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Cardiology Flashcards

1
Q

Name some causes of left ventricular/congestive heart failure

A
  • Pump failure
    • Heart muscle disease (IHD, cardiomyopathy)
    • Restricted filling (pericarditis, tamponade)
    • Inadequate heart rate (B blockers, heart block, post-MI)
    • Negatively inotropic drugs (antiarrhythmics)
  • Excessive preload
    • Mitral regurg
    • Fluid overload (NSAIDs causes retention, renal disease)
  • Chronic excessive afterload
    • Atrial stenosis
    • Hypertension
  • High output failure (anaemia, pregnancy, hyperthyroidism)
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2
Q

Name some symptoms of left heart failure

A
  • Fatigue
  • Dyspnoea on exertion
  • Exercise intolerance
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Persistent coughing (especially nocturnal)
    • Pink, frothy sputum
  • Leg/ankle swelling
  • Wheeze
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3
Q

Name some signs of left heart failure

A
  • General
    • Patients looks ill and exhausted
    • Cool peripheries
    • Peripheral cyanosis
  • Pulse
    • Resting tachycardia
    • Pulsus alternans
  • Auscultations
    • S3 gallop
    • Aortic/mitral murmurs
  • Chest
    • Tachypnoea
    • Bibasal end inspiratory crackles
    • Wheeze
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4
Q

Name some causes of right heart failure

A
  • Chronic lung disease
  • Pulmonary hypertension
  • PE
  • Tricuspid/Pulmonary valve disease
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5
Q

Name some symptoms of right heart failure

A
  • Fatigue
  • Dyspnoea
  • Anorexia
  • Loss of appetite
  • Abdominal swelling
  • Sudden weight gain
  • Protruding neck veins
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6
Q

Name some signs of right heart failure

A
  • Jugular venous distension
  • Cardiomegaly
  • Hepatomegaly
  • Ascites
  • Pitting oedema
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7
Q

Describe the compensatory mechanisms active during heart failure and explain why these mechanisms lead to some signs of heart failure

A
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8
Q

Name some investigations for suspected heart failure

A
  1. ECG and BNP, then echo OR just echo (if previous MI)
  • Bloods - FBC, U&E, BNP, TFT, LFT, cholesterol, glucose, eGFR
  • CXR
  • Echo
  • ECG
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9
Q

Describe the CXR findings for heart failure

A
  • Alveolar oedema (bat’s wings)
  • Kerley B lines (interstitial oedema)
  • Cardiomegaly
  • Dilated prominent upper lobe vessels
  • Effusion (pleural)
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10
Q

How is heart failure classified?

A

New York classification (NYHA):

  1. Heart disease present but no undue dyspnoea
  2. Comfortable at rest but dyspnoea with ordinary activities
  3. Less than ordinary activity causes dyspnoea, limiting lifestyle
  4. Dyspnoea present at rest
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11
Q

Describe the general priniciples of treating chronic heart failure

A
  • Treat the cause (arrythmias, valve disease, anaemia, thyroid disease, hypertension)
  • Avoid exacerbating factors (NSAIDS - fluid retention, verapamil - negative inotrope)
  • Lifestyle changes (less salt, weight loss, stop smoking, education)
  • Cardiac rehabilitation
  • Drugs
  • Surgical options (revascularisation, implantable cardioverter defibrillators, transplant)
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12
Q

Name the drugs used to treat chronic heart failure

A
  1. Loop diuretics if acute (furosemide 40mg/24hr PO)
  2. ACE inhibitor (lisinopril 10mg/24hr PO)
  3. B-blockers (start low and go slow)
  4. Hydrazaline with nitrate if black
  5. 2nd line - Spironolactone (25mg/24hr PO)
  6. Digoxin (0.125-0.25mg/24hr PO) if remaining symptomatic or AF
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13
Q

What are the contraindications of ACE-inhibitors?

A
  • Renal failure
  • Hyperkalaemia (K+ > 5.5)
  • Hyponatraemia (Na+ < 130)
  • Hypovolaemia
  • Hypotension (systolic BP < 90)
  • Aortic stenosis
  • Pregnancy/lactation
  • COPD or cor pulmonale
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14
Q

What are the side effects of ACE inhibitors?

A
  • Hypotension
    • Especially 1st dose - begin laying down)
  • Dry cough
  • Taste disturbance
  • Hyperkalaemia
  • Renal impairment
  • Urticaria
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15
Q

What value defines hypertension?

A

140/90

(malignant = BP > 200/130)

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16
Q

Name some causes of hypertension

A
  • Essential hypertension
  • Renal disease (impairs volume regulation and RAAS)
    • Glomerulonephritis
    • Polyarteritis Nodosa
    • Polycystic kidneys
    • Chronic pyelonephritis
    • Renovascular disease
  • Endocrine
    • Cushings
    • Conns (hyperaldosteronism)
    • Hyperparathyroidism
  • OCP
  • Pregnancy
  • Steroids
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17
Q

Name some signs and symptoms of hypertension

A
  • Headaches
  • Renal disease - fluid overload/retention, bruits
  • Radiofemoral delay
  • Cushings disease - central obesity, purple striae, thin limbs
  • End organ damage
    • Retinopathy
    • LVH
    • Proteinuria
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18
Q

Name some consequences of hypertension

A
  • Coronary heart disease
  • Left ventricular hypertrophy
  • Renal damage
  • Stroke
  • Retinopathy
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19
Q

Describe the appearance of hypertensive retinopathy

A

Grades:

  1. Tortuous arteries
  2. A-V nipping (narrowing where arteries cross veins)
  3. Flame haemorrhages and cotton wool spots
  4. Papilloedema
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20
Q

Name some investigations into hypertension

A
  • If 140/90 or higher - offer ambulatory BP monitoring to confirm diagnosis (unless severe)
  • Bloods - glucose, U&Es, creatinine, eGFR, cholesterol
  • ECG
  • Urine analysis (protein/blood)
  • Fundoscopy
  • Specific to exclude a cause
    • Renal ultrasound
    • Cortisol / renin/ aldosterone
    • Echo
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21
Q

Describe the stages of hypertension

A
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22
Q

Describe the treatment of hypertension

A
  • Lifestyle changes
    • Stop smoking
    • Lose weight
    • Redue alcohol and salt intake
  • Drugs
    • Thiazide diuretics (bendroflumethiazide 2.5mg/24hr PO)
    • Beta blockers (atenolol 50mg/24hr PO)
    • ACE inhibitor (lisinopril 2.5-20mg/24hr PO)
    • Calcium channel antagonist (nifedipine 30-60mg/24hr)
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23
Q

Describe hypertension treatment based on age and ethnicity

A
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24
Q

What is stable angina?

A

When coronary artery flow is limited by >70% stenosis due to atherosclerosis. During emotional or exertional stress the increased oxygen demand cannot be met, causing ischaemia and pain

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25
Q

Name some causes of angina

A
  • Atherosclerosis
  • Anaemia
  • Atrial stenosis
  • Tachyarrhythmias
    *
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26
Q

Name some signs and symptoms of angina

A
  • Crushing central chest pain
    • May radiate to jaw/neck/left arm
  • Dyspnoea
  • Dizziness/syncope
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27
Q

Name some investigations for the diagnosis of angina

A
  • Exercise stress test ECG
    • ST depression (stable) or elevation (unstable)
    • Flat or inverted T waves
    • Possible arrhythmia
  • Coronary angiography
  • Thallium 201 - visualise ischaemic tissue
  • Investigations into precipitating factors
    • FBC (anaemia)
    • Glucose/BM (diabetes)
    • Cholesterol
    • T3/T4
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28
Q

How is angina managed?

A
  • Lifestyle modifications (stop smking, exercise, weight loss
  • Modify/control risk factors (hypertension, diabetes)
  • Aspirin (75-100mg/24hrs)
  • Beta blockers or CCB
    • Long acting nitrate if not tolerated
  • GTN spray for symptom relief
  • Statin if total cholersterol > 5mmol/L
  • Revascularisation
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29
Q

What are the contraindications of beta blockers?

A
  • Asthma
  • COPD
  • Left ventricular failure
  • Bradycardia
  • Coronary artery spasm
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30
Q

Describe the pathophysiology of a myocardial infarction

A
  • Plaque rupture
    • Platelet aggregation and thrombosis
  • Thrombus propogates into coronary artery
    • Inflammation
  • Total occlusion of lumen = ischaemia
  • Infarction
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31
Q

What are the risk factors for Acute Coronary Syndrome?

A
  • Non modifiable
    • Age
    • Male sex
    • Family history of IHD (MI in 1st degree relative < 55 years old)
  • Modifiable
    • Smoking
    • Hypertension
    • Diabetes
    • Hyperlipidaemia
    • Obesity
    • Sedentary lifestyle
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32
Q

Name some symptoms of ACS

A
  • Central crushing chest pain > 20 min
    • May radiate to jaw/arms/neck
  • Sweating
  • Cold and clammy extremities
  • Nausea/vomiting
  • Dyspnoea
  • Intense anxiety
  • SYncope
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33
Q

Describe the appearance of an MI on ECG

A
  • ST elevation
    • Or new LBBB
  • Tall T waves
  • T wave inversion
  • Increased Q waves (pathological)
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34
Q

Describe some other investigations (other than ECG) into ACS

A
  • CXR
    • Cardiomegaly
    • Pulmonary oedema
    • Widened mediastinum?
  • Blood tests
    • FBC
    • U&E
    • Glucose (inc)
    • Lipids (dec)
    • Cardiac enzymes - creatine kinase, troponin T
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35
Q

Describe the immediate management of an MI

A
  • Morphine 5-10mg IV
      • antiemitic (metoclopramide)
  • High flow oxygen by face mask
  • GTN spray 2 puffs
  • Aspirin 300mg chewed
  • Thrombolysis <90 min onset
    • Streptokinase
    • Alteplase (if SK used previously)
    • Tissue plasminogen activator
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36
Q

What are the indications for thrombolysis?

A
  • Presentation within 12 hours
    • Ideally 90 mins
  • ST elevation > 2mm in 2 or more chest leads
  • ST elevation > 1mm in 2 or more limb leads
  • Posterior infarction
  • New onset LBBB
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37
Q

What are the contraindications of thrombolysis?

A
  • Internal bleeding
  • Suspected aortic dissection
  • Prolonged or traumatic CPR
  • Previous allergic reaction
  • Heavy bleeding
    • Vaginal
    • Varices
    • Peptic ulcer
  • Acute pancreatitic/lung/liver disease
  • Recent trauma or surgery
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38
Q

Describe the long term management of a patient after an MI

A
  • Lifestyle management
  • Antiplatelets/anticoagulants
    • Heparin (5000U/12hrs SC)
    • Aspirin (75-150mg/24hrs)
  • Beta blocker (metoprolol 50mg/6hrs)
  • ACE inhibitor
  • Statin (simvastatin 10-40mg PO at night)
  • General advice
    • Employment
    • Diet - oily fish, fibre, low sat. fats
    • Travel
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39
Q

Name the BMI categories

A
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40
Q

Name some complications of MI

A
  • Cardiac arrect
  • Bradycardias / heart block
  • Tachyarrhythmias
  • Left/right ventricular failure
  • Pericarditis
  • DVT / PE
  • Cardiac tamponade
  • Mitral regurg
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41
Q

What is CABG?

A

The use of a conduit (internal thoracic artery/saphenous vein) to anastamose between the Aorta and coronary arteries distal to stenosis

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42
Q

What are the risks of CABG?

A
  • Systemic inflammatory response
  • Bleeding from attached graft
  • Atrial fibrillation
  • Thromboemboli
    • Stroke
    • MI
  • Reaction to anasthesia
  • Infection at incision site
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43
Q

What is PCI/angioplasty?

A

Non-surgical procedure where a stenosed artery’s lumen is increased by inflating a balloon catheter

  • Introduced via a guiding wire through the femoral, brachial or radial artery
  • Within 2 hours of chest pain
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44
Q

What are the risks of PCI?

A
  • Restenosis (intimal hyperplasia)
  • Thrombosis
    • Decreased with aspirin/clopidogrel
  • Acute MI
  • Stroke
  • Cardiac tamponade
  • Systemic bleeding
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45
Q

Describe the criteria for PCI vs CABG

A

PCI = 1 or 2 diseased coronaries

CABG:

  • 3 or more diseased coronaries
  • Poor left ventricular function
  • Significant stenosis in left coronary mainstrem
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46
Q

What is Virchow’s Triad? Include examples

A

3 categories that contribute to thrombosis

  • Hypercoagulability - thrombocytosis, antithrombin deficiency, smoking, OCP
  • Stasis - cardiac failure, immobility, surgery
  • Endothelial damage - atherosclerosis, catheters, trauma, MI, hypertension, valve disease
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47
Q

Name some anti-platelet drugs and their mechanisms of action

A
  • Aspirin - COX inhibitor to decrease thromboxane A2 which decreases platelet activation
  • Clopidogrel - blocks P2Y receptors which inhibits ADP-induced platelet activation
    • Used in aspirin intolerance and stents
  • Abciximab (monoclonal antibody) - stops fibrinogen binding to GPIIb/IIIa receptors on activated platelts to decreased aggregation
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48
Q

Name some uses of antiplatelet drugs

A
  • Ischaemic stroke
  • MI / transient ischaemic attack
  • Prior to PCI
  • ACS
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49
Q

Name some anticoagulant drugs and their mechanisms of action

A
  • Heparin - activates antithrombin which inhibits clotting factors
    • Unfractionated (glycosaminoglycan) - rapid onset and recovery used perioperatively, thromboembolic disease and unstable angina
    • LMWH (dalteparin) - longer and more predictable response used in outpatients
  • Warfarin - inhibits vitamin K
  • Fondaparinux - factor Xa inhibitor
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50
Q

Name some causes of mitral stenosis

A
  • Rheumatic fever
  • Congenital
  • Old age calcification
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51
Q

Name some signs of mitral stenosis

A
  • Rumbling mid-diastolic murmur
    • Best heard in expiration lying on left side
    • Opening snap
    • Loud S1
  • Malar flush
  • Atrial fibrillation
  • Tapping apex beat
  • Pulmonary congestion (hypertension, oedema)
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52
Q

How is mitral stenosis managed?

A
  • Digoxin for rate control (if in AF) 0.125-0.25mg/24hrs
  • Beta blocker if rate > 90
  • Warfarin for anticoagulation
  • Diuretics to decrease preload and pulmonary venous congestion

Surgery if not controlled:

  • Balloon valvuloplasty (if non-calcified valve)
  • Mitral valvotomy / valve replacement
53
Q

What are the indications for anticoagulation?

A
  • DVT and PE
  • Stroke prevention
  • Atrial fibrillation
  • Prosthetic heart valve
  • Prevention of thromboembolism post-op
54
Q

What are the antidotes to anticoagulants?

A

Heparin = protamine sulphate (1mg IV)

Warfarin = prothrombin complex concentrate (<50 units/kg) and Vit K (5mg IV)

55
Q

Name some causes of mitral regurgitation

A
  • Prolapsed valve
  • Rheumatic fever
  • Post MI
  • Cardiomyopathy
    • LV dilatation
  • Annular calcification (elderly)
  • HCTD
  • Infective endocarditis
56
Q

What are the signs of mitral regurg?

A
  • Pansystolic murmur
    • Apex radiating to axilla
  • Malar flush
  • Displaced apex beat
  • Thrill
  • RV heave
  • AF
  • LV hypertrophy
  • Pulmonary oedema
57
Q

How is mitral regurg managed?

A
  • Digoxin (if AF)
  • Anticoagulation
    • AF
    • History of thromboembolism
    • Prosthetic valve
    • Additional mitral stenosis
  • Diuretics
  • ACE inhibitor
  • Antibiotics to prevent infective endocarditis
  • Valvuloplasty or replacement
58
Q

What are the causes of aortic stenosis?

A
  • Calcification due to age
  • Bicuspid valve (congenital)
  • Rheumatic fever
59
Q

What are the signs of aortic stenosis?

A
  • Ejection systolic murmur
    • Radiates to carotids
  • Slow rising pulse with narrow pulse pressure
  • Forceful apex beat
  • LV hypertrophy
60
Q

How can aortic stenosis present?

A
  • Angina
  • Dyspnoea
  • Decreased exercise tolerance
  • Dizziness and fainting
  • Systemic emboli (if infective endocarditis)
61
Q

How is aortic stenosis managed?

A
  • Valve replacement (+ anticoagulation)
    • TAVR
  • Valvuloplasty (balloon catheter)
  • Antibiotics for endocarditis prophylaxis
62
Q

What are the causes of aortic regurg?

A
  • Rheumatic fever
  • Bicuspid valve (congenital)
  • HCTD
  • Infective endocarditis
  • Dilation of aortic root
    • Dissection
    • Marfans
    • Age
  • Hypertension
63
Q

Name some signs of aortic regurg

A
  • Early diastolic murmur
    • High pitched
    • Best heard when leaning forward and in expiration
  • Collapsing pulse
  • Quincke’s sign = capillary pulsation in nail beds
  • De Mussets sign = head nodding
  • Pistol shot femorals
64
Q

How is aortic regurg managed?

A

Surgery if:

  • Increasing symptoms
  • Enlarging heart on CXR/echo
  • ECG deterioration (T wave inversion in lateral leads)

Endocarditis prophylaxis

65
Q

Describe the pathogenesis of atherosclerosis

A
  1. Endothelial damage (smoking, HTN, diabetes, hyperchosterolaemia)
  2. Promotes adhesion of circulating monocytes
  3. Accumlation and oxidation of LDLs
    • Uptake into macrophages = foam cells
  4. Release of cytokines to cause migration and proliferation of smooth muscle
  5. Formation of fibrous cap and thombi = narrowing of lumen
66
Q

How is hyperlipidaemia treated?

A
  • Low fat and high carb diet for 3 months
  • Statins (HMG-CoA reductase inhibitors - reduce hepatic synthesis)
    • ADR = hepatotoxicity, myositis, rhabdomyolysis
  • Bile acid sequestrants (cholestryamine - trap bile acids in the intestine to increase excretion)
  • Nicotinic acid (inhibits synthesis of VLDL by liver
  • Fibrates (stimulate lipoprotein lipase)
67
Q

Name some causes of atrial fibrillation

A
  • Heart failure
  • Hypertension
  • MI
  • Mitral valve disease
  • Pneumonia
  • Hyperthyroidism
  • Alcohol
68
Q

Describe some investigations into valve dysfunction

A
  • Echocardiography - assesses LV function and visualise valve
  • Doppler echo - assesses size and site of jet
  • Cardiac catheterisation - assesses coronary artery disease
  • ECG
    • Hypertrophy
    • Axis deviation
  • CXR
    • Enlargement
    • Pulmonary oedema
    • Calcification
69
Q

How can AF present?

A
  • Chest pain
  • Palpitations
  • Dyspnoea
  • Presyncope
    • Light headedness
    • Feeling faint
    • Blurred vision
  • Stroke/TIA
70
Q

Name some signs of AF

A
  • Irregularly irregular pulse
  • Apical pulse rate > radial pulse rate
  • Signs of emboli / PE
  • Signs of hyperthyroidism / mitral valve disease
71
Q

Describe the appearance of atrial fibrillation on ECG

A
  • Absent P waves
  • Narrow QRS complex (<120ms)
  • Irregularly irregular rhythm
  • Tachycardia (>100bpm
72
Q

How is acute AF treated?

A
  1. Treat associated acute illness (MI, pneumonia)
  2. Control ventricular rate with beta blocker or digoxin (0.5mg/12hr PO)
  3. Control rhythm with amiodarone (5mg/kg 1hr IV) or class I (flecainide 2mg/kg for > 25 mins)
  4. DC cardioversion (200J - 360J) - first line if heart failure, reversible cause or haemodynamic instability
  5. Left atrial ablation
73
Q

How is chronic AF managed?

A
  1. Rate control with beta blocker
    • Consider digoxin if non-paroxysmal and sedentary lifestyle
  2. Consider amiodarone if not controlled
  3. Anticoagulate with warfarin/apixaban if CHADSVASC >2 for women or >1 for men
    • Use aspirin if <65 with no other risk factors
74
Q

How is paroxysmal AF managed

A
  • Sotalol
    • Alternative: amiodarone
  • Anticoagulate with warfarin
75
Q

Describe the appearance of atrial flutter on ECG

A
  • Continuous atrial depolarisation (300/min)
  • Sawtooth baseline
  • +/- 2:1 AV block
  • Narrow QRS complex (<120 ms)
  • Tachycardia (>100 bpm)
76
Q

How is atrial flutter treated?

A
  • Beta blocker and flecainide
  • Catheter ablation

NB: Carotid sinus massage or IV adenosine transiently blocks the AV node and may unmask flutter waves

77
Q

Describe some differential diagnoses of supraventricular (narrow complex) tachycardia

A
  • Sinus tachycardia
  • AF = unstable re-entrant loops (350-500bpm)
  • Atrial flutter = re-entry rhythm in atria (300bpm) with AV nodal conduction usually 2:1 or 4:1
  • Atrial tachycardia = ectopic pacemaker (120-240bpm)
  • Supraventricular premature beats = ectopic impulses arising in the atria or AVN conducted to the ventricles to cause a premature beat, pause, normal rhythm
  • Wolf-Parkinson-White Syndrome = congenital accessory conduction pathway between atria and ventricles
78
Q

Describe the broad principles of treating supraventricular tachycardia

A
  • Lifestyle - reduce coffee, alcohol and tobacco
  • Physical manoevres - valsava / coughing / face into ice water
  • Carotid sinus massage
    • Caution if carotid bruit
  • Rate control (amiodarone/beta blocker/verapamil)
  • Amiodarone (rhythm control)
  • Adenosine 6mg bolus injection (suppresses AV conduction)
  • DC cardioversion
79
Q

Name some the categories and differentials of tachycardia

A
80
Q

Name some causes of ventricular tachyarrythmias

A
  • Ischaemic heart disease
    • Increase in SNS
    • Increase in K+
    • Slow conduction
  • Cardiomyopathy
  • Heart failure
  • Rare - caffeine, alcohol, exercise
81
Q

Describe the management of VT

A
  • Correct hypokalaemia and hypomagnesaemia
    • Magnesium sulphate 2g IV over 10 min
  • Amiodarone or lignocaine
  • DC cardioversion
82
Q

How is the recurrence of VT prevented?

A
  • Antiarrhythmic drugs
  • Implantable defibrillators
  • Surgical isolation of arrythmogenic area
83
Q

Describe the classes of anti-arrythmia drugs and what they are used to treat

A
  1. Na+ channel blocker (lignocaine, flecainide)
    • Ventricular arrhythmia, AF, WPW
  2. Beta blockers (propanolol, atenolol)
    • MI, tachyarrhythmia
  3. K+ channel blocker (amiodarone, sotalol)
    • WPW, AF, VT
  4. Ca2+ channel blocker (verapamil)
    • AV block, AVNRT, AF
  5. Adenosine (suppresses Ca2+ channel in A1 receptor)
    • SVT
  6. Digoxin (stimulates vagus nerve)
    • AF, SVT (heart failure)
84
Q

Name ECG

A

Atrial fibrillation with fast ventricular response:

  • Tachycardia (100-150 bpm)
  • Irregularly irregular rhythm
  • No P wave
  • Narrow QRS
85
Q

Name ECG

A

Atrial flutter:

  • Tachycardia (150bpm)
  • Regular rhythm
  • Normal axis
  • Saw tooth baseline (no P waves)
86
Q

Name ECG

A

Ventricular tachycardia:

  • Tachycardia (150 bpm)
  • Regular rhythm
  • Left axis deviation
  • Wide QRS complex
87
Q

Name ECG

A

Acute anterolateral MI:

  • ST elevation in V2-6
  • Reciprocal depression in II, III and aVF
88
Q

Name ECG

A

Wolff-Parkinson-White Syndrome (

  • Normal rate and regular rhythm
  • Shortened PR interval
  • Slurred upstroke on QRS = delta wave
89
Q

Name ECG

A

Pericarditis:

  • Normal rate and regular rhythm
  • PR segment depression
  • Narrow QRS
  • Widespread ST elevation
    • Saddle shaped
90
Q

Name ECG

A

Pumonary embolism:

  • Tachycardia (100 bpm)
  • Right axis deviation with right BBB
  • Wide QRS
  • T wave inversion in lead III

S1Q3T3:

  • Deep S wave in lead I
  • Pathological Q wave in lead III
  • Inverted T wave in lead III (and other anterior leads)
91
Q

Name ECG

A

Torsades de Pointes (VT):

  • Highly variable rate (up to 300 bpm)
  • Irregular rhythm
  • Wide QRS
    *
92
Q

Name ECG

A

Long QT syndrome:

  • Everything normal
  • Prolonged QT interval
    • > 480 ms (over half way to next QRS)

Main causes: Clarithromycin and diphenhydramine

93
Q

Describe the different types of Heart Block and how to recognise them on ECG

A
  • 1st degree = PR > 200ms
  • 2nd degree
    • Mobitz 1 = progressive PR lengthening, then a non-conducted P wave
    • Mobitz 2 = occasional non-conducted beats
    • 2:1/3:1 = 2 or 3 P waves per QRS compex with a regular P wave rate
  • 3rd degree = no relationship between P waves and QRS complexes (usually wide)
94
Q

Describe the appearance of RBBB on ECG

A
  • Wide QRS > 120 ms
  • Positive V1 with 2 R waves (RSR) pattern
  • Inverted T waves in V1 (and V2-3)
  • Deep and wide S waves in V6

MaRRoW

V1 = M QRS pattern

V6 = W QRS pattern

95
Q

Describe the appearance of LBBB on ECG

A
  • Wide QRS > 120 ms
  • Negative V1
  • Inverted T waves in I, aVL, V5-6

WiLLiaM

V1 = W QRS pattern

V6 = M QRS pattern

96
Q

Describe the appearance of left axis deviation on ECG

A
  • Negative QRS in II and III
  • High QRS in I and aVL
97
Q

Name some causes of left axis deviation

A
  • WPW
  • Left anterior hemiblock
  • Inferior MI
  • VT
  • LVH
98
Q

Describe the appearance of right axis deviation on ECG

A
  • Negative in I and aVL
  • Positive in III and aVF
99
Q

Name some causes of right axis deviation

A
  • Tall or thin
  • RVH
  • Lateral MI
  • Dextrocardia
  • WPW
100
Q

Name the infarct areas and affected leads

A
101
Q

Describe the methodological approach to ECGs

A
  • Presenting complaint and patient demographics
  • Rate (300 / number of big squares in R-R interval)
  • Rhythm
  • Axis
  • P wave (and relationship with QRS)
  • P-R interval (normally 0.12-0.2s
  • QRS complex (normally 0.12s)
  • QT interval
  • ST segment
    • Elevation >1mm
    • Depression < 0.5mm
  • T wave
    • Peaked in hyperkalaemia
    • Flattened in hypokalaemia
102
Q

Name ECG

A

1st degree heart block: Prolonged P-R interval (>0,2s)

103
Q

What is dilated cardiomyopathy? Name some associations

A

A dilated, flabby heart with decreased contractile function. Presents in a similar way to congestive heart failure

  • Alcohol
  • Hypertension
  • Haemochromatosis
  • Autoimuune
  • Thyrotoxicosis
104
Q

What is hypertrophic cardiomyopathy?

A

Septal/LV hypertrophy not caused by chronic pressure overload. Leading to impaired ventricular relaxation and high diastolic pressures due to stiff thickened muscles. Usually genetic causes (autosomal dominant)

105
Q

How is hypertrophic cardiomyopathy managed?

A
  • Beta blockers - reduce oxygen demand
  • Ca2+ channel blockers - reduce ventricular stiffness
  • Control of arrhythmias
    • Amiodarone (100-200mg/24hr)
    • Implantable defibrillator
  • Anticoagulation if AF
  • Myomyectomy
106
Q

What is restrictive cardiomyopathy?

A

Abnormally rigid ventricles with impaired diastolic filling but usually normal systolic function. Due to fibrosis or infiltration.

  • Idiopathic
  • Scleroderma
  • Infiltrative - sarcoidosis / amyloidosis
  • Storage disease - haemochromatosis
107
Q

Name some causes of acute pericarditis

A
  • Viral - coxsackie, influenza, Epstein-Barr, varicella
  • TB (from mediastinal lymph nodes)
  • Pyogenic bacteria (pneumococcus / staph
  • MI
  • Uraemic (dialysis)
  • Metastatic
  • HCTD
  • Drugs (procainamide)
108
Q

Describe the clinical features of acute pericarditis

A
  • Sharp and pleuritic chest pain
    • Worse on inspiration and lying flat
    • Relieved by sitting forward
  • Dyspnoea
  • Fever
  • Pericardial friction rub on auscultation
109
Q

Describe some investigations into acute pericarditis

A
  • ECG - global ST elevation (saddle shaped) and PR depression
  • Bloods - WCC, ESR, CRP, troponin I, viral serology
  • Echo - pericardial effusion?
  • TB skin prick
  • Serology
  • Malignancy (metastases)
110
Q

How is acute pericarditis treated?

A
  • Rest
  • Pain relief - analgesia/NSAID
  • Corticosteroids if sever
  • Antibiotics
  • Catheter drainage

Treat cause

111
Q

Name some causes of pericardial effusion

A
  • Any cause of pericarditis
  • Hypothyroidism (Inc. capillary permeability)
  • Congestive heart failure (Inc. hydrostatic pressure)
  • Cirrhosis/nephrotic syndrome (dec. oncotic pressure)
112
Q

Describe the clinical features of of pericardial effusion

A
  • Dull constant ache in left side of chest
  • Compression of adjacent structures
    • Dysphagia
    • Dyspnoea
    • Hoarseness
    • Hiccups
  • Pericardial rub on auscultation
  • Soft heart sounds
113
Q

How is pericardial effusion treated?

A
  • Treat cause
  • Pericardiocentesis
    • Send fluid for culture (TB)
114
Q

What is cardiac tamponade?

A

Progression of pericardial effusion to compression of cardiac chambers which causes poor ventricular filling and cardiac output

115
Q

Name some causes of cardiac tamponade

A
  • Same as pericardial effusion
    • Neoplastic
    • Viral
    • Uraemic (haemodialysis)
  • Acute haemorrhage
    • Chest trauma
    • Surgery
    • LV rupture
    • Dissection Aortic aneurysm
116
Q

Describe the clinical features of cardiac tamponade

A
  • Sinus tachycardia
  • Becks triad
    • Hypotension with pulsus paradoxus
    • Raised JVP
    • Quiet precordium (muffled heart sounds)
  • Kussmauls sign
117
Q

Name some causes of aortic aneurysms

A

Abnormal localised dilatation > 50% of normal vessel width

  • Cystic medial necrosis (degeneration)
  • HCTD
    • Marfans
    • EDS
  • Atheroscelerosis + risk factors
  • Genetic
  • Arterial wall infections
  • Vasculitis
118
Q

Describe the clinical features af aortic aneurysm

A
  • Pulsatile mass
  • Compression
    • Trachea - cough, dyspnoea, pneumonia
    • Oesophagus - dysphagia
    • Recurrent laryngeal nerve - hoarseness
  • Aortic regurg
  • Abdo/back pain
119
Q

Describe the clinical features of a ruptured aortic aneurysm

A
  • Hypotension
  • Haemothorax / pericardial effusion
  • Into abdomen
  • Abdo pain
    • Radiates to back / iliac fossa / groin
120
Q

How is a ruptured aortic aneurysm treated?

A
  • ABCDE
  • Fluid resuscitation (2 large bore cannulae)
    • Target systolic 90
  • Cross match 6 units
  • Activate massive haemorrhage protocol
  • Pain relief
  • FBC, U+E, clotting
  • ABG
  • ECG
  • Refer to vascular surgeon urgently
121
Q

Name some causes of aortic dissection

A
  • Chronic hypertension
  • Ageing (6th/7th decades)
  • Cystic medial necrosis
  • HCTD
  • Traumatic insult
122
Q

Describe the clinical features of aortic dissection

A
  • Sudden, severe pain in anterior chest
  • Rupture = haemothorax / pericardial effusion
  • Compression = MI / stroke / visceral ischaemia / renal failure
  • Aortic regurg
  • Hypertension
  • Unequal arm pulses
123
Q

How is aortic dissection treated?

A
  • Beta blockers (lower BP and HR)
  • Vasodilators (lower BP)
  • Surgical repair - suture / graft
124
Q

What are the indications for the insertion of a pacemaker?

A
  • Complete AV block (3rd degree)
  • Mobitz II heart blok
  • Persistent AV block after MI
  • Symptomatic bradycardias
  • Drug-resistant tachyarrhythmias
125
Q

What is the GRACE score?

A

Predictor of 6-month mortality for patients with ACS

126
Q

What is the CHADSVASC score?

A

Calculator for the risk of developing stroke in AF patients

127
Q

Name some complications of infective endocarditis

A
  • Cardiac - heart failure, perivalvular abscess, pericarditis
  • Septic emboli
  • Neurological - stroke, brain abscess, meningitis
  • Renal - renal infarction or abscess
  • MSK - vertebral osteomyelitis, septic arthritis
128
Q

What organism is most likely to cause endocarditis in an IVDU? Which valve?

A

Organism - staph aureus

Valve - tricuspid

IPE (13 decks)

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