Cardiology Flashcards
1
Q
What is hypertension
A
BP over 140/90
2
Q
Primary hypertension
A
No obvious cause
3
Q
Secondary hypertension
A
- renal disease eg renal artery stenosis
- endocrine eg Conn’s, Cushing’s, phaeochromocytoma
- aortic eg coarctation
4
Q
If BP in clinic is over 140/90
A
Then do ABPM - ambulatory BP monitoring
5
Q
Stage 1 hypertension
A
Over 140/99
Or
ABPM over 135/85
6
Q
Stage 1 HTN - first step
A
Lifestyle interventions
7
Q
Stage 1 HTN should be treated if…
A
- end organ damage
(fundoscopy - for hypertensive retinopathy, urine dipstick - for proteinuria, ECG - for LVF or IHD) - established CVS disease, renal disease, diabetes
- 10 year CVS risk above 20%
8
Q
Stage 2 HTN
A
BP over 160/100
Or
Over 150/95
9
Q
Stage 3 HTN
A
Systolic over 180
Or
Diastolic over 110
10
Q
Treatment of HTN - First line - Aged under 55
A
ACE Inhibitor
11
Q
Treatment of HTN - First line - Aged over 55 or black person of African or Carribbean family origin of any age
A
Calcium Channel Blocker
12
Q
Treatment of HTN - First line - Diabetics
A
ACEI
13
Q
Treatment of HTN - First line - Pregnant
A
B-Blocker
14
Q
Second line HTN treatment
A
ACEI + Calcium Channel Blocker
15
Q
Third line HTN treatment
A
ACEI + Calcium Channel Blocker + Diuretic
16
Q
Treatment for resistant HTN
A
ACEI + Calcium Channel Blocker + Diuretic + consider further diuretic or alpha or beta blocker
17
Q
Diuretic of choice for HTN
A
Indapamide
18
Q
Resistant HTN treatment…
A
K under 4.5 use spironolactone
K over 4.5 use higher dose thiazide diuretic
19
Q
Malignant HTN definition
A
BP over 200/130
Causes fibrinoid necrosis
20
Q
Features of malignant HTN
A
Headache, nausea, vomiting, visual disturbance
Papilloedema
Encephalopathy eg seizures
21
Q
Management of malignant HTN
A
Oral theray eg atenolol
If severe or encephalopathic use IV therapy eg IV labetalol or IV nitroprusside
22
Q
Definition of Unstable Angina
A
ST depression or T wave inversion
No troponin rise
23
Q
Definition of NSTEMI
A
ST depression or T wave inversion
Troponin rise
24
Q
Definition of STEMI
A
ST elevation
Troponin rise
25
STEMI Criteria
- Over 1mm ST elevation in 2 adjacent limb leads
- Over 2mm ST elevation in at least 2 contiguous precordial leads
- New onset Left Bundle Branch Block
26
Site of MI
Anterior
V1-V6
27
Site of MI
Anteroseptal
V1 - V4 (LAD)
28
Site of MI
Anterolateral
1, aVL, V5, V6 (circumflex)
29
Site of MI
Inferior
II, III and aVF (right coronary artery)
30
Site of MI
Posterior
ST depression and upright T waves in V1-V3 (right coronary artery)
31
Medical management of STEMI
```
Morphine and Metoclopramide (IV)
Oxygen
Nitrates (GT spray)
Aspirin 300mg
PLUS
Second antiplatelet usually given
Clopidogrel or ticagrelor
```
32
Medical intervention in STEMI
Primary PCI within 120 mins
If not use fibrinolysis
After fibrinolysis wait 90 mins and do ECG - if not greater than 50% resolution of ST elevation then transfer for PCI
33
Medical Management of NSTEMI
```
Morphine and metaclopramide (IV)
Oxygen
Nitrates (GTN spray)
Aspirin 300mg
Clopidogrel (and continue for 12 months)
```
Offer fondaparinux
Coronary angiography
34
Complications of MI
```
Arrhythmias
Ventricular fibrillation = most common cause of death post MI
Bradyarrhythmia (AV block)
Left ventricular aneurysm
Persistent ST elevation and LVF
Pericarditis/Dressler’s syndrome
Heart failure
```
35
All patients with angina should receive..
Aspirin
Statin
GTN Spray
36
First line treatment of angina
Beta blocker (eg atenolol) or Calcium Channel Blocker
If just CCB - verapamil or diltiazem
If CCB + BB = nifedipine
37
Symptoms of acute left ventricular failure - pulmonary oedema
Dyspnoea
Orthopnoea
Pink frothy sputum
38
Management of acute left ventricular failure - pulmonary oedema - LMNOP
```
Loop diuretic eg IV furosemide
Morphine
Nitrates
Oxygen
Postural - sit up
```
39
Chronic Left Sided Heart Failure overview
Causes include ischaemic heart disease, valvular disease, cardiomyopathy
Symptoms include dyspnea, orthopnoea, pink frothy sputum
Examination – fine crackles, pleural effusion, 3rd heart sound
40
Chronic Right Sided Heart Failure Overview
Causes include congenital heart disease, cor pulmonale, secondary to LVF
Symptoms/signs peripheral oedema, raised JVP, hepatomegaly, ascites
41
Investigation HF
```
Signs of symptoms
THEN
Examination (FBC, TFTs, Fasting glucose, U&Es, urinalysis, CXR)
THEN
BNP or ECG
THEN if still possibility
ECHO
```
42
What is BNP in relation to heart failure?
BNP = B natriuretic peptide (secreted by ventricles).
If < 100, heart failure is unlikely
If BNP raised or abnormal ECG → ECHO
43
1st Line Tx for HF
ACEI and beta blocker (eg bisoprolol)
Offer annual flu vaccine
Offer one off pneumococcal vaccine (CKD need booster every 5 years)
44
2nd line Tx for HF
Spironolactone, ARB (eg candesartan) or hydralazine with a nitrate
45
3rd line Tx for HF
Digoxin or Cardiac Resynchronisation Therapy
Ivabradine alternative - must be on suitable therapy, have HR over 75 and LVF under 35%
46
Diuretic of choice if fluid overload in HF
Furosemide
47
In Tachycardia - with a pulse - look for adverse features
```
Shock
Syncope
Heart failure
Myocardial ischaemia
If there are adverse features → DC cardioversion
```
48
In Tachycardia - with a pulse and no adverse features
Broad QRS Complex
If regular:
Ventricular tachycardia (treat with amiodarone)
If known to be SVT with bundle branch block then follow narrow complex tachycardia
If irregular – seek expert help
49
In Tachycardia - with a pulse and no adverse features
Narrow QRS Complex
If regular:
Vagal maneouvres
Adenosine (6mg, 12mg, 12mg)
If irregular – probable AF
Control rate with beta-blocker or diltiazem
50
In Bradycardia with a pulse look for...
```
Look for adverse features:
Shock
Syncope
Heart failure
Myocardial ischaemia
```
```
AND
Look for risk of asystole:
Recent asystole
Mobitz II AV block
Complete heart block with broad QRS
Ventricular pause > 3 s
```
51
In Bradycardia with a pulse and adverse features or risk of asystole...
Give 500micrograms of atropine to a maximum of 3mg
52
Atrial Fibrillation Management
Rate vs Rhythm control
53
AF Rate Control
Bisoprolol or Diltiazem
If one does not control rate then combination. With two of
- Beta blocker
- diltiazem
- digoxin
54
AF Rhythm Control used when..
Used if patient has heart failure, first onset of AF or a reversible cause of AF
55
Rhythm Control in unstable patient with AF
Electrical cardioversion
Patient should be anticoagulated for at least 4 weeks after
56
Rhythm Control Pharmacology in AF
Amiodarone
If structural heart disease
57
Rhythm Control Pharmacology in AF
Flecainide
Without structural disease
58
Rhythm Control Pharmacology in AF
Cardioversion
Patients should have under 48 hours of symptoms or be anticoagulated for 3 weeks before attempting cardioversion
59
CHA2DS2VS
```
Congestive Heart Failure = 1
HTN = 1
Age over 75 = 2
Age 65-74 = 1
Diabetes = 1
Stroke/TIA/thromboembolism = 2
Vascular disease = 1
Sex (female) = 1
```
60
Chadvasc score and offering anticoagulation
0 = no treatment
```
1 = males = consider anticoagulation
1 = females = no treatment
```
2 = females = offer anticoagulation
61
If after an ACEI a patient develops a dry cough..
Change to low cost ARB
62
If after an ACEI a patient develops a dry cough..
| Or angioedema, hyperkalaemia
Change to low cost ARB
63
Indications for warfarin and target INR
Venous thromboembolism
2.5
If recurrent 3.5
64
Indications for warfarin and target INR
AF
2.5
65
Factors that may potentiate warfarin
Liver disease
P450 enzyme inhibitors eg. Amiodarone and ciprofloxacin
Cranberry juice
NSAIDs
66
Stopping warfarin before surgery
Usually 5 days before
INR 1.5 or less
67
Primary prevention statins given if...
```
10 year CVS risk over 10%
OR
T1DM (over 40, over 10 years diabetic or established nephropathy)
OR
CKD if eGFR under 60
```
Atorvastatin 20mg OD
Titrate up to 80mg max if non-HDL hasn't fallen by 40%
68
Secondary prevention statins given...
```
If known ischaemic heart disease
OR
Cerebrovascular disease
OR
Peripheral arterial disease
```
Atorvastatin 80mg OD
69
Contraindications to thrombolysis
```
Active internal bleeding
Recent Haemorrhage, trauma or surgery
Coagulation and bleeding disorders
Intracranial neoplasm
Stroke under 3months
Aortic dissection
Recent head injury
Pregnancy
Severe HTN
```
70
Examples of thrombolysis
Alteplase
Tenecteplase
Streptokinase
71
Side effects of loop diuretics
```
Hypotension
Hyponatraemia
Hypokalaemia
Ototoxicity
Hypocalcaemia
Renal impairment
Hyperglycaemia (but less common that thiazides)
Gout
```
72
Management of Torsades de Pointes
IV MgSO4
73
Statin + Erythromycin/Clarithromycin =
Statin induced myopathy
74
Cautions and contraindications of ACEI
Pregnancy and breast feeding - avoid
Renovascular disease - significant renal impairment may occur in patients with undiagnosed bilateral renal artery stenosis
Aortic stenosis - may result in hypotension
High dose diuretic therapy - increases chance of hypotension
Hereditary idiopathic angioedema
75
Rheumatic fever diagnosis based on...
Recent streptococcal infection
(History of scarlet fever, positive threat swab, increase in DNase B titre)
And 2 major criteria
Or 1 major and 2 minor criteria
```
Major = erythema marginatum, Sydenham's chorea, polyarthritis, endo/myo/peri-carditis, subcutaneous nodules)
Minor = raised ESR or CRP, pyrexia, arthralgia, prolonged PR interval
```
76
Drugs shown to reduce mortality in patients with left ventricular failure
```
ACEI
Beta Blockers
ARBs
Aldosterone antagonists eg spironolactone
Hydralazine and nitrates
```
77
Side effects of Beta Blockers
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances
78
Contraindication of beta Blockers
Uncontrolled heart failure
Asthma
Sick sinus syndrome
Concurrent verapamil
79
Mack let Triad for Boerhaave syndrome
Vomiting
Thoracic pain
Subcutaneous emphysema
Commonly middle aged men with background of alcohol abuse
80
Coarctation of the aorta
| Features and associations
Congenital narrowing of descending aorta
More common in males despite association with Turners
Features - infancy:heart failure, adult:hypertension, radiofemoral delay, mid systolic murmur maximal over back, apical click from aortic valve, notching of inferior border of ribs
Associations - Turners, bicuspid aortic valve, berry anuerysms, neurofibromatosis
81
Features of complete heart block (3rd degree)
```
Syncope
Heart failure
Regular bradycardia 30-50bpm
Wide pulse pressure
JVP: cannon waves in neck
Variable intensity of S1
```
82
First degree heart block
PR interval >0.2s
83
Second degree heart block
Mobitz 1 - progressive prolongation of PR until drop
Mobitz 2 - PR interval constant but P wave is often not followed by QRS
84
Third degree heart block
No association between P waves and QRS complexes
85
Warfarin Management
Major bleeding
Stop warfarin
Give IV Vit K 5mg
Prothrombin complex concentrate - if not available then FFP
86
Warfarin Management
INR >8
Minor bleeding
Stop warfarin
Give IV Vit K 1-3mg
Repeat dose of Vit K if INR still too high after 24hours
Restart warfarin when INR under 5
87
Warfarin Management
INR>8
No bleeding
Stop warfarin
Give IV Vit K 1-5mg by mouth using IV preparation orally
Repeat dose of Vit K if INR still too high after 24hours
Restart warfarin when INR under 5
88
Warfarin Management
INR 5-8
Minor bleeding
Stop warfarin
Give IV Vit K 1-3mg
Restart when INR under 5
89
Warfarin Management
INR 5-8
No bleeding
Withhold 1 or 2 doses of warfarin
| Reduce subsequent maintenance dose
90
Becks Triad for cardiac tamponade
Falling BP
Rising JVP
Muffled heart sounds
91
Diagnostic test for cardiac tamponade
Echocardiogram
Can show enlarged pericardium or collapsed ventricles
92
Tetralogy of Fallot
Pulmonary stenosis
Right ventricular outflow obstruction
Right ventricular hypertrophy
VSD (right to left shunt caused by pulmonary stenosis)
Overriding of the VSD by the aorta
Most common form of cyanosis heart disease. Presents with cyanotic episodes usually at 1-2months of age
93
Amiodarone
| 6 Ps
```
Prolongs action potential duration
Photosensitivity
Pigmentation of skin
Peripheral neuropathy
Pulmonary alveolitis and fibrosis
Peripheral conversion of T4 to T3 is inhibited leading to hypothyroidism
```
94
Signs of mitral valve stenosis
Malar flush (mitral facies)
Atrial fibrillation (anything that causes left atrial enlargement can increase risk of AF)
Palpable S1 (tapping apex beat)
Loud S1 with opening snap (if pliable valve)
Rumbling low pitched mild diastolic murmur
95
Causes of AF
```
Soaring BP
Heart failure
IHD
MI
Mitral valve disease
Ethanol/endocrine (thyrotoxicosis)
Respiratory (pneumonia,PE,bronchial ca)
Sick sinus syndrome/Sepsis
```
96
AF Prophylaxis
Amiodarone
Flecainide
Chemical cardioversion
97
Systolic Murmurs
Occur on the pulse
Aortic Stenosis
Pulmonary Stenosis
```
Mitral Regurgitation (can be caused by mitral valve prolapse)
Tricuspid Regurgitation
```
98
Diastolic Murmurs
Aortic Regurgitation
Pulmonary Regurgitation
Mitral Stenosis
Tricuspid Stenosis
99
Aortic Stenosis
Ejection click
Crescendo Decrescendo - diamond shaped
Systolic ejection murmur
Heard most loudly at aortic area with radiation to carotids
100
Mitral Regurgitation
Best heard in apex
Pan systolic
No change in intensity
Radiates to axilla
Associated condition - mitral valve prolapse - mid systolic click sometimes with following murmur of MR
101
Aortic Regurgitation
Best heard in left sternal border
Decrescendo
Early diastolic murmur
102
Mitral Stenosis
Opening snap
Mid diastolic rumble
Decrescendo
Pre systolic accentuation
Heard in mitral area
