Cardiology Flashcards
what causes right sided heart failure?
left sided heart failure
chronic lung disease (hypoxia causes pulmonary capillary contraction - increases pressure in right heart) - cor pulmonale
atrial or ventricular shunt - blood moves down pressure gradient into the right side, increasing the pressure
What are the complications of an MI
Bradyarrythmias, tachyarrythmias, pericarditis (dresslers syndrome), cardiac tamponade, RVF, mitral regurgitation, systemic embolism, septal defect, cardiac arrest, cardiogenic shock
what are the signs and symptoms of malignant hypertension (aka a hypertensive emergency)?
papilloedema retinal bleeding headaches and nausea (due to raised intracranial pressure) chest pain (due to an overactive heart) haematuria (failing kidneys) uncontrollable epistaxis (nosebleeds)
How do we manage low risk NSTEMI ACS patients? (After initial management)
Discharge on aspirin and clopidogrel/ticagrelor
Arrange outpatient echocardiogram appointment
how do me manage a patient with a PE Wells score above 4?
send for a CTPA or V/Q scan, but if this is delayed, treat as if it is a confirmed PE with a LMWH (e.g. tinzaparin)
what’s the target INR for patients with AF?
2.5
whats the first step in managing AF?
beta blocker
what is dresslers syndrome?
a complication following an MI.
it is pericarditis occurring 2-6 weeks after the MI, and is thought to be an autoimmune reaction against antigenic proteins produced as the myocardium recovers
its characterised by pleuritic pain, fever, pericardial effusion and raised ESR
treated with NSAIDs
what are symptoms of CHF?
when the left side of the heart fails, blood backs up into the lungs. this leads to fluid leaking out into the lungs causing pulmonary oedema. this causes dyspnoea, orthopnea and crackles.
capillaries can rupture, leaking blood into the lungs. this blood is taken up by alveolar macrophages creating haemosiderin laden macrophages (heart failure cells)
when the right side of the heart fails, blood backs up into the body, this causes hepatosplenomegaly, peripheral pitting oedema, ascites, raised JVP
general symptoms include exercise intolerance, fatigue, weight loss
What are the symptoms of ACS?
Acute central chest pain, lasting over 20 mins
With associated nausea, sweating, breathlessness, palpitations
what are the investigations for an acute exacerbation of HF?
immediate CXR (looking for pleural effusion and consolidation) and ECG - looking for ACS, will probably point towards aetiology
blood tests - ABGs, FBC, U&E, LFTs, BNP, troponins (has there been an MI?)
What is involved in fibrinolysis reperfusion therapy?
IV administered clot dissolving enzymes
Most suitable is tenecteplase (a tissue plasminogen activator)
Goal: administer within 30 mins of admission
Once administered, patients should be transferred to a PCI centre. If thrombolysis is unsuccessful (residual STEMI) they should receive PCI.
If successful, receive angiography only.
CI: previous haemorrhage, stroke, bleeding disorders
Definition of stable angina
Not a new symptom.
No Change in frequency/ severity of attacks.
what drugs do we use to chemically cardiovert a patient in A Fib? (who’s stable)
amiodarone or flecinide (only in patients without structural abnormalities)
what concerns are there if a diabetic patient has changes on his ECG?
he may have had a silent MI
this can occur if neuropathy prevents him from sensing chest pain
you should test the patients troponins
how do we manage a cardiac arrest in VF/pVT?
1 shock followed by 2 minutes of CPR
what are side effects of beta blockers?
bronchospasm cold peripheries fatigue erectile dysfunction sleep disturbances incl. nightmares
Soft s1 is seen in…
Mitral regurgitation
What is the long term management for STEMIs?
Modify RFs
Anticoagulate with Fondaparinux until discharge
Double anti-platelet therapy for 12 months - aspirin and clopidogrel
Beta blockers - begin early for best outcome. If CI then CCB (verapamil or diltiazem)
ACE-Inhibitors for patients with HTN, LVF, diabetes
High dose statins
Eplerenone (anti mineral-corticoid) for those with EF <40%
What are the first line investigations for suspected ACS?
ECG - repeat at 3, 6 and 24 hours. Look for signs of MI
CXR - look for cardiomegaly, pulmonary oedema, widened mediastinum
Bloods: U&Es, HbA1C, lipids, FBC, troponins (looking for a rise)
what is a patient with takayasus arteritis at a risk of developing?
renal artery stenosis
what do anti-streptolysin antibodies show?
rheumatic fever
when is electrical cardioversion for AF favoured over pharmalogical cardioversion?
if the patient has new onset AF which has lasted longer than 48 hours
what’s the most common cause of infective endocarditis?
staphylacoccus aureus
what is an atrial myxoma?
a benign tumour, most commonly occuring the left atria (75% cases)
how does Left ventricular aneurysm present?
persistent ST elevation in anterior leads
couple weeks after an MI
pulmonary oedema
How is HBPM carried out?
the patients takes 2 sets of readings twice of day for at least 4 days.
for each set - he must take his BP twice, 1 minute apart - whilst sitting.
the readings from the first day are discarded and an average is taken from the remainder of the measurements
how do we manage ventricular tachycardia?
amiodarone ideally through a central line
lidocaine - not in severe left ventricle impairment
procainamide
Unstable angina definition
Recent onset angina - within 24 hrs (new symptom)
Change in frequency or severity of attacks - deterioration of previously stable angina with symptoms occurring increasingly at rest
how is primary pulmonary hypertension inherited?
autosomal dominant
10% of cases are familial
how do you manage severe chocking?
5 back-blows
5 abdominal thrusts
continue this cycle if unsuccessful
what factors can falsely raise BNP levels?
myocardial ischaemia, valvular disease, kidney disease (poor excretion),
in what ECG leads would you expect to see changes if the LAD is infarcted?
V1-V4 - the anteroseptal leads
what presents in a young female with an absent limb pulse, malaise, headaches?
Takayasu’s arteritis
a lager artery vasculitis
what is a typical echo finding for an atrial myxoma?
pedunculated heterogeneous mass- typically attached to the fossa ovalis region of the interatrial septum
persistent hypotension, tachycardia and raised JVP despite fluid resuscitation in a trauma patient - what do you suspect?
cardiac tamponade
which HTN med is important to stop if an AKI develops?
any ACE-i or ARBs
what’s the most common cause of aortic stenosis?
in elderly >65 = calcification
in the young <65 = bicuspid aortic valve
what medications should a post- MI patient be on after discharge?
aspirin clopidogrel statin beta blocker ACE-I
which anti-anginal medication do patients often develop tolerance to?
standard release isosorbide mononitrate
whats the MoA of statins?
it inhibits HMG-CoA reductase - the rate limiting enzyme in hepatic cholesterol synthesis
what murmur would you expect in ehlers danlos or marfans syndrome?
mitral valve prolapse and mitral regurgitation are associated with these collagen disorders
this would be a pansystolic murmur
what does clopidogrel interact with?
PPIs make clopidogrel less effective
which 3 drugs are used in anyphalaxis?
adrenaline, hydrocortisone and chlorphenamine (anti histamine)
what should we offer a stage 2 hypertensive patient with a QRISK3 of >20%?
statins!!!
what medication when combined with a macrolide antibiotic (-rythromycin) can cause rhabdomyolosis?
statins
what are ECG signs for acute pericarditis?
PR depression (most specific) widespread 'saddle shaped' ST elevations
what are the steps for BP management?
1) ACE-I or CCB
2) ACE-I and CCB
3) ACE-I and CCB and Thiazide diuretic
4) if K+>4.5 then higher dose thiazide like diuretic
if K+<4.5 then spironolactone
who do we usually give mechanical valves to?
younger patients - last longer. we give biprosthetic valves to older patients
when do you offer statins to BP patients/?
if QRISK3 is over 10%
what are common examination findings associated with aortic stenosis?
narrow pulse pressure slow rising pulse thrill over apex 4th heart sound showing LV hypertrophy absent/soft S2
What further investigations are needed for typical and atypical angina?
1st line: CT angiography of heart, with contrast
2nd line: Functional tests e.g. stress echo, myocardial perfusion imaging/scintigraphy(aka nuclear stress test) with PET/ SPECT
3rd line: transcatheter angiography
What are the first line investigations for suspected Angina?
1) ECG. Usually normal but may show signs of previous MI
2) Blood tests: U&Es, Lipids, FBC, HbA1C, TFTs
what is Eisenmengers syndrome and its pathophysiology?
the reversal of a left to right shunt due to pulmonary HTN and damage.
a left to right shunt exists, this leads to increased blood flow through the pulmonary system. increased pressure causes microvascular damage and irreversible pulmonary resistance. the shunt reverses, to blood moves from right to left - causing hypoxia and erythrocytosis
Soft s2 is seen in…
Aortic stenosis
which diuretics are responsible for hypocalcaemia?
loop diuretics e.g. furosemide
what adverse signs in bradycardia indicate treatment?
shock
syncope
heart failure
myocardial ischaemia
what is first line treatment for a massive PE?
thrombolysis
with immediate unfractioned heparin
what is classed as stage 2 hypertension?
clinical BP readings of 160/100
or ABPM/HBPM of 150/95 or above
how do you treat ventricular tachycardia?
amiodarone
Statins + erythromycin/clarithromycin - an important and common interaction. true or false?
TRUE
causes myopathy
raised creatinine kinase
how do we treat bradycardia with adverse signs?
immediate atropine
if this fails or there is a risk of asystole - the transvenous pacing is indicated
what is trifascicular block?
features of bifascicular block with first degree block as well
Chest pain causes (%)
25% Cardiovascular (99.9% ischaemic causes)
75% non cardiac (MS, GI, Resp)
what causes a rise in BNP?
LV hypertrophy, ischaemia, sepsis, RV overload, tachycardia, COPD, diabetes, liver cirrhosis, low GFR
What are symptoms of a silent MI?
Syncope, pulmonary oedema, Epigastric pain, vomiting, oliguira, confusion
a hypertensive patient with higher BP in upper limb than lower limb raises the suspicion of…
coarctation of the aorta - distal to the left subclavian branching off
what are features of Eisenmengers syndrome?
origional murmur may dissapear cyanosis clubbing RV failure haemoptysis, embolism
what are the DUKEs criteria for diagnosis of infective endocarditis?
2 major criteria
or 1 major and 3 minor
or 5 minor
Major criteria:
1) +ve blood culture for microorganisms assoc. with infective endocarditis (e.g. Staph A)
2) evidence of endocardal involvement e.g. new valvular regurgitation or +ve echo findings
minor criteria:
1) predisposition
2) temperature
3) vascular phenomena
4) microbiological phenomena
5) immunological phenomena
What is the MoA of adenosine ?
Agonist of the A1 receptor at the AV node
what does CHA2DS2 VASc score measure?
the risk of a stroke in patients with AF and therefore the need to anticoagulate them
how do we manage a cardiac arrest patient in asystole?
CPR, checking the rhythm every 2 minutes.
giving adrenaline
whats dipyridamole used for and what’s its MoA?
its an antiplatelet used in conjunction with aspirin after a stroke or TIA
its a phosphodiesterase inhibitor
What are the Indications for revascularisation?
If 2 anti anginals are tried and do not work
Aka medical therapy is inadequate
which beta blockers are used in heart failure?
bisoprolol
carvedilol
what does HASBLED measure?
the risk of a bleed in patients being anticoagulated because of AF
how does 100% occlusion of LAD present on ECG?
ST elevation in V1-V4
how do we treat Long QT syndrome?
avoid medications which lengthen the QT interval
Beta blockers
implantable cardioverter defibs in high risk cases
how does dilated cardiomyopathy present on echo?
reduction in LVEF <55%
dilated LV
no regional wall motion abnormalities
why do we measure BNP and what are the normal levels?
B type natriuretic peptide is a hormone produced mainly by the LV in response to strain.
normal levels <100
raised levels 100-400
high levels >400
what is the long term damage due to hypertension?
end organ damage:
eyes - hypertensive retinopathy, papiloedema, cotton wool spots, hard exudate, flame haemorrhages
kidneys - hypertensive nephropathy, shrunken kidneys, damaged glomeruli
brain - hypertensive cerebrovascular disease
heart - LV hypertrophy, HF, ischaemic heart disease
what signs are seen on ECG in digoxin toxicity?
short QT
elongated PR
inverted T waves
sloping ST depression (reverse tick)
what is torsades de pointes
a rare arrythmia associated with extended QT interval. it may lead to ventricular fibrillation and sudden death
what is the half life of adenosine?
10 seconds
what is rheumatic fever?
it develops after an immunological reaction to a recent (2-6 weeks) streptococcal infection
it requires evidence of a recent strep infection with 2 major features or 1 major and 2 minor features
major: sydnehams chorea, carditis, errythema magnimeta, polyarthritis, subcutaneous nodules
minor: raised CRP/ESR, polyarthralgia, pyrexia, prolonged PR
what is the most common presentation for pulmonary embolus?
normal clinical findings - with tachypnoea and tachycardia
How do patients with infective endocarditis present?
recent fever and breathlessness raised HR, RR, temp decreased oxygen sats fatigue, collapse low grade fever, pansystolic murmur clinical signs of heart failure classic peripheral signs (osler nodes, janeway lesions, splinter haemorrhages, petechia, Roth spots (haemorrhages seen in retina)
what is the most common cause of mitral stenosis?
rheumatic fever
what are the 4 classes of HF? (new york associates)
Class 1 = no limitation on ordinary activity class 2 = mild limitation on ordinary activity class 3 = marked limitation on less than ordinary activity e.g. walking a short distance class 4 = severe limitations at rest
what is subclavian steel syndrome?
it is an occlusive disease of the subclavian, proximal to where the vertebral artery branches off. this leads to posterior circulation symptoms (vertigo and dizziness) when exerting the arm.
treating with angioplasty and stenting
how do we treat symptomatic aortic stenosis?
valve replacement
what dosage of adrenaline should we give for an infant, child and adult?
<6 years = 150 micrograms
6-12 years = 300 micrograms
>12 year = 500 micrograms
which drugs interact with adenosine?
theophyllines block its effect
and dipyridamole enhances its effect
What are the initial/acute managements for a STEMI ?
- Do investigations
- Gain IV access
- Give aspirin 300mg P.O. (consider ticagrelor or prasugrel)
- Morphine 5-10mg IV and anti-emetic (metoclopramide)
- Oxygen if sats <95%
- Restore coronary perfusion for those presenting within 12 hours of symptom onset
- If PCI is available within 120 mins of presentation then PCI!
- If not - fibrinolysis/thrombolysis
when do we anti coagulate AF patients?
Males: CHADSVASC score 1 or more
Females: CHADSVASc score of 2 or more
what are the clinical features of aortic stenosis
chest pain
dyspnoea
syncope
which ECG leads are inferior leads and what artery is this area supplied by?
leads 2, 3 and aVF
supplied by right coronary
Which organism is most associated with infective endocarditis after the first 2 months following a prosthetic valve replacement ?
Staphylococcus Aureus
what medication is contraindicated if atenalol is already prescribed?
verapamil
when should statins be stopped?
if serum transaminase levels raise to 3 times the upper limit and persist there
in the jugular waveform, what do the waves A C X V and Y signify?
A = RA contraction C = Carotid pulse transmitted X = RA relaXation V = RA filling (Villing) Y = RA emtpYing (RV filling)
what % of HTN cases are due to secondary HTN?
10%
what drugs can cause QT elongation??
antiarythmics: sotalol, amiodarone
psychiatric drugs: TCA, SSRIs and haloperidol
antibiotics: erythromycin, clarithromycin, ciprofloxacin
are alcoholics at a greater risk of dilated cardiomyopathy?
yes
what is the most common cause of death following an MI?
cardiac arrest due to ventricular fibrillation
how should we manage a MI patient on the coronary care unit with type 2 diabetes?
stop his metformin etc and start IV insulin - tight glycaemic control post MI is very important
whats the MoA of aspirin?
inhibits production of thromboxane A2
how do we manage a patient in sinus tachycardia without a palpable carotid pulse?
this is an unshockable rhythm - manage with CPR for 2 minutes and then reassess rhythm
how do we manage heart failure?
firstly - treat fluid overload with IV loop diuretics e.g. furosemide
first line = ACE-I and BB
Second line = add an aldosterone antagonist (spironelactone) OR ARBs (-sartan) OR hydralazine in combination with a nitrate (isosorbide dinitrate)
Third line = if symptoms persist - cardiac resynchronisation therapy or digoxin.
ivabradine can be used as an alternative
all patients should have yearly influenza vaccinations and a one-off pneumococcal vaccine
following a PCI, what is the law in regards to driving and the DVLA?
a private vehicle owner should wait 4 weeks before driving again but does not have to notify the DVLA
a group 2 vehicle driver (bus or lorry) must notify the DVLA and not drive for 6 weeks. he then must meet assessment criteria before having his license reinstated
what is a widened pulse pressure?
larger difference between the systolic and diastolic pressures
can be caused by exercise
what is the target INR for patients with VTE disease?
2.5 and 3.5 if recurrent
when do we administer synchronised DC shocks for a patient in tachycardia?
if the patient is 'unstable' meaning they have: -symptoms of shock (systolic BP<90), sweaty, pallor - heart failure - myocardial ischaemia - syncope
What further investigations are needed in a patient presenting with typical angina and a history of IHD?
- Treat as stable angina
2. If needed - use non invasive testing e.g. exercise testing
in treating ventricular fibrillation, what is the correct initial dose of amiodarone?
300mg
how is aortic dissection classified?
stanford A = in ascending aorta (2/3 cases)
stanford B = in descending aorta, distal to the left subclavian
What are the key coronary artery branches
Right marginal Right posterior descending Left marginal Left anterior descending Left circumflex
how is AF secondary to a chest infection treated?
if the cause is reversible then only rhythm control is indicated - whilst the underlying cause is treated
what’s the first line of investigation in a patient with suspected heart failure?
in a patient without a previous MI: measure serum BNP, (B-type natriuretic peptide) if BNP is raised then Echo
in a patient with a previous MI: Echo within 2 weeks,
a patient develops complete heart block post- MI. which coronary artery was likely to have been affected?
right coronary artery
the AV node is supplied in most people, by a branch of the RCA (posterior interventricular artery)
How do we manage Angina?
1) address exacerbating factors (anaemia, thyrotoxicosis)
2) secondary prevention of CVD: smoking cessation, Aspirin 75mg OD, statin for hypercholesterolemia, consider ACE-I.
3) PRN relief : GTN spray/sublingual tabs
4) anti-anginal medication:
1st line: Beta blocker (bisoprolol) +/ Calcium channel blocker (amlodopine)
(Do NOT combine a BB with a non-dihydropyridine CCB e.g. verapamil/diltiazem)
2nd line: Isosorbide mononitrate, nicorandil, ivabradine, ranolazine
Last resort: Revascularisation (PCI or CABG)
Causes of myocardial ischaemia
Coronary artery disease - atherosclerosis Aortic stenosis Hypertrophic cardiomegaly Anaemia Thyrotoxicosis Tachyarrythmias Cocaine use
what is an acute exacerbation of HF?
sudden onset of symptoms of HF, with or without previous CVD
showing clinical signs of decreased CO, tissue hypoperfusion, increased pulmonary pressure, fluid overload
how do we manage a warfarin patient whos INR is 5-8?
if there is no bleeding - withhold 2 warfarin doses and continue at a lower dose
if there is minor bleeding, stop warfarin and give IV vitamin k (1-5mg). restart when INR<5
how are tachycardias classified?
broad complex tachys (AKA arising in the ventricles)
- ventricular tachycardia
- ventricular fibrilation
- torsades de pointes (polymorphic VT)
- OR a Supraventricular tachy with a BBB
narrow complex tachy (Supraventricular tachycardia)
- sinus tachycardia
- atrial tachycardia
- atrial fibrillation
- atrial flutter
- reentrant tachycardia
how do we monitor statin use?
LFTS at baseline, 3,and 12 months
Statins may cause liver damage
what are the indications for loop diuretics?
Heart failure
and resistant hypertension
what is first line investigation for a patient with renal failure and suspected PE?
a ventilation/perfusion scan
we avoid CTPA because of the contrast (renal failure)
what’s constrictive pericarditis commonly associated with?
Tb
what would you suspect when a patient with CLL presents with burning lower chest pain?
shingles
what can cause Left sided HF?
ANYTHING DECREASING STROKE VOLUME: long term hypertension leading to hypertrophy dilated cardiomyopathy ischaemic heart disease valvular disease ANYTHING DECREASING PRELOAD: hypertrophic cardiomyopathy restrictive cardiomyopathy long term hypertension causing hypertrophy aortic stenosis causing hypertrophy
what murmur would you expect to hear in an IV drug user?
a tricuspid regurgitation murmur
IV drug users are at a high risk of right sided cardiac valvular endocarditis
triccuspid regurg sounds like tricuspid valve endocarditis
what is normal correct QT interval?
<430 in males
<450 in females
what is Boerhaave syndrome?
transmural perforation of the oesophagus
what is the mackler triad for boerhaave syndrome?
vomiting
thoracic pain
subcutaneous emphysema
what are the criteria for ivabradine use in HF?
- patient already on suitable medication (ACEI, BB and Aldosterone antagonist)
- heart rate >75
- ejection fraction <35%
what ECG changes are present with RBBB?
wide QRS complex >120ms
rSR pattern in leads V1-3 (M)
slurred, wide S wave in lateral leads (aVL, V5, V6)
what Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications
atenalol
what are the systemic effects of angiotensin 2?
increases SNS activity
causes aldosterone release from adrenal glands
causes increased ADH release from hypothalamus
arterial vasoconstriction
H2O retention, NaCl absorption, K excretion
what BP is classified as a hypertensive emergency (malignant hypertension)?
systolic>210
diastolic>130
when is only rhythm control used to treat AF?
if there is coexist heart failure
first onset AF
obvious reversible cause
what are some causes for secondary HTN??
renovascular disease: diffuse atherosclerosis, unilateral small kidney
renal disease: diabetic nephropathy, glomerularnephritis, chronic nephritis, polycyistic kidney disease
primary aldosteronism cushings syndrome pheochromocytoma NSAIDs oral contraceptives drugs/stimulants antidepressants hypothyroidism primary hypoparathyroidism sleep apnoea coarction of the aorta
how do we treat isolated systolic HTN?
the same way as we treat standard HTN
is there an association between marfans and pneumothorax?
yes
what are the contraindications for thrombolysis?
recent haemorrhage, bleeding disorder, stroke in past 3 months, intracranial neoplasm, severe hypertension, pregnancy, active internal bleeding, recent trauma
how do we diagnose HF?
first line investigation is serum BNP. if this is raised we arrange for a transthoracic echo within 2-6 weeks (depending on the level)
if the patient has had a previous MI, we do not wait for BNP but book an echo within 2 weeks.
what is coarction of the aorta?
it is a congenital narrowing of the descending aorta.
it is more common in males
it is associated with bicuspid aortic valves, turner syndrome, berry aneurysms and neurofibromitosis
What are the 4 classes of Angina?
Canadian Cardiology Society
Class 1 - angina with strenuous/ prolonged exertion
Class 2 - slight limitation of ordinary daily activities. Able to walk 2 blocks/ climb 1 flight of stairs without angina.
Class 3 - marked limitation of ordinary daily activities - unable to walk 2 blocks/ climb 1 flight of stairs.
Class 4 - unable to do any physical activity without discomfort. Angina may be at rest.
what 3rd agent should you had to a hypertensive patient who’s already on an ACE-I and CCB?
a thiazide-like diuretic
e.g. indapamide or chlortalidone
what tests are important prior to starting oral amiodarone treatment?
CXR - because of the risk of pulmonary fibrosis
U and E - potassium levels may increase risk of arrhythmias
what are causes for torsades de pointes?
a rare arrythmia associated with long QT - may deteriorate to ventricular fibrillation
causes of long QT include: subarachnoid haemorrhage, hypothermia, myocarditis, hypo-calcaemia/kalaemia/magnesium, TCAs, antipyschotics, erythromycin,
what medication do we use to rate control AF in an asthmatic patient?
NOT a beta blocker! contraindicated
use a CCB = diltiazem
how does aortic dissection present?
it presents very similarly to a myocardial infarction. sudden onset, severe, central chest ripping/tearing pain, that radiates into back and down arms
how do we investigate suspected aortic stenosis
transthoracic echo followed by a more invasive transoesophageal echo in more severe cases.
how do we treat a post-MI patient who now develops AF?
switch from antiplatelets (aspirin and clopidogrel) to an oral anticoagulant (e.g. warfarin or apixaban)
what are the classic ECG changes in a pulmonary embolism?
S1Q3T3
big S wave in lead 1
large q wave in lead 3
inverted t wave in lead 3
what CCB should be used in conjunction with a BB in management of stable angina?
a long acting dihydropyridine e.g. nifedipine
which ECG changes point to myocardial ischaemia?
hyperacute T waves
ST elevation
pathological Q waves
T wave inversion
explain the Frank-Starling Law
this law describes the relationship between the Stroke Volume and the End Diastolic Volume. the larger the EDV, the bigger the contraction and therefore the bigger the SV. Simply, the more you put in, the more that comes out. untill a certain point where no matter how much you increase the EDV, the heart is unable to contract with enough force to maintain the SV.
in a failing heart, there is decreased contractility. this means the curve shifts to the right - downwards. so to reach the same SV, you need a much higher end diastolic pressure and more powerful contractions
how long do you have to wait before administering a second dose of adrenaline in an anaphylactic patient?
5 mins
what are the features of ostium secondum?
thrombi can pass through the atrial septal defect in the left heart and cause a stroke
ECG shows RBBB with RAD
50% mortality by age 50
when can ivabradine not be used?
if the patient is NOT in sinus rhythm e.g. has AF
whats doses of chlorphenamine should be given in anaphylaxis?
<6 months 25 micrograms
6 months - 6 years 2.5 mg
6-12 years 5 mg
>12 years 10 mg
what factors can falsely lower BNP levels?
ACE-I, ARBs, BBs, diuretics
what is HOCM?
hypertrophic obstructive cardiomyopathy
an autosomal dominant disease, 1:500
a genetic mutation causing problems with contractile proteins
what are side effects of nitrates?
hypotension
headaches
tachycardia
flushing
what dermatological side effects are associated with Warfarin?
skin necrosis
what does of adrenaline should be given in a cardiac arrest?
1mg
how do you differentiate between aortic stenosis and aortic sclerosis?
in aortic sclerosis there is no radiation to the carotids and the ECG is normal
how do we treat AF, post stroke?
2 weeks 300 mg aspirin
lifelong anticoagulation - warfarin is preferred
when should clopidogrel be stopped before an elective surgery?
7 days before
what are the limitations to amiodarone?
long half life: 20-100 days
best given through a central vein: there’s a risk of thrombophlebitis
interacts with commonly used drugs e.g. warfarin
long list of long term adverse effects
lengthens the QT interval (proarrythmic effect)
what is Wolff Parkinson White
a congenital accessory conduction pathway between atria and ventricle (can be right or left sided)
can cause AF which degenerates into VF
what is the first line treatment for supraventricular tachy?
valsalva manouvre
what are the ECG features of Wolff Parkinson White (WPW)
short PR duration
delta waves - slurred upstroke after QRS
wide QRS
what are side effects of loop diuretics?
ototoxicity, hyponatraemia, hypokalaemia, hypotension, hypochloraemic alkalosis
in AF treatment, when do we use amiodarone over flecanide?
if the patient has structural disease of the heart
ATYPICAL ANGINA features
2 of the following 3 features present:
1) central constricting CP, radiating to shoulder, jaw, neck
2) precipitated by exertion
3) relieved by rest or GTN within 5 mins
describe a mitral stenosis murmur
mid-late diastolic murmur, best heard on expiration
what are complications of malignant hypertension?
target organ damage:
Brain - stroke, haemorrhage, encephalopathy
myocardium - damage, HF (common)
kidneys - renal insufficiency, failure
what is an Austin-Flint murmur?
a Mid-end diastolic murmur, signifying severe aortic regurgitation
what are side effects of Bendroflumethiazide?
hyponatraemia
hypokalaemia
what ECG changes are an indication for urgent thrombolysis or PCI?
> 2mm ST elevation in 2 consecutive anterior leads (V1-V6)
OR
1mm ST elevation in 3 or more consecutive inferior leads (2,3 aVF or aVL)
OR
New LBBB
what are causes for LBBB?
ischaemic heart disease cardiomyopathy hypertension aortic stenosis rarely: idopathic fibrosis, digoxin toxicity, hyperkalaemia
what antihypertensive first line medication do we give to a diabetic patient who’s over 55?
an ACE-I
if he wasn’t diabetic, we would try a CCB
Describe the procedure of Percutaneous coronary intervention (PCI)
- a balloon is inflated in the stenosed vessel and usually a stent is left in place to prevent restenosis
- accessed via brachial/radial/femoral artery
- very cost effective
- dual platelet therapy (aspirin and clopidegrol) is recommended for 12 months post PCI
- best for young uncomplicated patients - CAD of 1 or 2 vessels, not involving the LAD and no diabetes
what are the features of constrictive pericarditis
dyspnoea
right heart failure ( raised JVP, oedema, hepatomegaly, ascies)
positive kussmuls sign (paradoxical raising of JVP on inspiration)
pericardial knock - S3
prominent X and Y descents on JVP waveform
how do we treat atrial fibrillation?
if onset is less than 48 hours, consider chemical or electrical cardioversion to return to normal sinus rythm
if cardioversion is NOT an emergency - ensure patient has been anticoagulated for 3 weeks prior to cardioversion. (with heparin)
OR just control the heart rate with beta blockers, CCBs and digoxen (and anticoagualation )
what is a stokes adam attack?
sudden collapse into unconsciousness due to a heart arrhythmia
what is the mechanism of action of loop diuretics?
act on the Na-K-Cl cotransporter in the thick ascending loop of Henle - to prevent the reabsorption of NaCl
Musculoskeletal causes of CP
Costochondritis
Herpes zoster - shingles
which murmur is a ventricular septal defect associated with?
pansystolic
can warfarin be used when breast feeding?
yes
how does a patient with ventricular fibrillation present?
unconscious
v fib does not produce a cardiac output
What are the differential diagnoses for suspected ACS?
Stable angina, pericarditis, myocarditis, aortic dissection, PE, pneumothorax, GORD, pancreatitis, musculoskeletal pain
what drug is eptifibatide?
glycoprotein 2b/3a receptor antagonist
what is the traid for atrial myxoma?
mitral valve obstruction systemic embolisation (stroke) constitutional symptoms e.g. weightloss, breathlessness, fever
how does a patient with acute pericarditis present?
pleuritic chest pain - relieved by sitting forward tachypnoea, tachycardia flu-like symptoms non-productive cough, dyspnoea pericardial rub
What are the risk factors for developing CAD? (And IHD)
Age Male Hypertension Diabetes Hypercholesterolemia Obesity Smoking
what condition is associated with a double systolic pulse beat (bisferiens beat)?
HOCM
what does the RAAS contribute in HF?
in left sided HF, decreased perfusion of the kidneys leads to activation of the RAA system, this leads to water retention (and low sodium) - leading to fluid overload.
how do we test if a reaction was due to anaphylaxis?
measure serum tryptase levels
these can be elevated for 12 hours post reaction
How do you initially manage suspected non- STEMI?
Assess and investigate
If sats low, oxygen Morphine and antiemetic Aspirin 300mg GTN spray Fondaparinux (or unfractioned heparin for those who may undergo PCI within 24 hours)
Use GRACE score to determine risk.
As soon as risk has been assessed, offer a loading dose of Ticagrelor/clopidogrel (in combo with aspirin) (recommended for 12 months for those with NSTEMI Or hospital admittance with unstable angina.)
What are the signs of ACS?
Anxiety, distress, pallor, sweatiness
Raised or lowered pulse or BP
May be signs of HF or pan-systolic murmur
4th heart sound
Later there may be signs of pericardial rub or peripheral oedema
which ACS patients do we give a glycoprotein receptor antagonist to?
those who have a high GRACE score (intermediate to high risk) and who are set to have an angiography within 96 hours of hospital admission
what are side effects of ACE -inhibitors?
cough, angioedema (may begin during year after starting), first dose hypotension, hyperkalaemia
What is the MoA of amiodarone
Blocks potassium channels
what medication is bosentan ?
an endothelin-1 receptor antagonist. used to treat pulmonary hypertension
what is a common side effect of ticagrelor?
breathlessness (described as air hunger) - sudden onset and episodic
present in 10-20%
how do thiazide diuretics work?
they inhibit sodium reabsorption in the beginning (proximal part) of the distal convoluted tube (DCT)
what is bifascicular block?
RBBB with left anterior or posterior hemiblock e.g. left axis deviation
What does primary PCI involve?
Angiographic detection of the disease coronary artery and deployment of a metallic stent to reduce the narrowing.
Recommended for all patients who can be transferred to a primary PCI centre within 120 mins of first medical contact (who present within 12 hours of symptom onset and STEMI)
Anticoagulation must be used in all PCI. e.g. bivalirudin (direct thrombin inhibitor)
Patients who don’t receive PCI should be given fondaparinux or enoxaparin (heparin)
what MoA is clopidogrel etc?
adenosine diphosphate inhibitor (ADP)
which heart rythms are shockable rhythms in a situation of cardiac arrest?
ventricular fibrillation and ventricular tachycardia
what are BP targets for diabetic patients?
<130/80 if renal disease
othewise
<140/80
Describe Coronary artery bypass grafting CABG
Veins/ arteries are harvested and anastomosed to the ascending aorta and then to the coronary arteries, distal to the stenosed region.
Best outcome for complicated and multi vessel disease and less need for repeat revascularisation compared to PCI
But the very invasive surgery means more risky, slower recovery and patients left with 2 large scars: sternal and vein harvesting.
in resuscitation, how do we manage shockable rhythms?
(Shockable rhythms include pulseless VT and VF)
immediate CPR and then defibrillate as soon as possible. continue CPR whilst defibrillator is charging
if pVT/VF persists, give 1mg IV adrenaline and 300mg amiodarone IV
Respiratory Causes of CP
PE
Pneumothorax
Pleurisy
Pneumonia
what is pulmonary hypertension?
when pulmonary pressure is >25 at rest or >30 when exercising.
it causes progressive SOB and cyanosis.
common in females, ages 20-40
what ECG signs are seen in hypokalaemia?
U waves
absent T waves
long QT and PR
do we give adenosine to asthmatics?
NO it is contraindicated
instead give verapamil
what is the most common ECG finding in a patient with pulmonary embolism?
sinus tachycardia
how many doses of adenosine do we give when treating supraventricular tachycardia?
6mg then 6mg then 12mg
what is wellens syndrome?
ECG sign: deep arrowhead inversion of T waves in anterior leads
associated with myocardial ischaemia
what are causes of a 3rd heart sound?
failure of LV e.g. dilated cardiomyopathy, mitral regurg and constrictive pericarditis
What ECG changes indicate a STEMI?
> 1mm ST elevation in both leads 2 and 3
Or new LBBB
what is the mechanism of action of thrombolytic drugs?
they activate plasminogen to form plasmin. plasmin then breaks down fibrin which breaks down the clot/thrombi
when do we treat hypertension?
1) stage 1 hypertension in under 80 YO patient with one of the following:
- established target organ damage
- diabetes
- CVD
- renal disease
- 10 year CVD risk of 20%+
2) or stage 2 hypertension`
How do we calculate a HAS BLED score?
Hypertension Abnormal liver/renal Stroke Bleeding history/disorder Labile INR (unstable) Elderly >65 Drugs which increase risk of bleeding/alcohol
a score of 3 means high risk.
how do you identify a Graham Steell murmur and what does it indicate?
it is a high-pitched, early distolic murmur, best heard in the 2nd ICS at the Left sternal edge. during inspiration
it is associated with pulmonary regurgitation (which goes on to cause cor pulmonale)
how does HOCM present?
in young
mostly asymptomatic
chest pain, breathlessness, syncope
sudden death (arrythmias, heart failure) - mostly due to ventricular arrythmias
jerky pulse, double apex beat
ejection systollic murmur
ECG changes (LV hypertrophy, deep Q waves, progressive T wave inversion)
how do we manage a PE?
give LMWH or fondaparinux straight away (or unfractioned heparin if thrombolysis is being considered for a massive PE)
start warfarin within 24 hours
continue LMWH/fondaparinux for 5 days or until INR is 2 for 24 hours
warfarin should be continued for 3 months and then reassess for risk
cancer patients should be on 6 months
usually unprovoked PE patients will continue beyond 3 months
what type of bacteria commonly cause endocarditis?
gram positive cocci
what are common ECG findings for atrial flutter?
saw tooth appearnce
multiple atrial deplarisations with a ventricular depolarisation
depends on the amount of AV block, what atrial:ventricular ratio is
if ACE inhibitors are not tolerated, what medication should you use?
angiotensin receptors blockers
‘sartans’
e.g. losartan
what are the rules re- driving post- MI?
can’t drive for 4 weeks post-MI
what are fusion and capture beats on ECG associated with and what are they?
ventricular tachycardia
fusion beats = a complex beat made from an atrial and ventricular signal occurring simultaneously and acting on the ventricles.
capture beats = a supra-ventricular signal seen amongst beats showing AV dissociation. an attempt of the atria to regain control of the ventricles.
GI Causes of CP
GORD
gall stones
Peptic ulcers
Pancreatitis
what is the most important cause of ventricular tachycardia clinically?
hypokalaemia
and hypopmagnesemia
how are Ambulatory BP measurements carried out?
2 measurements are taken every hour during the patients waking hours
it is worn for 7 days
an average is taken of at least 14 measurements
an inferior STEMI and aortic regurgitation raise suspicions of what?
ascending aortic dissection
what will the pulse of a patient with heart failure be like?
pulsus alternans
the upstroke varies between strong and weak - signifying systolic dysfunction
Prinzmetal Angina/ variant angina/ coronary vasospasm definition
Angina that occurs without provocation, at rest, due to coronary artery spasm
Occurs mainly in women
ST elevation seen on ECG during pai.
how is malignant HTN managed?
in intensive care unit
with IV BP meds e.g. vasodilators, beta blockers, CCB
Acute coronary syndrome is an umbrella term for…
Unstable angina
Non STEMI
STEMI
Classic ischaemic CP symptoms
Gripping, heavy, tight pain Central, retrosternal pain Ranging from mild to severe Radiates to left shoulder, neck, jaw Associated with nausea, sweating, breathlessness, fear
what are the symptoms of severe HTN? (>180 systolic or >110 diastolic)
headaches, nosebleed, SOB, severe anxiety
what decreases the effects of warfarin?
anything which induces the P450 enzymes. e.g. phenobarbitone, St. Johns wort
what are the stages of hypertension?
Stage 1 = clinical reading >140/90, ABPM >135/85
Stage 2 = clinical reading >160/100, ABPM >150/95
Severe HTN = stystolic >180, diastolic >110
what is the QT region?
from start of Q wave to end of T wave
3 features of TYPICAL ANGINA PECTORIS
- Constricting discomfort in centre of chest radiating to shoulder, neck, jaw
- Precipitated by physical activity, made worse after a meal, with cold weather or heightened emotions
- Relieved by rest or GTN spray- within 5 minutes
what is the long term treatment for AF post-stroke?
anticoagulation with warfarin or another anticoagulant e.g. apixaban
why do we measure CK-MB?
to test for reinfarction
troponins remain raised for 10 days
CK-MB returns to normal after 2 days
what is the target BP for type 2 diabetics?
<130/80 if they have end organ damage e.g. retinopathy
<140/80 in other cases
can you use ACEI or ARBs in pregnancy?
no
how do we treat a regular narrow complex tachycardia?
vagal manouevers (e.g. carotid sinus massage) followed by IV adenosine - first 6 mg, followed by 12 mg if no response and a further 12mg.
when do we send a patient with CP to hospital under emergency admission?
CP within past 12 hours with abnormal ECG
what is QRISK3?
an assessment tool to calculate the risk of CVD over a 10 year period
(if it is 20% or more, treatment for stage 1 HTN is indicated)
How do we manage high risk NSTEMI patients? (After initial management)
Consider glycoprotein inhibitors e.g. eptifibatide or tirofiban in combination with a heparin
Offer coronary angiography (with PCI if indicated) within 96 hours of admission if no contraindications and patient has moderate to severe risk of CV incidence.
Patients should be placed on cardio protective medication: statins, beta blockers/CCB, ACE-I etc. If needed
In what situations do we offer Atorvastatin 20mg to Type 1 diabetic patients?
- if they are over 40
- had diabetes for >10 years
- have established nephropathy
- have other CVD risk factors (obesity or HTN)
how do we treat torsades des pointes?
IV magnesium sulphate
how are proximal aortic dissections generally managed?
aortic root replacement
what are the preferred rate control drugs in AF patients?
Beta blockers
then maybe a CCB
digoxin (no longer first line)
what are the symptoms of malignant hypertension?
SOB, CP, weakness, difficulty speaking, numbness, back pain, change in vision
what is the first line investigation for suspected mitral stenosis?
echocardiography
what kind of murmur does aortic regurgitation produce?
early diastolic murmur
what is the target BP for treated hypertension ?
<140/90 in patients under 80
why are troponins raised in sepsis?
inadequate perfusion leads to ischaemie of cardiac tissue and so release of troponins
this can be called type 2 MI
other causes include anaemia, heart failure, rate-releated ischaemia
how do we manage a patient on warfarin with a major bleed?
stop warfarin
give IV vitamin K
give prothrombin complex concentrate (or FFP if unavailable)
Which organism is most associated with infective endocarditis in the first 2 months following a prosthetic valve replacement ?
Staphylococcus epidermis
what’s the mechanism of action of fondaparinux?
it activates prothrombin 3 which then potentiates the inactivation of clotting factor Xa
it acts the same as LMWH (enoxaparin)
how do we manage a post- PE patient whos INR is <2?
increase warfarin dose and give rapid acting LWMH
what are names of thrombolytic drugs
tenecteplase
alteplase
streptokinase
in what respiratory conditions do we find a respiratory alkalosis patter in ABGs?
pulmonary embolism, asthma and pneumonia
due to hyperventilation
when do we offer ABPM? (or HBPM)
if the clinical BP reading is over 140/90
what does CHA2DS2 VASc measure and what does it stand for?
it measures the risk of a patient with AF having a stroke. do we need to anticoagulate?
congestive heart failure 1 hypertension 1 age >75 2 diabetes 1 stroke/TIA 2
Vascular disease 1
Age 65-75 1
Female 1
What are the main types of cardiovascular disease
Coronary heart disease
Stroke
Peripheral arterial disease
what drug is tirofiban?
glycoprotein 2b/3a receptor antagonist
when can an anaphylactic patient by discharged?
after observation for 6-12 hours. a reaction can be biphasic
