Cardiology Flashcards
Dressler’s syndrome tends to occur around **** following a MI.
2-6 weeks
Left ventricular free wall rupture
This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.
Indications for surgery in IE
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
Prominent V waves
TR
Cannon A waves in JVP
Complete heart block
Absent a waves
AF
Prominent x descent
Cardiac tamponade and consrictive pericarditis
Absent x descent
AF
Warfarin - mechanical and mod - severe mitral stenosis
Warfarin is used second line in patients where direct oral anticoagulants are unsuitable, and warfarin remains the preferred option for patients with mechanical heart valves and those with moderate to severe mitral stenosis
The administration of adenosine is contraindicated by her history of*****. Verapamil should therefore be given.
asthma
slow y descent is a feature of
cardiac tamponade and tricuspid stenosis
SCN5A
Brugada syndrome
A 24-year-old man attends the clinic with recurrent episodes of collapse. These are often preceded by heart palpitations described as a rapid heart rate. On examination, heart sounds were normal. there was no evidence of heart murmurs, and he was euvolaemic.
ECG : Convex ST-segment elevation in V1-V3 followed by a negative T wave; Partial right bundle branch block; QTc 410 ms
Long QT syndrome is associated with what genetic defect
CAV3
HCM results in left ventricular hypertrophy, ECG findings
T wave inversion in the precordial leads, and deep, narrow (‘dagger-like’) Q waves in the lateral (I, aVL, V5-6) +/- inferior (II, III, aVF) leads.
Tricuspid regurgitation murmur is louder in
Inspiration
Pulmonary stenosis , murmur is louder
Inspiration
Mitral regurgitation, holo sysytolic murmur , louder on
Expiration
Late systolic murmur- mitral valve prolapse , and coarctation of aorta
non-sedating antihistamine and classic cause of prolonged QT in a patient, especially if also taking P450 enzyme inhibitor, e.g. Patient with a T* cold takes and E*** at the same time
erythromycin and terfanadine
Idioventricular rhythm is incorrect because this arrhythmia typically occurs after a severe myocardial infarction or cardiac arrest.
ECG of idioventricular rhythm—such as very slow, wide QRS complexes.
Idioventricular rhythm is incorrect because this arrhythmia typically occurs after a severe myocardial infarction or cardiac arrest.
ECG of idioventricular rhythm—such as very slow, wide QRS complexes.
Hypercalcaemia causes certain calcium ion channels to be opened for shorter amounts of time which in turn reduce phase 2 (the plateau phase) of the cardiomyocyte leading to
This shortens the QT interval.
The characteristic U waves
Hypokalemia , due to slow efflux of K leading to delayed ventricular repolarisation
*** are slurred upstrokes (in the QRS) showing early ventricular activation present in Wolf-Parkinson-White syndrome.
Delta waves
Renal impairment is a risk factor for restenosis’ - Lastly, this statement is true as well. Patients with renal impairment have been found to have higher rates of restenosis after PCI due to factors like
increased platelet aggregation and inflammation.
WPW ECG findings
short PR , and delta wave
Bivalurudin
Reversible Direct Thrombin inhibitor
*** actiavates anti- thrombin 3
Heparin
Inhibits Thromboxane A2 - prostaglandin derivative that plays a role in platelet aggregation and vasoconstriction
Aspirin
These drugs prevent platelets from binding to fibrinogen and thereby inhibit platelet aggregation - they are powerful antiplatelet agents used especially in ACS
abciximab and tirofiban., Glycoprotein IIb/IIIa receptor antagonist
Peripheral signs of endocarditis are not only rare, but occur mostly secondary to left sided valvular endocarditis, which produces systemic emboli that disseminate in the peripheral tissue, brain, spleen and kidneys.
Digoxin is a cardiac glycoside that increases the force of myocardial contraction and slows conduction through the atrioventricular node. It can cause various ECG changes including
ST segment depression, T wave inversion and arrhythmias due to its effect on sodium-potassium ATPase pump inhibition.
Myopathy is more common in lipophilic statins (*****) than relatively hydrophilic statins (rosuvastatin, pravastatin, fluvastatin)
simvastatin, atorvastatin
**** has a similar mechanism of action to clopidogrel - inhibits ADP binding to platelet receptors
Ticagrelor
, *** refers to a different class of antiplatelet agents. These medications work by inhibiting the binding of fibrinogen and von Willebrand factor to glycoprotein IIb/IIIa receptors on activated platelets, thereby preventing platelet aggregation. Examples of *** include abciximab and eptifibatide.
Glycoprotein IIb/IIIa inhibitor
A 24-year-old male is diagnosed as having hypertrophic obstructive cardiomyopathy. Which one of the following markers is most useful in assessing risk of sudden death?
Abnormal blood pressure changes on exercise
Arrythmogenic right ventricular cardiomyopathy (ARVC/ARVD)
2nd most common cause of sudden cardiac death in young adults after HOCM
an autosomal recessive variant of ARVC
a triad of ARVC, palmoplantar keratosis, and woolly hair
Naxos disease
The atrioventricular node is supplied by the posterior interventricular artery, which in the majority of patients is a branch of the right coronary artery. In the remainder of patients the posterior interventricular artery is supplied by the left circumflex artery.
Complete heart block secondary to right coronary artery infarction
***** should be avoided in HOCM
Ramipril
Prolonged PR interval in aortic root abscess
IE in aortic valve , Extension of the PR interval beyond 200ms (first-degree heart block) can be an early warning sign of more severe conduction defects that may develop in endocarditis, either due to the disease process itself or as a side effect of antimicrobial therapy.
ECG demonstrates convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave.
Brugada syndrome
Mutation in Myosin Heavy Chain 7
DCM
Mutation in KCNE1
Jervell and Lange-Nielsen syndrome, which is a form of long QT syndrome.
Mutation in PKP2 is incorrect. A mutation in this gene is associated with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
Patients with HOCM often present with palpitations, chest pain, and exertional syncope (rather than at rest).
PAH
Exertional dyspnoea
Asymmetric dosing regimes should be used for standard-release ISMN to prevent nitrate tolerance
An asymmetric dosing regimen would involve taking the morning dose as normal, then taking the second dose in the early afternoon. This allows a sufficiently long nitrate-free period and helps reduce tolerance.
In AF , NICE advocate using a rate control strategy except in a number of specific situations such as
coexistent heart failure, first onset AF or where there is an obvious reversible cause.
For Rythm control,
For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment in pregnant women with seizures as they are started on
MgSO4 infusion ,
BNP - actions:
vasodilator: can decrease cardiac afterload
diuretic and natriuretic
suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
Pre eclampsia management
oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
is defined as new-onset high blood pressure after 20 weeks of pregnancy in the absence of significant proteinuria.
Gestational hypertension
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Clippdogrel
ADP receptor antagonist
Dabigatran and bivalirudin are
direct thrombin inhibitors.
Tirofiban and abciximab are
glycoprotein IIb/IIIa inhibitors.
valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.
*** , which is a common cause of infective endocarditis, particularly in patients with pre-existing heart valve abnormalities
Streptococcus viridans infection
Most common cause of endocarditis:
Staphylococcus aureus
Staphylococcus epidermidis if < 2 months post valve surgery
Mitral prosthetic valves generally require a higher INR than aortic ones due to their higher thrombotic risk.
The target INR for mitral mechanical prosthetic valves should be 2.5-3.5, whereas for aortic mechanical prosthetic valves, it should be 2.0-3.0 according to NICE guidelines
Target INR for Rx of VTE/PE
2.5
**** is a vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.
Nicorandil
Poor prognostic factors following MI
age
development (or history) of heart failure
peripheral vascular disease
reduced systolic blood pressure
Killip class*
initial serum creatinine concentration
elevated initial cardiac markers
cardiac arrest on admission
ST segment deviation
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction
Unprovoked’ pulmonary embolisms are typically treated for
6 months
Admission is typically reserved for severe pre-eclampsia or blood pressure readings ≥ 160/110 mmHg, necessitating closer monitoring and intensive management to mitigate potential risks.
***** is the leading organism contributing to mortality in infective endocarditis
Staphylococci ,
Staph aureus followed by coagulase-negative staphylococci are two of the most common organisms causing infective endocarditis.
mid-diastolic Austin-Flint murmur in** - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
severe AR
On examination, he had a midsystolic murmur heard best at the left lower sternal border. It was louder with the Valsalva manoeuvre. An echocardiogram reported mitral regurgitation, systolic anterior motion of the anterior mitral valve leaflet, asymmetric hypertrophy and left ventricular outflow tract obstruction.
HOCM , avoid - nitrates , ACE inhibitors, ionotropes
A patient who is intolerant of aspirin is started on clopidogrel for the secondary prevention of ischaemic heart disease. Concurrent use of which one of the drugs may make clopidogrel less effective?
Omeprazole
SSRIs inhibit platelet uptake of serotonin (which is needed for platelet aggregation) and clopidogrel prevents platelet aggregation by blocking ADP receptors on platelets. The clinical significance of this interaction is unclear but it’s generally advisable to monitor patients closely if these drugs are used together.
Also, the concurrent use of nicorandil and PDE5 inhibitors is contraindicated as it can cause severe refractory hypotension.
Hypothermia ECG findings
ECG: hypothermia
The following ECG changes may be seen in hypothermia
bradycardia
‘J’ wave (Osborne waves) - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
Non-selective phosphodiesterase inhibitor is incorrect because these drugs, such as** are primarily used for their bronchodilator effects in conditions like asthma and chronic obstructive pulmonary disease (COPD). They work by increasing cAMP levels in cells leading to smooth muscle relaxation.
caffeine and theophylline
is a rare congenital heart defect that is characterised by apical displacement of the septal and posterior tricuspid leaflets onto the right ventricular wall, leading to atrialisation of part of the right ventricle. Severe cases often present in infancy but milder cases can remain asymptomatic until adulthood. This commonly presents with arrhythmia and shortness of breath predominantly on exertion. ECG changes include right bundle branch block and Wolf-Parkinson-White (WPW) syndrome due to aberrant conduction pathways. Echocardiography will be useful in the diagnosis
Ebstein’s anomaly
A 27-year-old man presents to the Emergency Department after a syncopal episode. On inspection of the neck veins he has a prominent ‘a’ wave. On auscultation of the heart, there is a harsh crescendo-decrescendo systolic murmur that is heard best at the apex and lower left sternal border.
HOCM
**, also known as or microvascular angina, typically presents with angina-like chest pain and ST depression during stress testing, despite normal coronary arteries on angiography. The ST depression is thought to be due to microvascular dysfunction.
Syndrome X , cardiac syndrome X
*** causes characteristic ‘scooped’ or ‘reverse tick’ ST depression on ECG, known as the ‘effect’. This is due to the drug’s effect on the sodium-potassium ATPase pump and is seen in therapeutic doses, not just in toxicity. The ST depression is most prominent in leads V5 and V6.
Digoxin
Furthermore, long-term use of LMWH can cause significant complications such as osteoporosis. In addition, daily injections have a negative effect on patients’ quality of life.
. In patients with accessory pathways, such as those with Wolff-Parkinson-White syndrome, AV nodal blocking drugs should be avoided in atrial fibrillation. This is because blocking the AV node may enhance the rate of conduction through the accessory pathway, causing atrial fibrillation to degenerate into ventricular fibrillation (VF).
Drugs that can be used , Flecainide
Sotalol could have been used if there is no AF
Avoid
Beta blockers
Verapamil
Digoxin
People with cardiac syndrome X have normal coronary angiograms despite ECG changes on exercise stress testing
Downslpoing ST Depression in ECG during exercise
Cholesterol embolisation
Overview
cholesterol emboli may break off causing renal disease
the majority of cases are secondary to vascular surgery or angiography. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta
Features
eosinophilia
purpura
renal failure
livedo reticularis
one of the following cardiac conditions is most associated with a louder murmur following the Valsalva manoeuvre?
HOCM
. *** refers to an exaggerated decrease in pulse amplitude during inspiration and can be seen in conditions such as cardiac tamponade or severe asthma
Pulsus paradoxus
is characterised by two peaks in systole and can be felt as a double beat for each cardiac cycle. This type of pulse is typically associated with conditions like hypertrophic cardiomyopathy or severe aortic regurgitation, not PDA
Bisferiens pulse
refers to alternating strong and weak pulses which may indicate left ventricular failure or other serious cardiac disease
Pulsus alternans
Features suggesting VT rather than SVT with aberrant conduction
AV dissociation
fusion or capture beats
positive QRS concordance in chest leads
marked left axis deviation
history of IHD
lack of response to adenosine or carotid sinus massage
QRS > 160 ms
The most specific ECG finding in acute pericarditis is
PR depression
Risk of falls or old age alone is not sufficient reasoning to withhold anticoagulation
Pre-excitation on ECG with a tricuspid regurgitation murmur are suspicious for**** , which is associated with Wolff-Parkinson-White syndrome.
Ebstein’s abnormality
It can present in neonates with cyanosis or with heart failure or an incidental murmur in childhood. It typically presents with arrhythmia in adults. Some cases of Ebstein’s abnormality are associated with lithium and benzodiazepine use in pregnancy.
