Cardiology Flashcards
Warfarin INR ranges
Venous thromboembolism- INR 2.5, if recurrent 3.5
A fib INR 2.5
Mechanical heart valves differ by site
Warfarin s/e
Haemorrhage Teratogenic Skin necrosis Purple toes Bleeding- stop 5 days prior to surgery
Statins s/e
Myopathy- myalgia, myositis, rhabdomyolysis
Liver impairment - baseline 3, and 12 months
Who should get statins?
All people with established cardiovascular disease
NICE- anyone with a 10 year cardiovascular risk
Patients with dm2 - QRISK2 and decide
Dm1 over 10 years or over 40 or nephropathy
New evidence suggests don’t need to be taken at night.
Bradycardia treatment;
Management depends on
If signs of hemodynamic compromise
Identifying potential risk of asystole
Haemodynamic compromise; shock - bp<90, pallor, sweating, cold extremities, confusion, syncope.
Atropine is first line, doesn’t work or if risk of asystole-pacing is ind.
ABPM results
If >135/85
Treat if under 80 and target organ damage, CV disease, renal disease, diabetes or QRISK over 20.
If 150>95
Treat
PPV vaccine
Most only need one dose, if asplenia, splenic dysfunction or CKD need booster every 5 years
Pericarditis - features
Differential in any patient presenting with chest pain
Features;
Chest pain- can be pleuritic- relieved by sitting forwards
Non productive cough, dyspnoea flu like symptoms
Pericardial rub
Tachypnoea
Tachycardia
Pericarditis- causes
Viral infection- coxsackie TB Uremia Trauma Post MI- Dresslets syndrome CTD Hypothyroidism
ECG changes in pericarditis
Widespread saddle shaped ST elevation
PR depression
WPW
Caused by a congenital accessory conducting pathway between atria and ventricle leaving to AV reentry tachycardia.
AF can become VF
ECG features;
Short PR
Wide QRS with slurred upstroke
LAD* usuallyor RAD
WPW associations
HOCM Mitral valve prolapse Epstein’s anomaly Thyrotoxicosis Secundeum ASD
WPW treatment
Definitive treatment; radio frequency ablation of the accessory pathway
Medical; amidarone, flecainide, sotalol
Infective endocarditis
Risk factors
Most important is prev hx of endocarditis
Previously normal valves (50% at presentation)
Rheumatic valve disease 30%
Prosthetic valves
Congenital heart defects
IV drug users
Causes of infective endo
Staph aureus now- strep viridans in developing world
Non infective- Libman sacks- seen in SLE
Malignancy- marantic endocarditis
MI complications
Cardiac arrest- usually from v fib, most common cause of death following MI
Cardiogenic shock-damage to myocardium, reduced ejection fraction
Chronic heart failure
Tachyarrhythmias- V fib most common, VT also
Bradyarrthymias- AV block more common after anterior infaraction
Pericarditis- first 24hrs following trans mural 10%. Dressler tends to happen 2-6 weeks following mI
Left ventricular aneurysm- weaken myocardium, persistent st ELEVATION AND lv failure. Need to be anticog, thrombus might form in a.
LV free wall rupture 3% 1-2 weeks after
VSD 1-2% patient in first week
Acute MR- papillary muscle damage
Anaphylaxis in <6months
Adeneline 0.15ml 1in 1000
Hydrocortisone; 25mg
Chorphenamine- 250mcg per kg
Anaphylaxis in 6month- 6year
Adrenaline 0.15ml 1in 1000
Hydro or 50mg
Chlorphenamine 2.5mg
6-12 years
Adrenaline 0.3ml 1 in 1000
Hydrocortisone 100mg
Chlorpheamine 5mg
Over 12
Adrenaline 0.5mls 1 in 1000
Hydrocortisone 200mg
Chlorphenamine 10mg
Adrenaline repeat every 5 mins
Long QT
Inherited condition- delayed repolarization of the ventricles.
Can lead to VT and death
Corrected QT in adults M is 430 and F 450
Causes of prolonged QT
Congenital- jervell- Lange- Nielsen syndrome- includes deafness
Romano-ward- no deafness
Drugs- cispadone, domperidone, anti arrhythmic, citalopram, escitalopram, venlafaxine, erythromycin, clarithromycin, TCA, amiodarone, sotalol, methadone, chloroquine, haloperidol, chlorpromazine
Electrolyte imbalances- hypocalcemia, hypokalaemia, hypomg, hypothermia
ECG In hypothermia
Prolonged QT Bradycardia J Wave First degree heart block A and V arrhythmias
Complete heart block following an MI
Right coronary artery lesion
Complete heart block
Features; Syncope Heart failure Bradycardia Wide pulse pressure Cannon waves
Types of heart block
First degree- prolonged PR > 0.2 s
Second degree- type 1 mobitz
Type 11- p wave often not followed by a QRS complex
Third degree, no association between p WAVES AND QRS
Takayasu arteritis
Large vessel vasculitis
Typically causes occlusion of the aorta- often an absent limb pulse
More common in females and Asian
Features of Takayasu arteritis
Systemic features of vasculitis- malaise, headache Unequal pressure in upper limbs Carotid bruit Intermittent claudication Aortic regurg in 20%
Associated w renal artery stenosis
Mgmt
Steroids
Ejection systolic
AS PS HOCM ASD Fallon’s
Pansystolic
MR
TR- both are blowing in character
VSD
Late systolic
Mitral valve prolapse
Coarc of Aorta
Early diastolic
AR
Graham steel murmur- PR
Mid-late diastolic
MS
Austin- flint
Continuous
PDA
Clopidogrel
Stop a week before elective surgery
If used with PPI- makes it less effective - still new data
A flutter ECG findings
Sawtooth appearance
Mgmt - similar to a fib but meds are less effective
More sensitive to cardioversion
Radiofreq abalation of the tricuspid valve isthmus is curative for most patients
ECG myocardial disease
MI;
Hyperactive T waves often the first sign- only last for a few mins
ST elevation
T wave inversion- in fist 24hours- can last for days to months
Pathological Q waves
Statin interaction
Statin +erythromycin/clarithromycin
Loop diuretics
Furosemide and bumetanide - inhibit the Na K Cl cotransporter in the thick ascending limb of the loop of Henley
Indication; heart failure
Resistant hypertension- particularly if renal impairment
Adverse effects- Ototoxicity Hypokalemia Dehydration Angioedema Nephrotoxicty Gout
LEAD IN MI
I V5 V6- Circumflex- LATERAL
II III AVF- inferior- RCA
V1-V4- LAD Anterior
Don’t prescribe beta blockers with
Verapamil- Bradycardia and asystole
Management of Torsades de POINTS
IV mag sul
Causes of long QT
Congenital - jervell Lange Nielsen, Romano ward syndorme Antiarrhythmics- amiodarone, sotalol TCA Anti psychotics Chloroquine Tergenadine Erythromycin Hypoca, hypokalemia, hypomag, Myocarditis Hypothermia SAH
SVT management
Fatal manoeuvres- valsalva
IVO adenosine- use verapamil in asthma some
Elective cardio venison
Prevention- beta blockers, radiofreq abalation
Amidarone
MOA- Blocks potassium channels which inhibits repolarisition and hence prolongs action potential.
NEED TFT left every 6 months
S/e Thyroid dysfunction Corneal deposits Liver fibrosis Pulmonary fibrosis Peripheral neuropathy Photo sensitivity Slate grey appearance Brady cardia
Thrombolysis
Activate plasminogen to form plasmin- degrades fibrin
Contraindications Active internal bleeding Recent haemorrhage, trauma or surgery- including dental extraction Intracranial neoplasm Stroke <3 months Recent head injury Pregnancy severe hypertension
Hep E
Associated with face all oral spread, commonly affecting shellfish and pork products
Bloods show elevated bilirubin and transaminits
Mody
Mature onset diabetes of the young DM2 in under 25 Inherited in AD fashion Family history is often present Usually very sensitive to SUR
Mody 3 60% of cases
C Diff
Gram positive - encountered in hospital practice
Causes pseudomembranous colitis - intentional damage due to exotoxins.
Commonly caused by broad spectrum antibiotics- suppress normal flora
2nd and 3rd generation cephalosporins
Features of c diff
Diarrhoea
Abdo pain
Raised white blood cell count
Toxic mega colon may develop
Detect in stool
Tx for c DIFF
Oral methronidazole for 10-14 days
Add in vancomycin if not responding
All oral
IV if life threatening
Raised ALP
Liver- cholestasis, hepatitis, fatty liver, neoplasia Pagets Osteomalacia Bone mets Hyperparathyroidism Renal failure Pregnancy Growing children Healing fractures
Raised alp and raised calcium
Bone mets
Hyperparathyroidism
Roared ALP and low calcium
Osteomalacia
Renal failure
Goodpastures
Associated with rapidly progressive glomerulnephritis +- pulmonary haemorrhage
Caused by anti glomerular basement membrane ab against IV collagen
More common in men and has biomodal age dis 20-30 60-70
Hal dr2
Plamaphoeriss
Steroids
Cyclophosphamide
Dipyridamole MOA
Used as an anti-coag
Inhibits phosphodiesterase
NICE BP targets for DM2
If end organ damage <130/80
Otherwise <140/80
Evidence of anterior MI and AR
Proximal aortic dissection ?
Macklemore triad for Boerhaave syndrome
Vomiting
Thoracic pain
Subcutaneous emphysema
Middle aged men with background of alcohol abuse
Treating aortic dissection
Type a- Surg
Type b - non surg
Boerhaaves syndrome
Rupture of the oesophagus as a result of repeated episodes of vomiting
Usually c/o sudden onset severe chest pain that may complicate severe vomiting
Nicorandil
Potassium channel activator - vasodilator effect on coronary arteries
S/E- headache, flushing, anal ulceration
Used to treat angina
ACEi S/E
Cough- 15% of patients and may occur up to 1 year after starting treatment
Angioedema- up to 1 year after starting treatment
Hyperkalemia
First dose hypotension
ACEI cautions and CI
Avoid if preg/ breastfeeding
Renal disease
Aortic stenosis
High dose diuretics
U& E before - rise in creatinine and K may be expected. Cr rise of no more than 30% . EGFR should be less than 20%
HTN in diabetes treatment
First line - ACEi - renal protective effect
Isosorbide mononitrare
Patients may develop tolerance to this med and you might need to change dosing regime
Angina drug mgmt
All patients should get aspirin and statin - if not CI
Sublingual GTN for attacks
Beta blocker or CCB first line based on co morbidities
If CCB by itself- verapamil or diltiazem
Ejection systolic
AS PS HOCM ASD Fallots
Pansystolic
MR TR- blowing
VSD
Late systolic
M prolapse
Coarch
Early diastolic
AR- blowing
Graham steel
Mid late diastolic
MS
Austin flint- severe AR
Continuous machine like
PDA
HOCM
AD disorder of muscle tissue caused by defects in the genes encoding contractile proteins.
1/500
HCOM features
Often asymptomatic Dypnoea Angina Syncope Sudden death Ejection systolic murmur- increases valsalva- decreases squatting
Associations HOCM
WPW
Friedrechihs ataxia
Echo findings
MR
Systolic anterior motion of MV leaflet
Asymmetric hypertrophy
MR SAM ASH
ECG HOCM
LVhypertropghy
Progressive t wave inversion
Deep q waves
A fib
A fib rate control
Beta blockers
CCB
Digoxin- not first line
Rate control if
Older than 65
Hx of ischemic heart disease
Rhythm control if
Younger than 65
Symptomatic
First presentation
Congestive heart failure
Epstein anomaly
Low insertion of the tricuspid valve - large atrium and small ventricle
Associations - tricupsid incompetence
WPW
Li exposure in uterus
Tricuspid valve leaflets are attached to the walls of the septum and tight ventricle
BNP
Made in response to strain- left ventricular myocardium
Effects- vasodilator
Diuretic and natriuretic
Clinical uses of BNP
Diagnosisi of patients with a true dyspnoea
Prognosis of chronic heart failure
Guiding treatment in chronic HF
Screen for cardiac dysfunction
