IHD
364
INR target mechanical heart valves
Aortic 3.0
Mitral 3.5
365
Pulmonary embolism rule out criteria
Age 50+
HR ≥100
Oxygen sats ≤94%
Previous DVT or PE
Recent surgery or trauma in past 4 weeks
Haemoptysis
Unilateral leg swelling
Oestrogen use, e.g. HRT, contraceptives
If all criteria ABSENT, low chance of PE
366
Wells score
Clinical signs/symptoms of DVT (leg swelling, pain on palpation of deep veins) - 3
Alternative diagnosis less likely than PE - 3
HR >100 - 1.5
Immobilisation for more than 3 days, or surgery in past 4 weeks - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy - 1
367
Interpretation of Wells score
PE likely if 4+
PE unlikely if 4 or less
368
Management PE likely Wells score
Immediate CTPA
If delay in getting CTPA, interim therapeutic anticoagulation (apixaban or rivaroxiban)
If CTPA negative, consider proximal leg vein USS if DVT suspected
369
Management PE unlikely Wells score
D-dimer test - if positive, CTPA. If negative, stop anticoag and consider alternative diagnosis
370
Use of V/Q scanning
Investigation of choice in renal impairment
371
ECG changes PE
Large S wave in lead I
Large Q wave in lead III
Inverted T wave in lead III
RBBB
Right axis deviation
Sinus tachy
372
CXR PE
Usually normal
Sometimes wedge-shaped opacification
373
Other causes of V/Q mismatch
Old PE
AV malformations
Vasculitis
Previous radiotherapy
374
First line anticoagulant PE
Apixaban or rivaroxiban
375
Second line anticoagulant PE
Dabigatran or edoxaban
LMWH → warfarin
376
Anticoagulant PE with severe renal impairment (<15)
LMWH → warfarin
377
Anticoagulant PE in antiphospholipid syndrome
LMWH → warfarin
378
Length of anticoagulant PE
3 months if provoked (3-6 months if acitive cancer)
6 months if unprovoked
379
Treatment PE with haemodynamic instability
Thrombolysis
380
Treatment repeated PEs on anticoagulation
Consider IVC filter
381
What is pulsus paradoxus
Greater than 10mmHg fall in systolic BP during inspiration, presenting as faint or absent pulse in inspiration
382
Causes pulsus paradoxus
Severe asthma
Cardiac tamponade
383
Causes slow-rising/plateau pulse
Aortic stenosis
384
Causes collapsing pulse
Aortic regurgitation
PDA
Hyperkinetic states, e.g. anaemia, thyrotoxic, fever, exercise, pregnancy
385
Causes pulsus alternans
Severe LVF
386
What is bisferiens pulse
Two systolic peaks
387
Causes bisferiens pulse
Mixed aortic valve disease
388
Causes jerky pulse
HOCM
389
Adverse effects statins
Myopathy
Liver impairment
Some evidence of increased risk of intracerebral haemorrhage in previous stroke patients
390
Risk factors myopathy caused by statins
Female
Low BMI
Multisystem disease, e.g. diabetes mellitus
391
Which statins more likely to cause myopathy
Simvastatin, atorvastatin
392
Liver monitoring statins
LFTs at baseline, 3 months, 12 months
393
Management of deranged LFTs with statins
Treatment discontinued if serum transaminase concentrations rise to and persist 3x upper limit of normal
394
Interactions statins
Macrolides, e.g. erythromycin, clarithromycin - stop statins until course complete
395
Who should be on statin
Everyone with established cardiovascular disease, e.g. stroke, TIA, IHD, PAD
Anyone with 10 year cardiovascular risk ≥10%
Patients with T1DM diagnosed over 10 years ago or 40+ or established nephropathy
396
Time of day to take statins
Night (when majority of cholesterol synthesis occurs)
397
First line statin primary prevention
20mg atorvastatin
398
First line statin secondary prevention
80mg atorvastatin
399
When to increase dose statin primary prevention
If non-HDL not reduced ≥40%
400
Management SVT
Vagal manoeuvures
IV adenosine - rapid bolus 6mg → 12mg → 18mg
Electrical cardioversion
401
Who can't have adenosine in SVT
Asthmatics - give verapamil instead
402
Prevention of SVT
Beta blockers
Radio-frequency ablation
403
Types of syncope
- Reflex
- Orthostatic
- Cardiac
404
Causes reflex syncope
Vasovagal
Situational, e.g. cough, micturition, GI
Carotid sinus
405
Causes orthostatic syncope
Primary autonomic failure
Secondary autonomic failure
Drug-induced
Volume depletion, e.g. haemorrhage, diarrhoea
406
Causes primary autonomic failure → syncope
Parkinsons disease
Lewy body dementia
407
Causes secondary autonomic failure → syncope
Diabetic neuropathy
Amyloidosis
Uraemia
408
Drug causes of orthostatic syncope
Diuretics
Alcohol
Vasodilators
409
Causes cardiac syncope
Arrhythmias
Structural - valvular, MI, HOCM
PE
410
What is Takayasu's arteritis
Large vessel vasculitis, typically causing obstruction of aorta
411
Risk factors Takayasu's arteritis
Younger females (10-40)
Asian people
412
Features Takayasu's arteritis
Systemic features of vasculitis, e.g. malaise, headache
Unequal BP in upper limbs
Carotid bruit and tenderness
Absent or weak peripheral pulses
Upper and lower limb claudication on exertion
Aortic regurgitation
413
Conditions associated with Takayasu's arteritis
Renal artery stenosis
414
Investigations Takayasu's arteritis
Vascular imaging of arterial tree - either MRA or CTA
415
Management Takayasu's arteritis
Steroids
416
Use thiazide diuretics
Mild heart failure (but loop diuretics better)
Hypertension (but now recommended to use thiazide-like diuretics instead)
417
Common adverse effects thiazide diuretics
Dehydration
Postural hypotension
Hypokalaemia, hyponatraemia
Hypercalcaemia
Gout
Impaired glucose tolerance
Impotence
418
Rare adverse effects thiazide diuretics
Thrombocytopenia
Agranulocytosis
Photosensitivity rash
Pancreatitis
419
Contraindications thrombolysis
Active internal bleeding
Recent haemorrhage, trauma, or surgery
Coagulation and bleeding disorders
Intracranial neoplasms
Stroke <3 months
Aortic dissection
Recent head injury
Severe hypertension
420
SEs thrombolysis
Haemorrhage
Hypotension
Allergic reactions with streptokinase
421
What is torsades de pointes
Form of polymorphic ventricular tachycardia associated with a long QT interval
422
Management ventricular tachycardia with adverse signs
Immediate synchronised cardioversion
423
Management ventricular tachycardia without adverse signs
Amiodarone
Lidocaine (caution in severe LV impairment)
Procainamide
424
Management ventricular tachycardia if drug treatment fails
Electrophysiological study
ICD
425
INR target VTE
2.5, 3.5 if recurrent
426
INR target AF
2.5
427
Factors increasing action of warfarin
Liver disease
P450 enzyme inhibitors, e.g. amiodarone, ciprofloxacin
Cranberry juice
NSAIDs
428
SEs warfarin
Haemorrhage
Teratogenic
Skin necrosis
Purple toes
429
Warfarin and breastfeeding
Can be used
430
Management of major bleeding on warfarin
Stop warfarin
Give IV vitamin K 5mg
Give prothrombin complex concentrate (if not available then FFP)
431
Management INR >8.0 minor bleeding
Stop warfarin
Give IV vitamin K 1-3mg, repeat dose if INR still high after 24 hours
Restart warfarin when INR <5.0
432
Management INR >8.0 no bleeding
Stop warfarin
Give vitamin K 1-5mg, using IV preparation orally, repeat dose if INR still too high after 24 hours
Restart when INR <5.0
433
Management INR 5.0-8.0 minor bleeding
Stop warfarin
Give IV vitamin K 1-3mg
Restart warfarin when INR <5.0
434
Management INR 5.0-8.0 no bleeding
Withhold 1 or 2 doses warfarin
Reduce subsequent maintenance
435
What is WPW
Syndrome caused by congenital accessory conducting pathway between the atria and ventricles leading to AVRT
436
ECG features WPW
Short PR interval
Wide QRS complexes with slurred upstroke - delta wave
Left axis deviation if right sided pathway (and vice versa)
437
Type A vs type B WPW
Type A (left sided) - dominant R wave in V1
Type B (right sided) - no dominant R wave in V1
438
Conditions associated with WPW
HOCM
Mitral valve prolapse
Ebstein's anomaly
Thyrotoxicosis
Secundum ASD
439
Definitive management WPW
Radiofrequency ablation of accessory pathway
440
Medical management WPW
Sotalol (avoid if AF)
Amiodarone
Flecainide
