Cardiology Flashcards
Nicorandil MOA and Side Effects ?
a nitrate and a non-selective potassium channel activator
GI ulcers including Anal Ulcers, Upset, Headaches Flushing
Investigations for DVT and/or PE in Pregnancy ?
If Pregnant and Suspicious of DVT —> Duplex USS
If Pregnant and No DVT on USS –> V/Q
Valve Replacement concepts
Aspirin - Bioprosthetic (A –> B)
Warfarin (+ Aspirin) - Mechanical (W –> upside down = M)
INR targets
2.5 for A fib and PE/DVT
3.0 for aortic valve
3.5 for recurrent DVT
3.5 for mitral vale AM
The following factors favor choice of a mechanical valve:
-For aortic valve replacement, age <55 years
-For mitral valve replacement, age <70 years
-No contraindication to anticoagulation with a vitamin K antagonist (VKA)
-Presence of an additional indication for anticoagulation (eg, an existing mechanical valve)
-High-risk of morbidity/mortality with reintervention (eg, porcelain aorta)
The following factors favor choice of a bioprosthetic valve:
-Patient’s life expectancy is shorter than the expected effective longevity of a bioprosthetic valve
-Reoperation after mechanical valve thrombosis occurring despite good long-term control of anticoagulation and absence of structural defects
-Anticoagulation with a VKA is contraindicated, cannot be managed appropriately, or is not desired by the patient.
Associations with Patent Foramen Ovale
Migraine
Aortic Stenosis Facts
Crescendo - Decrescendo Ejection Systolic Murmur
Opening Snap
Narrow Pulse Pressure
Slow Rising Pulse
Soft S2 + Paradoxical Splitting
Stroke Adam Attack
Management of Aortic Stenosis
If Asymptomatic -
Watch and Wait
No nitrates/ACEi - decrease afterload and precipitate hypotension
If
1. Symptomatic
2. BP drop on exercise tolerance test
3. Heart failure
4. Pulmonary hypertension
5. Severe stenosis <0.6cm2
6. Valvular Gradient > 40mmHg + LVH
Then TAVI/Open
Often Coronary Angio Prior TRO CAD
If TAVI/Open Contraindicated –> Balloon valvuloplasty
Acute Idiopathic/Viral Pericarditis Management
1st Line - NSAIDs + Colchine for 3 months
2nd Line - NSAIDs + Steroids + Colchicine
3rd Line - Azathioprine or IVIG + Anakinra
Long QT Syndrome Drugs and Other Causes
AntiArrythmics - Amiadarone , Sotalol - Class 1a
AntiBiotics - Erythromycin
AntiCsyhotics - Haloperidol, Quetiapine, Risperidone
AntiDepressants - SSRI, TCA
AntiEmetics - Ondansetron
Romano Ward
Jervell-Lange-Nielsen syndrome
HypoCalcemia
HypoKalemia
HypoThermia
ACS
SAH
Complications Post MI
0-24 hours
Sudden Cardiac Death
Ventricular Arrythmias
Acute Left Ventricular Failure (Most Important Predictor of Post MI Outcome - Killip Class)
1-3 days
Fibrinous Pericarditis
3-7 days
Papillary Muscle Rupture and MR
Left Ventricular Free Wall Rupture
Pseudoaneurysm
Ventricular Free Wall Rupture
7 days - 6 weeks
Dressler Syndrome
Reinfarction
CCF
Centrally Acting Antihypertensives
MMC
methyldopa
moxonidine
clonidine
DVLA Guidelines
successful catheter ablation 2 days
pacemaker insertion 1 week
Prophylactical ICD 1 month
sustained ventricular arrhythmia with ICD
6 months
PCI 1 week
ACS 1 month but 1 week if successfully treated with Angioplasty
CABG 1 month
Heart transplant 6 weeks
aortic aneurysm of 6cm annual review
aortic aneurysm of 6.5 cm disqualifies patients from driving
ICD G.2 Permanent
HTN G.2 Permanent BP Sys >180 , Dias >100
HF G.2 EF <40 or symptomatic
Angina Permanent if happened in rest
Brugada , WPW and Jervell and Lange-Nielsen Syndrome Genes
SCN5A - Brugada (+ KCNE3, CACNB2)
PRKAG2 - Wolff-Parkinson White
KCNQ1 - Jervell and Lange-Nielsen syndrome + hearing loss
Pulmonary
Hypertension
Causes
HIV
Cocaine
Anorexigens (e.g. fenfluramine)
10% Autosomal Dominant
Clinical Signs
Large A waves
Right Parasternal Heave
Loud P2
Tricuspid Regurgitation
Management
Stabilize + Anticoagulated for ?PE because of Right Heart Strain
Acute Vasodilator Testing
If + response = Oral CCB
If - response
- prostacyclin analogues: treprostinil, iloprost
- endothelin receptor A antagonists - Teratogenic / Limb Edema Common SE
2.1 non-selective: bosentan (deranged LFTs)
2.2 selective : ambrisentan - phosphodiesterase inhibitors: sildenafil
Heart Transplant if progressive Symptoms
Differentials for REGULAR Broad Complex Tachycardia
Ventricular tachycardia (VT)
Supraventricular tachycardia (SVT) with aberrant conduction due to bundle branch block
SVT with any metabolic disturbance that slows supraventricular action potential propagation — hyperkalaemia, sodium channel blockade, severe acidosis
Antidromic AVRT — re-entrant tachyarrhythmia seen in Wolff-Parkinson-White syndrome
Accelerated idioventricular rhythm (AIVR)
Drug Contraindicated in Ventricular Tachycardia
Verapamil
Furosemide inhibits Na/K/2Cl- in the Ascending or Descending Limb of the Loop of Henle
Thick Ascending Limb
Mechanism of Action of Hydralazine
Increases cGMP causing smooth muscle dilatation to a greater extent in ARTERIOLES > VEINS
Long QT Syndrome due to Gain of Function or Loss of Function of Na or K channels
Loss of Function
K Channels
Which Cardiac Marker Rises First ?
Myoglobin
Which Cardiac Marker is used for re-infarction ?
CK-MB - returns to normal after 2-3 days
Troponin T - elevated for 10 days
Wolf Parkinson White Syndrome Associations
HOCM
Mitral valve prolapse
Ebstein’s anomaly
Thyrotoxicosis
Secundum ASD
Differentiating Type 1 and Type 2 WPW Syndrome
Type A (left-sided pathway): dominant R wave in V1 & Right Axis Deviation
Type B (right-sided pathway): no dominant R wave in V1 & Left Axis Deviation
Hypertension in Pregnancy defined by
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Difference between Chronic HTN , Gestational Hypertension and Pre-Eclampsia
> 140/90 before Pregnancy or before 20 weeks
Gestational Hypertension - AFTER 20 week WITHOUT proteinuria/edema
Pre-eclampsia - AFTER 20 weeks WITH proteinuria/edema
If High Risk take 75mg Aspirin OD from 12 weeks
Antihypertensives in Pregnancy
Labetalol
Nifedipine (if asthmatic)
Hydralazine
Methyldopa
Mechanism of Actions of Antiplatelets
Aspirin –> Inhibit COX 1 –> Inhibit release of TXA2 from platelets –> Reducing Aggregation
Clopidogrel/Ticagrelor —> ADP Receptor Antagonist / PYG12 inhibitors —> Reduced activation of GIIb/IIIa receptors
Tirofiban/Eptifibatide/Atciximab —> GIIb/IIIa receptor inhibitors —> Preventing Fibrogen bridges between GIIb/IIIa receptors
Dipyridamole —> Phosphodiesterase Inhibitors –> Decrease cAMP to AMP conversion which activates Ca pumps and Decreasing influx of Ca via Voltage Gated Ca Channels —> Reduced Ca intracellularly –> Reduced release of pro-aggregates like ADP and TXA2
Dipyridamole –> Also inhibit uptake of Adenosine by Platelets –> Increasing Extracellular levels of Adenosine –> Vasodilation
Dabigatran –> Direct Thrombin Inhibitor
Bivalirudin –> Reversible direct thrombin inhibitor
Heparins –> Activates antithrombin III
Stable Angina Management
GTN
Non DHP CCB (Verapamil)
BB
Increase all to Max Tolerated DOSE
DHP CCB + BB
If on Monotherapy and Cant add CCB or BB then
add :
1. a long-acting nitrate - Asymmetric dosing if Standard Release w/ nitrate free interval
2. ivabradine
3. nicorandil
4. ranolazine
If on 2 drugs only add 3rd drug whilst awaiting PCI or CABG assessment
INR Targets
A fib / DVT / PE - 2.5
Aortic Valve - 3.0
Mitral Valve - 3.5
Recurrent DVT - 3.5
BUT
Bioprosthetic Valve
Bioprosthetic Valve PLUS DVT
Recurrent DVT or DVT on Warfarin
(bioprosthetic) valve > no need for warfarin > long term aspirin
(bioprosthetic) valve + DVT > if given warfarin (here would be second line after DOAC) > INR 2.5
DVT recurrence or DVT while on warfarin > INR 3.5
Metallic aortic valve > warfarin INR 3.0
PE anticoagulation management
if neither apixaban or rivaroxaban are suitable then either
LMWH followed by dabigatran or edoxaban OR
LMWH followed by VKA
if the patient has active cancer
DOAC
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
APLS (Triple Positive) —> LMWH followed by a VK
High and Moderate Risk Factors for Pre-Eclampsia ?
High Risk Factors -
1. HTN disease in Previous Pregnancy
2. CKD
3. Autoimmune SLE APLS
4. T1DM or T2DM
4. Chronic HTN
Moderate Risk Factors
1. first pregnancy
2. >/=40
3. Pregnancy Interval > 10 years
4. BMI >/= 35
5. Family History of Pre-eclampsia
6. Multiple Pregnancy
> 1 High OR >/=2 Moderate = Aspirin 75-150mg OD from 12 weeks until birth
Pre-Eclampsia - >160/110 + Proteinuria/Edema
Admit urgently
SEVERE PRE ECLAMPSIA FEATURES
hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
Do Oral Labetalol
Delivery is definitive management
24 vs 72 hour Holter for Palpitations
Bloods and ECG review
24 hour if daily
72 hour if less frequent than daily
If Holter NAD –> Implantable or External Loop recorder
Antibiotics for Infective Endocarditis
Empirically - Native
- Amoxicillin +/- Gentamicin
- If MSRA / Septic / Pen Allergic –> Vancomycin +/- Gentamicin
Empirically - Prosthetic
- Vancomycin + Rifampicin + Gentamicin
Staphylococci - Native
1. Flucloxicillin
2. Vancomycin + Gentamicin
Staphylococci - Prosthetic
1. Flucloxicillin + Rifampicin + Gentamycin
2. Vancomycin + Rifampicin + Low dose Gentamicin
Streptococci (Viridans)
1. BenzylPen
2. Vancomycin + Gentamicin
Streptococci (Others) -
1. BenPen + Gentamicin
2. Vancomycin + Gentamicin
Aortic Regurgitation Management
surgery:
- symptomatic patients with severe AR
- asymptomatic patients with severe AR who have LV systolic dysfunction
Aortic Regurgitation Causes
Valve - Bicuspid, RHD, Calcification, Connective Tissue Disease
Aortic Root - Bicuspid, Syphillis , HTN , Marfan/Ehler Danlos
Acute - IE, Dissection
Drugs Contraindicated in HOCM
Nitrates - Vasodilate
Inotropes
ACEi - Reduce Afterload
DHP CCB’s
Digoxin
B2 Agonist - Vasodilate
HOCM Signs
Crescendo Decrescendo Ejection Systolic Murmur
MR SAM ASH
Mitral Regurgitation
Asymmetric Septal Thickening
Systolic Anterior Movement of Mitral Valve
S4
Pulsus Bifirengens
Paradoxical Splitting of S2
Tripple Ripple
RHF and LHF Symptoms
Aortic Stenosis Management
If Asymptomatic –> Observe
If Aymptomatic + Valve Gradient >40mmHg + LVF –> Valve Replacement
If Symptomatic –> Valve Replacement —> Coronary Angiogram Prior as CVD usually Co-exist then SURGICAL Correction if Low Risk / Young
If High Risk –> TAVR
Balloon Valvuloplasty –>
Children without Calcification or Adults not for Replacement
Peripheral Arterial Disease Management
5HT1-B agonist: Sumatriptans
5HT-2 Antagonists:
Risperidone - Olanzapine -
Cyproheptadine
Naftidrofuryl
5HT3 antagonists: Ondansetron
Drugs Triggering Hypertensive Crisis and Secondary HTN
Phenelzine (MAOI)
steroids
the combined oral contraceptive pill
NSAIDs
leflunomide
Poor Prognostic Factors for HOCM
syncope
family history of sudden death
young age at presentation
non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
abnormal blood pressure changes on exercise
Septal thickening >3cm
What vessels vasodilate and Vasoconstrict in Exercise
GI / Kidneys –> Vasoconstriction
Skin does both
Skeletal muscle dilates
When do we stop a ETT and Contraindications for ETT ?
Contraindications
1.MI < 7 days ago
2. unstable angina
3. uncontrolled hypertension (systolic BP > 180 mmHg) or 4.hypotension (systolic BP < 90 mmHg)
5. aortic stenosis
6. left bundle branch block: this would make the ECG very difficult to interpret
Stop if:
1.exhaustion / patient request
2. ‘severe’, ‘limiting’ chest pain
3. > 3mm ST depression
4. > 2mm ST elevation.Stop if rapid ST elevation and pain
5. systolic blood pressure > 230 mmHg
6. systolic blood pressure falling > 20 mmHg
7. attainment of maximum predicted heart rate
8. heart rate falling > 20% of starting rate
9. arrhythmia develops
Causes of Dilated CardioMyopathy
Causes of DCM - THIAMIN
- Thiamine deficiency (wet beri-beri)
- Hypertension
- Ischaemic heart disease
- Alcohol (and cocaine)
- Myocarditis
- Infiltrative (haemochromatosis and sarcoidosis)
- No cause (idiopathic)
- Selenium Deficiency
Cardiac Syndrome X
What is it ?
Angina on Exertion
ST depression on ETT
BUT normal coronary arteries on angiography
What are the features of SVT with Aberrancy vs V Tach
Ventricular Tachy if :
- AV dissociation
- fusion or capture beats
- positive QRS concordance in chest leads
- left axis deviation
- history of IHD
- lack of response to adenosine or carotid sinus massage
7.QRS > 160 ms
In Eclampsia what’s the dose of Magnesium Sulphate ?
What is the reversal agent for Magnesium Sulphate Toxicity ?
4g in 5-10 minutes with an infusion 1g/hour
Calcium Gluconate
Pulmonary HTN Murmurs
Tricuspid Regurgitation - Pansystolic
Early Diastolic Murmur at the Pulmonary Area (Graham-Steele Murmur)
What feature seen in Auscultation of Complete Heart Block ?
Variable Intensity of S1
Causes of Loud S2, Soft S2, Fixed Split S2, Widely Split S2 and Paradoxical S2 split
Causes of a loud S2
- hypertension: systemic (loud A2) or pulmonary (loud P2)
- hyperdynamic states
- atrial septal defect without pulmonary hypertension
Causes of a soft S2
aortic stenosis
Causes of fixed split S2
atrial septal defect
Causes of a widely split S2
deep inspiration
RBBB
pulmonary stenosis
severe mitral regurgitation
Causes of a reversed (paradoxical) split S2 (P2 occurs before A2)
LBBB
severe aortic stenosis
right ventricular pacing
WPW type B (causes early P2)
patent ductus arteriosus
ECG Findings for AVRT and AVNRT
AVNRT,
retrograde P waves occur early, so we either don’t see them (buried in QRS) or partially see them (pseudo R’ wave at terminal portion of QRS complex)
In AVRT, retrograde P waves occur later, with a long RP interval > 70 msec
AVNRT is the most common regular, narrow-complex tachycardia.
If 2:1 Block then think Atrial Flutter
BUT QUESTIONS IF TACHCARDIA WITH >150 Think Atrial Flutter
atrial flutter rate: 250-350 (block usually 2:1, or 3:1)
atrial fibrillation: 400-600 (inconsistent impulse transmit)
Afib > 48 hours Cardioversion and Anticoagulation Guidelines
If Afib > 48 hours then
Anticoagulated for 3 weeks –> Cardiovert –> 4 weeks anticoagulated
AFTERWARDS
Alternatively … TOE and Immediate Heparinized and Cardioversion.
If Afib with > 48 hours + RECURRENT A FIB or FAILED CARDOVERSION then Anticoagulated for 4 weeks along with AMIODARONE or SOTALOL
Amiodarone Half Life and Why is a loading dose 300mg 10-30 mins followed by 900mg infusion / day given ?
20-100 days
Highly Lipophilic and reduced bioavailability hence need loading dose and maintenance dose to maintain therapeutic levels
Is OS - Primum or Secundum LBBB ?
Trick Question - Neither
ASD - Primum - RBBB with LEFT Axis Deviation
(Primary School LEFT alone by parents)
ASD - Secundum - RBBB with RIGHT Axis Deviation
(Secondary School on the RIGHTPath to Success)
Swan Ganz Catheter measures pressure within which chamber of the heart ?
Swan LAke - Left Atrium
Amiodarone MOA
Potassium Channel Blocker
Prophylaxis for SVT in Pregnancy
Metaprolol
Treatment for Mitral Stenosis Severe (Loud S1/Symptomatic)
percutaneous mitral valve commissurotomy»_space;>if unsuccessful»_space;surgical replacement»_space; if unsuitable»_space;transcatheter valve replacement
Causes of PR Prolongation
idiopathic
ischaemic heart disease
digoxin toxicity
hypokalaemia*
rheumatic fever
aortic root pathology
Lyme disease
sarcoidosis
myotonic dystrophy
When to Start DOAC post Stroke Vs TIA
2 weeks for Stroke
Immediately for TIA (If no cerebral infarction or hemorrhage)
Rheumatic Heart Disease Histology Findings ?
Aschoff Bodies - Granulomatous Nodules
AND
Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)
OTHER ones to remember :
Councilman bodies -> hepatitis C, yellow fever
Mallory bodies -> alcoholism (hepatocytes)
Call-Exner bodies-> granulosa cell tumor
Schiller-Duval bodies -> yolk-sac tumor
Jones Criteria Recall for Rheumatic Heart Disease
The rheum professor wore specs and I called him Papi
Evidence of recent strep infection: + 2 major or (1 major + 2 minor)
Major: SPECS
Sydenham’s Chorea, Polyarthritis, Erythema Marginatum, Carditis + Valvulitis, Subcut nodules
Minor: PAPI
Pyrexia, arthralgia, prolonged PR interval inflammatory markers - raised ESR/CRP
post acute coronary syndrome (medically managed): add ticagrelor to aspirin, stop ticagrelor after 12 months
post percutaneous coronary intervention: add prasugrel or ticagrelor to aspirin, stop the second antiplatelet after 12 months
Marker of Aortic Stenosis Severity
S4
Arrhythmogenic Right Ventricular Cardiomyopathy Recall
Inheritance Pattern
ECG findings
Management
Autosomal Dominant
Mutations in Cardiac Desmosomes
Right Ventricle replaced by Fibro Fatty Tissue
ECG : T wave INVERSION in leads V1-V3 with EPSILONE WAVE (A notch at the end of QRS complex)
Management
1. Sotalol
2. Catheter ablation to prevent VTachy
3. ICD
Naxos disease
an autosomal recessive variant of ARVC
a triad of ARVC, palmoplantar keratosis, and woolly hair
Whats Naxos Disease ?
Autosomal recessive variant of ARVC
a triad of ARVC, palmoplantar keratosis, and woolly hair
Pritmental Angina Treatment ?
Worse at Rest due to Vasospasm
DHP CCB
BETA BLOCKER CONTRAINDICATED ***** as they trigger vasospasm
Aortic Dissection Standford and Debakey Classification
Standford
Type A : Ascending Aorta
Type B : Descending Aorta , Distal to Left Subclavian Artery
Debakey
Type 1 : Originates in ASCENDING Aorta and extends distally
Type 2 : Localized to Ascending Aorta
Type 3 : Originates at DESCENDING Aorta and moves distally
Management for Aortic Dissection
Type A - Surgical Management
Type B - Conservative with IV Labetalol
If ?Aortic Dissection patients not suitable/risky for CT then what is the next best investigation of Choice ?
TOE
How do Thiazide Diuretics cause HYPOKALEMIA
BLOCK sodium reabsorption at proximal DCT
&
INCREASE sodium delivery to distal DCT
Poor Prognostic Factors in Infective Endocarditis ?
Low Complement Levels
Staphylococcus Aureus
Prosthetic Valve
Culture Negative Organisms
Staphylococcus - 30% mortality
Streptococcus - 15% mortality
Bleeding and INR rules
Major Bleed: STOP, Vit K 5mg iv, PCC
INR >5, Bleed: STOP, Vit K 1-3mg iv, Resume <5
INR >8 , No bleed: STOP, Vit K 5mg po, Resume <5
INR 5-8: HOLD 1-2 dose
Gold Standard Investigation for Myocarditis ?
Structural CMR
Statins MOA ?
Inhibit HMG-CoA Reductase –> Decreasing Intrahepatic Cholesterol Synthesis
Biggest Risk Factor for Stent Thrombosis ?
Premature withdrawal of antiplatelets
Diabetes is a risk factor for RESTENOSIS
HOCM Histology
myofibrillar hypertrophy with chaotic and disorganized fashion myocytes (‘disarray’) and fibrosis on biopsy
Causes of
- Pulsus Alternans
- Pulsus Paradoxus
- Collapsing Pulse
- Bisferiens pulse
- ‘Jerky’ pulse
- Pulsus Alternans
- Severe LVF - Pulsus Paradoxus - Severe Asthma or Cardiac Tamponade
- Collapsing Pulse - AR, PDA, hyperkinetic states (anemia, thyrotoxic, fever, exercise/pregnancy)
- Bisferiens - Mixed Aortic Valve disease and HOCM
- Jerky - HOCM
MOA of dipyridamole
Non Selective Phosphodiesterase Inhibitor
Reduce uptake of Adenosine
Vasodilatation
4P’s of Tricuspid Regurgitation
Parasternal Heave
Pulsatile Hepatomegaly
Pan Systolic Murmur
Prominent V waves
Actions of BNP
vasodilator: can decrease cardiac afterload
diuretic and natriuretic
suppresses both sympathetic tone and RAAS
