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Internal Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Pulmonary stenosis

A

Noonan’s syndrome, congenital rubella

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2
Q

Coarctation of aorta

A

Turner’s syndrome (bicuspid aortic valve)

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3
Q

Fallot’s teratology

A

Ventricular septal defect
Overlying aorta
Right ventricular outflow tract obstruction
Right ventricular hypertrophy

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4
Q

Cyanotic heart disease

A

Teratology of Fallots
Transposition of great arteries
Single ventricle
Tricuspid atresia

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5
Q

Heart failure in Infancy

A

Enlarged liver
Tachypnoea 60-100
Intercostal insuction

Early: feeding difficulty, failure to thrive, apnoea

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6
Q

Sympathetic innervation

A 
Innervates:
SA node (B1): increase heart rate
Cardiac muscle (B1): increase contractility
Blood vessels (B1 and B2): vasodilitation
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7
Q

Parasympathetic innervation

A

Basal vagal tone, slows heart rate and conduction in SA and AV nodes

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8
Q

Layers of blood vessel

A

Tunica adventitia: fibrous tissue
Tunica media: elastic membrane and smooth muscle layer
Tunica interna: internal elastic membrane, lamina propria
Basement membrane
Endothelium

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9
Q

Left axis deviation

A 
Left ant hemiblock
Inferior MI
WPW
RV pacing
Normal variant
Elevated diaphragm
Lead misplacement
Endocardial cushion defect
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10
Q

Right axis deviation

A 
RVH
Left post hemiblock
PE
COPD
Lateral MI
WPW
Dextrocardia
Septal defects
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11
Q

LBBB

A

QRS >120ms
Broad notched or slurred R waves in leads I, aVL and usually V5 and V6
Deep broad S waves in leads V1-2
Secondary ST-T changes

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12
Q

RBBB

A

QRS >120ms
Positive QRS in lead V1 (rSR’)
Broad S waves in leads I, V5-6
Usually secondary T wave inversion in leads V1-2

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13
Q

MI evolvement

A

Hyperacute T waves (first hour)
ST elevation (within 6 hours)
Inverted T waves (1-7days)

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14
Q

Hyperkalemia ECG

A

Tall peaked T waves
Flattened P waves
Widened QRS

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15
Q

Hypokalemia ECG

A

ST segmant depression
Prolonged QT interval
Low T waves
Prominent U waves

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16
Q

Hypercalcemia ECG

A

Shortened QT interval

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17
Q

Hypocalcemia ECG

A

Prolonged QT interval

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18
Q

Pericarditis ECG

A

Diffuse ST elevation + PR segment depression

Saddle ST segment

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19
Q

Digitalis effect

A

ST “scooping”
T wave depression or inversion
QT shortening +/- U waves

Side effects:
palpitations, fatigue, visual changes, decreased appetite, hallucinations, confusion and depression.

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20
Q

Massive PE

A

S1Q3T3 (S in I, Q and inverted T wave in III)
Sinus tachycardia and AF
RAD and RVH with strain

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21
Q

Troponin

A

Peak 1-2d, elevated up to 2 weeks.
Elevated with:
MI, CHF, acute PE, myocarditis, CRF, sepsis, hypovolaemia

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22
Q

CK-MB

A

Peak 1d, elevated up to 3d.

Elevated with: MI, myocarditis, pericarditis, muscular dystrophy, cardiac defibrillation

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23
Q

Transthoracic echo

A

Non-invasive, evaluation of RA, RV and LV

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24
Q

Transoesphageal echo

A

Down the esophagus, evaluation of LA, mitral and aortic valves, interatrial septum.

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25
Q

Stress echo

A

Demonstrates MI and assesses viability

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26
Q

Exercise testing

A

Demonstrates CAD in low risk patients. Positive shows ST elevation of >1mm.
CI: acute MI, aortic dissection, pericarditis, myocarditis, PE, severe AS, arterial HTN, inability to exercise adequately

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27
Q

Arrhythmias pathophysiology

A

Alterations in impulse formation

  • Abnormal automacity
  • Triggered activity due to afterdepolarisations

Alterations in impulse conduction

  • Re-entry circuits
  • Conduction block
  • By-pass track
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28
Q

Arrhythmias approach

A 
Bradyarrhythmia (100bpm)
[] Regular
  \+ Narrow QRS (SVT)
    - Sinus tachycardia
    - Atrial tachycardia
    - AVNRT
    - AVRT
    - Atrial flutter
  \+ Wide QRS
    - SVT with BBB
    - Ventricular tachycardia
    - AVRT
[] Irregular
  \+ Narrow QRS (SVTs)
    - Afib
    - AF with variable block
    - Multifocal atrial tachycardia
    - Premature atrial contraction
  \+ Wide QRS
    - Afib with BBB
    - AF with BBB and variable block
    - Polymorphic VT
    - Premature ventricular contraction
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29
Q

Bradyarrhythmias

A

Sinus bradycardia: increased vagal tone, sick sinus, increased ICP, hypothyroidism, hypothermia
Sinus block: sinus pacemaker fires but fails to depolarise atrial muscle, no initial P wave.
Sick sinus: sinus node dysfunction

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30
Q

AV conduction blocks

A

First degree: prolonged PR interval >200ms

Second degree: described by ratio of P waves to QRS

  • Type 1 (Mobitz I): gradual prolongation of PR interval
  • Type 2 (Mobitz II): abrupt failure of conduction of P wave, increased risk of 3rd degree AV block (permanent pacing)

Third degree: complete AV block, escape pacemaker rhythm distal to the block, no relationship between P and QRS.

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31
Q

Supraventricular tachyarrhythmias

A 
Originate from atria or AV node, have narrow QRS.
Include:
Sinus tachycardia
Premature ectopics
Atrial flutter
Multifocal atrial tachcardia
Atrial fibrillation
AV nodal re-entrant tachycardia
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32
Q

CHADS2-VASc score

A 
Congestive heart failure
Hypertension
Age >75 (2)
Diabetes
Stroke/TIA (2)
Vascular disease
Age 65-75
Sex category (female)

Scores >2 should start on oral anticoagulants

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33
Q

HAS-BLED score

A 
Hypertension
Abnormal renal or liver function
Stroke
Bleeding
Labile INRs (in TI < 65%)
Elderly >65
Drugs (alcohol, or antiplatelets)
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34
Q

AF management

A

Rate control
- B blocker, diltiazem, verapamil, (digoxin, amiodarone)
Anticoagulation
- Warfarin
Cardioversion (electrical)
- if 48hrs: anticoagulate for 3wks prior and 4 weeks post cardioversion

Etiology
- HTN, CAD, valvular disease, pericarditis, cardiomyopathy, myocarditis, ASD, post-operative, PE, COPD, thyrotoxicosis, sick sinus, “holiday heart”

35
Q

Premature ectopics

A

Premature atrial contraction (different P wave morphology) or junctional premature beat (near AV node, P wave not seen)

36
Q

Atrial flutter

A

Rapid regular atrial depolarisation from a macro-re-entry circuit within the atrium (~300bpm). Diagnosis by carotid sinus massage, Valsalva maneuver, adenosine (decrease AV conduction)

37
Q

Multifocal atrial tachycardia

A

Irregular rhythm caused by presence of 3 or more atrial foci, >3 distinct P wave morphology. Treat with CCB

38
Q

Atrial fibrillation

A

Single circuit re-entry/ectopic foci, tachycardia causes remodelling that further promotes AF resulting in suboptimal CO, increases risk of thrombus.

39
Q

AV nodal re-entrant tachycardia

A

Re-entrant circuit with fast and slow conducting pathways around the AV node. Accounts for 60-70% of paroxysmal SVTs.
Acute management: Valsalva or carotid massage, adenosine first line and then metoprolol, digoxin.
Long term management: B-blocker, diltiazem, digoxin, antiarrhythmics, catheter ablation.

40
Q

Pre-excitation syndromes

A

Subset of SVTs mediated by accessory pathway which can lead to ventricular excitation.
- Wolff-Parkinson-White

41
Q

Wolff-Parkinson-White syndrome

A

Congenital defect of the conduction pathway. An accessory conduction tract allows early electrical activation of part of one ventricle and bypasses AV node. Shows as:
Slurring of QRS (delta wave),
PR interval

42
Q

Ventricular tachyarrhythmias

A 
Premature ventricular contraction
Accelerated idioventricular rhythm
Ventricular tachycardia
Torsades de pointes
Ventricular fibrillation
43
Q

Premature ventricular contraction

A

QRS >120ms with no preceding P wave. Usually benign.

44
Q

Accelerated idioventricular rhythm

A

Ectopic ventricular rhythm with rate 50-100bpm. Frequently occurs in patients with acute MI or other types of heart disease

45
Q

Ventricular tachycardia

A

> 3 consecutive ectopic ventricular complexes. Rate >100bpm.
Wide QRS >140ms
AV disociation
Can be monomorphic or polymorphic.
Rx: sustained VT requires electrical cardioversion.

46
Q

Torsades de Pointes

A

Predisposition:

  • Congenital long QT syndromes
  • Drugs quinidine, phenothiazines, erythromycin, quinolones
  • Electrolytes hypokalemia, hypomagnesia

Rx: IV magnesium, temporary pacing, electrical cardioversion if hemodynamically unstable

47
Q

Ventricular fibrillation

A

Requires prompt ventilation and cardiac support

48
Q

Electrical pacing

A

Indications: symptomatic bradycardia, hemodynamic instability, Mobitz II, complete heart block

Pacing techniques:
Temporary: transvenous or external
Permanent: into RA or apex RV

49
Q

Implantable cardioverter defibrillators

A

For spontaneous VT or VF

50
Q

Catheter ablation

A

Indications:

  • Paroxysmal SVT (most AVNRT)
  • Atrial flutter
  • Afib pulmonary vein ablation
  • VT arises in RV outflow tract
51
Q

Stable angina

A

Rx:

  • Lifestyle modification, diet, exercise, statins
  • Antiplatelet therapy: aspirin, clopidogrel
  • Beta-blockers: increase coronary perfusion, decrease demand, decrease afterload (BP)
  • Nitrates: symptomatic control, decrase preload and afterload, maintain nitrate free intervals to prevent tolerance
  • CCB: second-line to increase coronary perfusion
  • ACE inhibitors:for hypertension
  • Revascularisation
52
Q

NSTEMI

A

Incomplete or transient vessel occlusion.

Criteria:

  • symptoms of angina
  • rise and fall of serum markers of myocardial necrosis
  • evolution of ischemic ECG changes without ST elevation

Rx:

  • Clopidogrel 300mg
  • Aspirin 150mg
  • Ticagrelor 180mg
  • Enoxaparin infusion
  • Beta blockers
  • Statins
  • ACEi
53
Q

STEMI

A

Total coronary occlusion resulting in MI.

Criteria:

  • ST elevation in 2 leads or new BBB
  • elevated cardiac enzymes. PCI within 90mins.

Rx

  • < 90mins PCI
  • > 90mins fibrinolysis: tenectaplase bolus, aspirin, clopidogrel, enoxaparin, beta-blocker
54
Q

Long term management of ACS

A

1) Education, risk factor modification
2) Antiplatelet and anticoagulation: aspirin, clopidogrel, warfarin if high risk
3) Beta blockers
4) Nitrates
5) CCB
6) ACEi
7) Spironolactone if signs of heart failure
8) Statins

55
Q

CABG

A

Indications:

  • > 50% of LMCA
  • > 70% of LAD, LCx or RCA
Grafts
- Saphenous vein
- Left internal thoracic artery
Right internal thoracic artery
- Radial artery
56
Q

Congestive heart failure

A

Left heart failure
Low cardiac output: fatigue, syncope, systemic hypotension, cool extremities, slow cap refill, peripheral cyanosis, pulsus alternans, mitral regurge, S3
Venous congestion: dyspnea, orthopnea, PND, cough, crackles

Right sided heart failure:
Low cardiac output: left sided symptoms due to underfilling, tricuspid regurgitation, S3
Venous congestion: peripheral edema, elevated JVP, Kussmal’s sign, hepatosplenomegaly, pulsatile liver

Most common causes of CHF:

  • CAD
  • HTN
  • Idiopathic/dilated cardiomyopathy
  • Valvular
  • Alcohol

Precipitants of existing CHF:

  • Hypertension
  • Endocarditis
  • Anemia
  • Rheumatic heart disease and valvular disease
  • Thyrotoxicosis
  • Failure to take meds
  • Arrhythmia
  • Infection
  • Lung problems
  • Endocrine
  • Dietarty indiscretions
57
Q

CHF management

A 
Lifestyle measures: alcohol consumption, smoking, diet exercise, fluid restriction
Medications:
- ACEi/ARBs
- Beta-blockers
- Furosemide
- Spironolactone (mortality benefit)
- Digoxin (additional symptom control)
- Antiarrhythmic (for those with AF)
- Anticoagulants (if needed)
58
Q

Pulmonary edema - acute management

A 
Furosemide
Morphine (decrease anxiety and pre-load)
Nitroglycerin
Oxygen
Positive airway pressure CPAP
59
Q

Myocarditis

A

Inflammatory process, important cause of dilated cardiomyopathy.

Etiology:

  • Idiopathic
  • Infectious (coxsackie B, poliovirus, HIV, mumps)
  • Toxic
  • Hypersensitivity
  • Systemic diseases (SLE, RA, sarcoidosis, autoimmune)

Diagnosis: increased cardiac enzymes, echo shows dilated, hypokinetic chanmbers, segmental wall motion abnormalities, myocardial biopsy

Management: supportive, usually self limited but may progress to dilated cardiomyopathy.

60
Q

Dilated cardiomyopathy

A

Unexplained dilation and impaired systolic function of one or both ventricles.
May present as: CHF, systemic or pulmonary emboli, arrhythmias, sudden death

61
Q

Hypertrophic cardiomyopathy

A

Unexplained ventricular hypertrophy.
Can be due to genetic defect of cardiomyocyte protein, results in myocyte hypertrophy and disarray. May cause obstruction of LV outflow tract

62
Q

Restrictive cardiomyopathy

A

Impaired ventricular filling with preserved systolic function in non-dilated, non-hypertrophied ventricle. Caused by fibrosis/infiltration

63
Q

Infective endocarditis

A

Duke’s criteria

64
Q

Rheumatic fever

A

Complications
Acute: myocarditis, conduction abnormalities, valvulitis, acute pericarditis
Chronic: rheumatic valvular disease, adhesion, calcification of valves

65
Q

Aortic stenosis

A

Etiology: congenital, calcification, rheumatic disease

Signs + symptoms

  • exertional angina, syncope, dyspnea, PND orthopnea, peripheral edema
  • narrow pulse pressure, brachial radial delay
  • ejection systolic murmur radiating to clavicle
  • LVH and strain, CHF
66
Q

Aortic regurge

A

Etiology: Marfan’s, atherosclerosis and dissecting aneurysm, congenital, IE

Signs + symptoms:

  • LVF, dyspnea, orthopnea, PND
  • waterhammer pulse, bisferiens pulse, wide pulse pressure, hyperdynamic apex
  • Early diastolic murmur at LLSB best heard sittin g forward, full expiration
67
Q

Mitral stenosis

A

Etiology: rheumatic disease, congenital

Signs + symptoms:

  • SOB on exertion, orthopnea, fatigue, palpitations, peripheral edema, malar flush
  • afib, left parasternal heave, iastolic thrill at apex
  • mid-diastolic rumble at apex radiates to axilla
68
Q

Mitral regurgitation

A

Etiology: mitral valve prolapse, congenital, LV dilatation, IE abcess, papillary muscle rupture

Signs + symptoms

  • dyspnea, orthopnea, palpitations, peripheral edema
  • displaced hyperdynamic apex, left parasternal heave, apical thrill
  • holosytolic murmur at apex, radiating to axilla
69
Q

Tricuspid stenosis

A

Etiology: rheumatic disease, congenital, carcinoid syndrome

Symptoms + Signs:

  • peripheral edema, fatige, palpitations
  • prominent a waves in JVP, Kussmaul’s sign
  • diastolic rumble in LLSB
70
Q

Tricuspid regurgitation

A

Etiology: RV dilatation, IE, rheumatic disease, congenital, carcinoid

Signs + symptoms:

  • peripheral edema, fatigue palpitations
  • cv waves, Kussmaul’s signs,
  • holosystolic murmur at LLSB accentutated by inspiration
71
Q

Pulmonary stenosis

A

Etiology: congenital

Signs + symptoms:

  • chest pain, syncope, fatigue, peripheral edema
  • systolic murmur at LUSB accentuated by inspiration, pulmonary ejection click
72
Q

Acute pericarditis

A

Most commonly viral (Coxsackie B), can be secondary to MI or Dressler’s syndrome

73
Q

Pericardial effuction

A

Transudative: CHF, hypoalbuminemia,/hypoproteinemia, hypothyroidism
Exudative: similar causes to acute pericarditis

74
Q

Cardiac tamponade

A

Features: tachypnea, dyspnea, shock, pulsus paradoxus

Treatment: pericardiocentesis, pericardiotomy

75
Q

Constrictive pericarditis

A

Chronic pericarditis resulting in fibrosed, thickened, adherent, calcified pericardium.
Causes: idiopathic, post-infectious, radiation, post-cardiac surgery, uremia, MI

Features: similar to CHF with pericardial knock, increased JVP, Kussmaul’s sign

76
Q

Acute arterial occlusion

A

Embolic or thombotic, aortic dissection, trauma. Increase risk with hypercoagulable states

Acute limb ischemia:
Pain
Pallor
Pulselessness
Paresthesia
Paralysis
Perishingly cold

Investigations

  • ABI
  • ECG
  • FBC
  • PT/INR

Treatment:
- Heparin bolus and continuous infusion

Complications:

  • Compartment syndrome
  • Renal failure from toxic metabolites
77
Q

Chronic arterial occlusion

A

Atherosclerosis of lower extremities. Risks same as CAD.

Features:

  • claudication
  • critical limb ischemia: night pain, tissue loss
  • signs of poor perfusion

Investigations

  • ABI
  • Arterial duplex
  • CTA/MRA
  • Arteriography

Treatment:

  • Conservative: lifestyle changes, exercise, foot care
  • Pharmacotherapy: aspirin
  • Surgical: stenting, angioplasty, bypass grafting
78
Q

Carotid artery disease

A

Atherosclerosis of carotid artery, commonly near carotid bifurication.

Features: TIA, reversible ischemic neurologic deficit, stroke, retinal insufficiency, amaurosis fugax, MCA occlusive symptoms

Investigations:

  • FBC, PT/INR
  • Fundoscopy
  • Carotid bruits
  • Carotid duplex
  • Angiogram
79
Q

Aortic dissection

A

Tear in aorta intima allowing blood to disect into media.

Causes:

  • HTN
  • Connective tissue disease (Marfan’s, Ehlers-Danlos), cystic medial necrosis, atherosclerosis

Features: sudden onset tearing chest pain radiating to back, HTN, asymmetric BP and pulses between arms, ischemic syndromes due to occlusion of branches, unseating of aortic valve cusps, syncope.

Investigations:
CXR - widened mediastinum, left pleural effusion
TEE
ECG
CT

Treatment

  • Beta-blocker, then nitroprusside, aim BP of 110mmHg
  • Surgical resection with intimal tear
80
Q

Aortic aneurysm

A

Localised dilatation of an artery 1.5x the normal diameter.

Etiology: degenerative, traumatic, etc

75% asymptomatic. Common presentation: syncope, pain, hypotension, palpable pulsatile mass above umbilicus.

Investigations:

  • Abdominal US
  • CT/MRI
  • Doppler/duplex

Treatment

  • Conservative: CV risk factor reduction, watchful waiting US every 6/12
  • Surgical: >5.5cm or >0.4cm/yr, requires elective AAA repair
81
Q

Superficial venous thrombosis

A

Erythema, induration and tenderness along superficial vein.

Features: most common in greater saphenous vein, pain and cord-like swelling along the vein, induration, erythema and tenderness correspond to dilated and often thrombosed superficial veins

Conservative: compression bandages, NSAID, aspirin, surgical excision

82
Q

Varicose veins

A

Distention of tortuous superficial veins from incompetent valves in the saphenous.

Features: diffuse aching, fullness/tightness, nocturnal cramping, aggravated by prolonged standing, visible long tortuous behaviour, ulceration, hyperpigmentation and induration.

Complications:

  • recurrent superficial thrombophlebitis
  • hemorrhage
  • ulceration, eczema, lipodermatosclerosis and hyperpigmentation

Treatment

  • Elevation and compression stockings
  • Surgical ligation and stripping
83
Q

Chronic venous insufficiency

A

Due to muscle pump dysfunction and valvular incompetence from phlebitis, varicosities or DVT

Investigations:
Compression stockings, leg elevation.

84
Q

Lymphedema

A

Obstruction of lymphatic drainage resulting in edema with high protein content.

Classically non-pitting edema.

Treatment:

  • Skin hygiene
  • Compression bandages, lymphedema sleeve
  • Exercise, massage and manual lymph drainage therapy.

Internal Medicine (12 decks)

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