Cardiology 2 Flashcards
Management of aortic dissection
-
-
- eg of drug
Stanford Type A- ascending aorta (2/3 of cases)
surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Stanford Type B- descending aorta, distal to left subclavian origin (1/3 cases)
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
Investigations in aortic dissection
CXR what do you see?
If stable-
- key finding:
If unstable-
CXR- Widen mediastrinum
If stable- CT angiography of the chest, abdomen and pelvis
- key finding: false lumen is a key finding in diagnosing
If unstable- Transoesophageal echocardiography (TOE)
Management steps of HF
First line
Second Line
Remember adding this can cause…
Can add in….
Third line (4 med options)
a- criteria (2)
b- criteria (1)
c- especially in who?
d- especially in who?
1 non-medical option!! criteria (1)
First line: ACEi + B-blocker
Second Line: + Sprinolactone
Hyperkalaemia: Because ACEi and Sprinolactone are K+ sparing
Add in… SGLT2 Inhib -flozins
Third line (4 options)
a) Ivabradine
criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
b) sacubitril-valsartan
criteria: left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period
c) digoxin
digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation
d) hydralazine in combination with nitrate
this may be particularly indicated in Afro-Caribbean patients
cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
Stable patient, AF with a broad complex tachy will indicate what?
Atrial fibrillation with bundle branch block is the most likely cause of an irregular broad complex tachycardia in a stable patient
STEMI criteria - 2 continuous/ adjacent leads with…
- > 2.5mm (2.5 small sqaures) ST elev. in leads V2-V3 in men < 40years or 2mm ST elev in V2-3 in men. 40 years
- 1.5 mm elev in V2-3 in women
- 1mm ST elev in other leads
- new LBBB (WiLLiaM- V1 W, V6- M)
other cause of increased pro-BNP other than HF?
Renal dysfunction (eGFR < 60) can cause a raised serum natriuretic peptides
if no HF signs and poor CKD then it’ll be the CKD and breathlessness will be anaemia
Talk through how you interpret and ECG: 11 steps and their lengths
- Patient details
- Rate
- Rhythm- irreg or reg?
- Sinus- p waves and QRS following
- Anything grossly abnormal- ST elevation
- Axis deviation
- PR interval (0.12- 0.2s therefore 3-5 squares!)
- QRS (< 3 small sqaures 0.12s)
- ST segment
- QT interval- 0.4s (10 small squares)
- T wave inversion
what class is carvediol?
What is the rule for adding sprinolcatone or a/B-blocker in HTN?
Beta blocker
K + < 4.5 - sprinolcaonte
K + > 4.5 - alph or beta block
Side effect of b blocker-
What anti-anginal drug can cause perforated GU ulcers?
B-blocker = E.D (cock blocker)
Nicorandil
Half life of adenosine
10s therefore SE are quick
Management of Wolf-Park White
definitive-
medical (3 options)
Def- radiofrequency ablation of the accessory pathway
medical
- sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation
Infective endocarditis
what valve affected the most?
Rheumatic fever
IE
- If IV drug user- Tricuspid
- If previously normal valves then Mitral
Rh- Mitral
Bradycardia peri-arrest management
1. 1st line
2. can repeat up to..
3.
4.
5. specialist advice for…
- 1st line- Atropine 500mcg IV
- repeat up to 3mg
- Transcutaneous pacing/ external pacing
- Adrenaline/ isoprenaline IV
- Specialist advuse for transvenous pacing
ADENOSINE
how does adenosine have to be given?
1.
2
3. with…
avoid in (1 and why?)
what drug enhances it?
what drug blocks it?
What is the MOA of the drug and what receptor does it act on?
-
-
large calibre (16G) or central route
give over 2 seconds followed by 30ml NaCl 0.9% or can be diluted with NaCl
avoid:
-asthmatics due to bronchospasm
enhances- dipyridamole (anti-platelet)
blocks- theophylline
MOA
- Agonist of A1 receptor in AVN and induces a temporary heart block in AVN
Side effects:
- flushing
- chest pain/ SOB/ impeding doom
- bronchospasm
Investigations of stable angina
1st
2nd
3rd
examples of 2nd line (2/4)
1st- CT contrast coronary angio
2nd - non-invasive functional imaging
3rd - invasive coronary angiography
non-invasive functional
1. myocardial perfusion scintigraphy with SPECT)
- stress echo
- first-pass contrast-enhanced magnetic resonance (MR) perfusion or
- MR imaging for stress-induced wall motion abnormalities
Aortic stenosis
symptomatic relief with…
what is contraindicated and why?
Symp- furosamide
CI- nitrates due to theoretical risk of profound hypotension
Long QT syndrome is due to what?
what is a normal QT interval?
what can it lead to? (2)
features/ staging?
Long QT1
Long QT 2
Long QT 3
usually due to loss-of-function/blockage of K+ channels
430ms - female 450ms- males
- VT
- Tosardes de pointes and death
Long QT1- syncope during exercise
Long QT 2- syncope during emotional stress, auditory or exercise
Long QT 3 - syncope at rest/ night
Long QT syndrome
management
- avoid…
- med =
- if high risk-
management
- avoid… strenuous exercise also sotolol may exacerbate
- med = B-blocker
- if high risk- implant cardioverter defib
Drugs which can cause long QT syndrome
1.
2 psych class
3. psych class
4. psych example
5. drugy
6. abx
7.
8.sickly
- 1a antiarrythmias- amioderone, sotolol
- TCA
- SSRI esp. citalopram
- Methadone
- Chloroquine
- Erythromycin
- Haloperidol
- Ondasteron (5- HT3 serotonin for antiemetic)
statins and what other drug is a common interection to raise CK?
Statins + erythromycin/clarithromycin - an important and common interaction
it induces a myopathy
MOA of fondiparinux
Activates antithrombin III (similar to LMWH)
Levine Scale: for murmurs
Grade 1 -
Grade 2 -
Grade 3 -
Grade 4 -
Grade 5 -
Grade 6 -
Levine Scale:
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
dose for statin
atorvastatin primary prevention dose-
secondary prevention dose-
primary- 20mg
secondary- (After MI) - 80mg
MOA of alteplase
activates plasminogen to form plasmin
If somone is >80 and has stage 1 HTN which is…. then what should the management be?
stage 2 =
ABPM reading of >= 135/85 mmHg
just advise lifestyle changes
stage 2 = >= 150/95 mmHg
how many days before surgery should you stop warfarin?
5 days and once INR < 1.5 then can start
Do you need to anticoag someone new onset acute AF < 48hrs?
YES! always anticoag
Bumetanide class?
What electrolyte abnormality can it cause?
Loop diuretic
hypokalaemia
What murmur is associated with tertiary cardiovascular syphilis and rheumatoid arthritis.
how can you tell the difference between aortic and mitral diastolic murmurs?
Aortic Regurg- early diastolic murmur
syphilitic aortitis
mitral sten- low-pitched mid diastolic
aortic regurg- high-pitched early diastolic
what investigations do you need to do before starting someone on amioderone and why?
when do you reg and what do you check?
TFT- hypo and hyperthyroidism
CXR- pulmonary fibrosis (lower zone)
LFT- liver fibrosis
U+E- check for hypokalaemia which can increase arrythmia risk
TFT and LFT every 6 months
Aortic stenosis mangement criteria (2)
- > 40mmHg
or - Symptomatic
what vein passes anterior to the medial malleolus and is sometimes used for a venous cut down (IV access when awaiting interossious)
long saphenous vein
what do you with anti-coag if Well’s is <= 4 and d-dimer is negative
stop the anti-coag
consider alternative diag
how can you differentiate pericarditis and myocarditits from history and investigations (3)
- both pleuritic chest pain
- both have viral flu-like prodrome
- both pain worse on laying down
Myocarditis
- left ventricular dysfunction S+S (bibasal crackles)
- troponin more likley to be raised
- focal ECG changes (ST just v1-v4 in Q)
Peri
- global ECG ST elevation
PE what do you see on ABG and why?
Resp alkalosis
- hyperventilate and drop CO2
which out of left ventricular free wall rupture and ventricular septal defect cause acute mitral regurg murmur?
Vent septal defect- caused by papillary muscle rupture
presents with acute heart failure and a pan-systolic murmur.
free wall causes cardiac tamponade
ie raised JVP/muffled heart sounds, pulsens alternans
