Cardiology Flashcards
List three important investigations to carry out in the acute setting when a patient presents with chest pain.
ECG
Troponins
Echocardiogram
What is the next step in the management of a patient whose troponins are: Negative
Exercise tolerance test
What is the next step in the management of a patient whose troponins are:Positive
Coronary angiography
List possible causes of chest pain from each of the following systems:
Cardiac
Respiratory
Gastro
Musculoskeletal
Cardiac Ischaemic heart disease Pericarditis Aortic dissection Respiratory PE Pneumonia Pneumothorax GI Oesophageal spasm Oesophagitis/Gastritis Musculoskeletal Costochondritis
List the symptoms, associated symptoms and risk factors of ischaemic heart disease.
Symptoms: Central, crushing chest pain Associated Symptoms: Nausea Sweating Risk Factors: Smoking Diabetes mellitus Hypertension
List the symptoms and associated symptoms of pericarditis.
Symptoms:
Pleuritic pain (worse on inspiration), which is better when leaning forward
Associated Symptoms:
Preceding flu-like symptoms
List the symptoms, associated symptoms and risk factors of aortic dissection.
Symptoms: Tearing pain between the shoulder blades Associated Symptoms: Based on where blood supply is being lost (e.g. if dissection spread up the carotid arteries it can cause stroke) Risk Factors: Hypertension Marfan’s Syndrome Ehlers-Danlos Syndrome
List some specific respiratory symptoms that you should ask a patient about when taking a history.
Wheeze Breathlessness Haemoptysis Cough Weight loss
What is a common and major risk factor for gastritis?
Excessive alcohol
Which upper GI infection are immunocompromised patients at risk of developing?
Oral candidiasis
Following ECG, describe the management of a patient with a:
STEMI
NSTEMI
STEMI:
Go to cathlab immediately for percutaneous coronary intervention
Give aspirin + clopidogrel
NSTEMI
Go to cathlab within 24 hours
Give aspirin + clopidogrel + fondaprinux
State the artery affected and the ECG leads showing ST elevation in myocardial infarction affecting the following parts of the heart:
Anterior
Lateral
Inferior
Anterior Left Anterior Descending V1-V4 Inferior Right Coronary Artery II, III, aVF Lateral Left Circumflex I, aVL, V5/V6
Which common artery do the left circumflex and left anterior descending coronary arteries originate from?
Left Main Stem
How long after an MI does the troponin level peak?
24-48 hours
How long after an MI does the troponin level return to normal?
5-14 days
Describe how collapse caused by a cardiac condition is different from collapse caused by a neurological condition.
The sequence of events before, during and after the collapse is important
Before:
Cardiac – no warning
Neurological – there may be an aura
During:
Cardiac – no tongue biting
Neurological – there may be tongue biting
After:
Cardiac – the patient will not be confused
Neurological – patients tend to be confused
What are the three main cardiac causes of collapse?
Arrhythmia
Outflow Obstruction
Postural Hypotension
List the main causes of collapse.
Hypoglycaemia (DO NOT EVER FORGET GLUCOSE)
Cardiac
Vasovagal syncope (increased vagal discharge leads to bradycardia and collapse – it can be precipitated by certain conditions)
Arrhythmia
Outflow obstruction
Postural hypotension
Neurological - seizure
List some features of seizures.
Tongue biting
Aura
Wetting themselves
Being confused after the seizure
Define syncope.
Collapse caused by hypoperfusion of the brain
List some investigations for arrhythmias.
ECG
24 hr tape
Cardiac monitor
State two causes of left-ventricular outflow obstruction.
Aortic stenosis
Hypertrophic obstructive cardiomyopathy (HOCM)
List two signs of aortic stenosis.
Slow-rising pulse
Ejection-systolic murmur
What is the main investigation for outflow obstruction?
Echocardiogram
What is the main investigation for postural hypotension?
Lying/standing blood pressure
List some causes of Long QT Syndrome.
Congenital (mutations of K+ channels)
Hypomagnesaemia
Hypokalaemia
Drugs
List three causes of pan-systolic murmur.
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
How do you differentiate between left-sided murmurs and right-sided murmurs?
Left-sided murmurs are louder on EXPIRATION
Right-sided murmurs are louder on INSIPRATION
State an important non-cardiac feature of tricuspid regurgitation.
Hepatomegaly – due to backpressure causing hepatic congestion
List three causes of a raised JVP.
Tricuspid regurgitation
Right heart failure
Constrictive pericarditis
List two causes of tricuspid regurgitation.
Damage to valve leaflets (e.g. by bacteria)
Right ventricular dilation
List two causes of right heart failure.
Left heart failure
Pulmonary hypertension
List some causes of constrictive pericarditis.
Infection (e.g. TB)
Inflammation (e.g. connective tissue disease)
Malignancy
List four causes of a systolic murmur.
Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Describe how you would differentiate between these causes of systolic murmur
Where is it loudest and where does it radiate?
Aortic stenosis – loudest in aortic area and radiates to the neck
Mitral regurgitation – loudest in mitral area and radiates to the axilla
Associated signs
Aortic stenosis – slow-rising pulse, ejection systolic murmur
Mitral regurgitation – displaced apex beat
State four broad causes of palpitations.
Sinus tachycardia
Supraventricular tachycardia
Atrial fibrillation
Ventricular tachycardia
State three causes of sinus tachycardia.
Shock
Hypovolaemia
Endocrine (e.g. hyperthyroidism, phaeochromocytoma)
What is supraventricular tachycardia?
Regular narrow complex tachycardia with no p waves
SVT refers to AVRT and AVNRT
Explain the difference between AVNRT and AVRT
AVNRT – a local circuit forms around the AV node
AVRT – a circuit forms between the atria and ventricles via an accessory pathway
What key feature can be spotted on the ECG of a patient with AVRT who has been restored to sinus rhythm?
Delta wave (slurred upstroke on the QRS complex)
What is the name of the accessory pathway in AVRT?
Bundle of Kent
How is AVRT definitively treated?
Radiofrequency ablation of the accessory pathway
Describe the ECG morphology of atrial fibrillation.
Irregularly irregular with no p waves
State two important causes of atrial fibrillation that must be considered in young people.
Thyrotoxicosis
Alcohol
List some causes of atrial fibrillation.
Heart Muscle: ischaemic heart disease, rheumatic heart disease, hypertensive heart disease
Valvular heart disease
Pericarditis
Lung: pneumonia, PE, cancer
Why do respiratory conditions cause AF?
AF originates in the part of the right atrium that is close to the pulmonary vasculature – so changes in the levels of oxygen, carbon dioxide and pressure can impact on the myogenic cells within the right atrium
Describe the ECG morphology of ventricular tachycardia.
Regular broad complex tachycardia
State three causes of VT.
Ischaemia
Electrolyte abnormalities
Long QT syndrome
Under what circumstance would you DC cardiovert a patient with SVT?
If they are haemodynamically unstable
What is the difference between cardioversion and defibrillation?
Cardioversion is synchronized with the cardiac cycle – the electrical impulse is delivered at a certain point during the cardiac cycle
Defibrillation is not synchronized
Describe the management of a patient with SVT who is not haemodynamically compromised.
Start with manoeuvres (e.g. valsalva, immerse face in cold water, blow into a syringe)
If that doesn’t work give ADENOSINE, and put the patient on a cardiac monitor
6 mg rapid IV bolus
If that doesn’t work, give 12 mg
If that doesn’t work, give another 12 mg
In which patients is adenosine contraindicated?
Asthmatics
What are the two main aims of management of AF?
Rate control
Reduce risk of stroke
Describe the criteria for cardioversion of patients with acute fast AF.
Cardioversion should only occur if the patient has presented within 48 hours of onset of symptoms or if they have presented after 48 hours and have been anticoagulated for 3-4 weeks
If the onset is > 48 hours then you will need to anticoagulate them for 3-4 weeks before cardioversion is possible
Which two drugs are regularly used for rate control in AF?
Beta-blockers
Digoxin
Under what conditions would digoxin not be particularly effective as a drug for rate control?
If the patient is acutely unwell (e.g. pneumonia)
Which drug is used to treat ventricular tachycardia without haemodynamic compromise?
IV Amiodarone
State some causes of ventricular tachycardia.
Hypomagnesaemia
Hypokalaemia
What is the treatment of choice for patients who experience recurrent VTs?
Implantable cardioverter defibrillator (ICD)
Which variant of VT requires defibrillation?
Pulseless VT
Describe the appearance of left ventricular hypertrophy on ECG.
Deep S wave in V1/V2
Tall R wave in V5/V6
If S wave + R wave = > 7 large squares then it is left ventricular hypertrophy by voltage criteria
What is the definitive diagnostic test for left ventricular hypertrophy?
Echocardiography
Describe the ECG morphology of:
first-degree heart block.
mobitz type 2 heart block
complete heart block
first degree: Fixed prolonged PR interval
type 2: Fixed prolonged PR interval with a dropped QRS every few beats
complete heart block:
Complete dissociation between the atria (p waves) and ventricles (QRS complexes)
QRS complexes will be broad
Bradycardia
State three ECG signs of ischaemia.
ST elevation
Pathological Q waves
T wave inversion
What features of an ECG would suggest ventricular strain or hypertrophy?
S waves and R waves
Axis deviation
What is responsible for the following heart sounds?
S1 Closure of the mitral valve S2 Closure of the aortic valve Fixed wide splitting of S2 Atrial septal defect S3 Rapid ventricular filling (sign of heart failure) S4 Ventricular hypertrophy (caused by atria contracting against stiff ventricles
Describe how you would distinguish between fixed wide splitting of S2 and S3
Fixed wide splitting of S2 is heard better with the diaphragm
S3 – better with the bell and light pressure
Describe the relationship of S3 and S4 to S1 and S2.
S3 comes just after S2
S4 comes just before S1
Describe the steps in the management of acute heart failure.
Sit up Oxygen GTN infusion Diamorphine Furosemide (IV)
Why are the three drugs mentioned above used in acute heart failure?
GTN, diamorphine and furosemide are all venodilators – they reduce venous return to the heart, hence reducing preload
Describe the ALS protocol for VT and pulseless VF.
Shock CPR (2 mins) Assess rhythm Adrenaline every 3-5 mins Correct reversible causes
What are the two non-shockable rhythms?
Pulseless electrical activity (PEA)
Asystole
State the 4Hs and 4Ts – reversible causes of cardiac arrest.
Hypoxia Hypothermia Hypovolaemia Hypokalaemia Toxic Thromboembolic Tamponade Tension pneumothorax
Describe the appearance of pericarditis on ECG.
Diffuse ST elevation (in all leads)
ST elevation is saddle-shaped
List causes of pleuritic chest pain.
PE Pneumothorax Pneumonia Pericarditis Pleural pathology NOTE: and subphrenic pathology (e.g. hepatic abscess)
