Cardiology Flashcards
Risk score to assess when patients should be started on anticoagulation if they have had a history of AF
CHA2DS2VASc
What are the points in the CHA2DS2VaSc Score
C - Congestive Heart failure - 1
H - Hypertension - 1
A - Age >75 - 2
Age 64-74 - 1
D - Diabetes - 1
S - Stroke, VTE, Thromboembolic - 2
Vas - Vascular disease - PAD - 1
S - Sex - F - 1
What indication is there to start Anticoagulation in AF patients
1) CHADSVASC Score of >2 in anyone or Male >1
2) Echo - Mitral stenosis/metallic heart valve
What bleeding score is used to deliniate risk/benefit ratio
ORBIT score
What parameters are in the Orbit score
Hb - <130 M, <120 F - 1
eGFR <60 - 1
Previous Bleeds - 2
Age >74 - 1
Treatment with antiplateles - 1
Orbit score to risk equivalent
0-2 - Low
3 - Medium
4-7 - High risk
1st line management for AF to prevent the risk of stroke
DOAC
What is Holiday Heart syndrome
Paroxysmal AF due to Heavy alcohol consumption acutely which should self resolve
What is a J point on ECG
It is the point where the QRS complex meets the ST segment and signifies the end of depolarisation and start of repolarisation
Why does a J-wave form in hypothermia
Due to delayed repolarisation of the myocardium secondary to hypothermia
- Therefore you would see a J-wave which is an UPWARD deflection (In the true limb leads) between the point where the QRS complex meets the ST segment
How does Hypothermia present on a ECG
Bradycardia
Heart block - 1st degree or higher depending on severity of hypothermia
J waves
QT prolongation
Severe hypothermia - Torsades de points secondary to QT prolongation
How to classify a SVT
Origin - Atria/AV node
Regularity - Regular vs Irregular
Classification of SVT’s
Regular Atria:
- Atrial flutter
- Sinus Tachycardia
Irregular Atria:
- AF
- Atrial flutter + Hear block
Regular AV node:
- AVNRT
- AVRT - WPW
- Junctional tachycardias
Cause of WPW
Accessory pathway - Bundle of Kent
ECG findings of WPW
PR <120ms
Delta wave - Sloping of the R wave
Broad QRS complex >120ms
Management of SVT
1ST LINE:
- Vagal manouvres
Valsalva –> Expiration with a closed glottis
carotid artery massage
2ND LINE:
Adenosine 6mg –> 12mg –> 18mg
3rd LINE:
Ectrical cardioversion (1st line in case of Haemodynamic compromise)
C/I of adenosine
Asthma
Management of known SVT to prevent further episodes
B-blockers -1st line
Radio-frequency ablation - 2nd line
Medication to prevent SVT in pregnancy
Metoprolol
When should Synchronised DC cardioversion be used in the management of AF (Rhythm control)
If haemodynamically unstable (Hypotensive, Chest pain)
If definitely <48 hours in AF
Why use synchronised DC cardioversion for rhythm control
SYnchronise to the R wave to prevent VF if unsynchronsied shock delivered
Management of AF <48 hours (Rhythm control)
Heparinise and cardiovert.
1) Electical - Synchronsied DC cardioversion
2) Chemical - Amiodarone if structural heart issues or Flecanide/amiodarone if no structural heart issues
Management of AF >48 hours
Anticoagulate for 3 weeks
DC Cardiovert
Anticoagulate for 4 weeks after
Name of the classification system used to classify anti-arrhythmics
Vaughan Williams classification
Class 1 Anti-arrhythmics as per Vaughan Williams classification
Double Quarter Pounder, with Lettuce and Mayo and Fries Please
Class 1a - Disopyramide, Quinidine, Procainamide
Class 1b - Lidocaine, Mexiletine
Class 1c - Felcainide, Propafenone
Mechanism of action of class 1 anti-arrhythmic drugs
Na+ Channel blockers
Class 1a - Increase AP time
Class 1b - Recued AP time
Class 1c - No effect on AP
Mechanism of action of Class II Anti-arrhythmic drugs
B-adrenergic receptor blockers
Exampels of Class II Anti-arrhythmic drugs
MBAPe
Metoprolol
Bisoprolol
Atenolol
Propranolol
Mechanism of action of Class III Anti-arrhythmic drugs
K+ Channel blockers
Examples of class III Anti-arrhythmic drugs
AIDS
A - Amiodarone
I - Ibutilide
D - Dofetilide
S - Sotalol
Mechanism of action of Class IV anti-arrhythmic drug
Calcium channel blocker
Examples of Class IV Anti-arrhythmic drugs
Verapamil - Rate limiting
Diltiazem - Non -rate limitin, Non-dihydropyridine
Context in which digoxin is used for the treatment of AF
In the context of heart failure
- +VE Inotrope –> Also diuretic effects due to increased renal perfusion
- -ve chronotrope
Mechanism of action of digoxin
Na+/K+ ATPase inhibitor - Increase Ca2+ accumulation in the sarcoplasmic reticulum –> +ve inotropic effect
-ve chronotropic effect:
- Stimulates vagun nerve
- Slows AP conduction via AVN
Signs of digoxin toxicity
Lethargy
Anorexia
Green-Yellow vision
Confusion
Gynaecomastia
Bradycardia
AV Block
ECG signs of Digoxin toxicity
Reverse tick sign
Short QT interval
Precipitants of Digoxin toxicity
Hypokalaemia - Main
Iatrogenic interaction
Management of dig toxicity
Digibind
Monitor K+ levels
What type of murmur can you hear with AVR
Early diastolic murmur best heard on the left sternal edge
Signs of Aortic valve regurgication
Orthopnoe
Dyspnoea
Reduced exerise tolerance
Angina like pain
Signs of Aortic valve regurgitation (7)
1) Early diastolic murmur
2) Severe AR - Mid diastolic (Austin flint murmur)
3) Wide pulse pressure
4) Collapsing (Water hammer pulse)
5) Quinke sign - Nail bed thrombbng
6) De Musset’s sign - Head bobbing
Diagnosis of Aortic regurg
Echo
Causes of aortic regurg - Acute vs chronic and also valvular vs aortic root
Acute:
- Valve - Infective endocarditis
- Root - Aortic dissection
Chronic:
1)Valve:
- Bicuspid aortic valve
- Rheumatic fever (MOST COMMON IN THE DEVELOPING WORLD)
-Connective tissue disorders:
Rheumatoid arthritis
SLE
2) Root:
- Bicuspid aortic valve
- Hypertension
-Syphyllis
- Marfans
- Spondyloathropathies - Psoriatic
Most common cause of aortic regurgitation in the developing world
Rheumatic fever
How would you classify Stage 1 hypertension
Clinic BP >140/90
ABPM >135/85
How would you classify Stage 2 HTN
Clinic BP > 160/100
ABPM > 150/95
Severe HTN
Clinic BP Sys >180 Diastolic >120
When should you initiate treatment
Any patient with a BP of >140/90 sould be offered ABPM
Based on that treatment should be started
Based on the ABPM When should you start treatment
ABPM <135/85 -No treatment
ABPM>135/85:
<80 + RF - Start Rx
>80 - Start Rx
ABPM > 150/95 - Strart treatment
1st line treatment for HTN
<55 Or T2DM - ACEi or ARB
> 55 or afrocarribean - CCB
