Cardiology Flashcards
Order for presenting ECGs (11 steps)
- Pt details, time of ECG, presenting complaint
- Paper speed
- Rate
- Rhythm
- Axis
- P waves
- PR interval
- QRS complex
- ST segment
- T waves
- QT interval
ECG paper speed
25 mm/s
Rate on ECG
300/big squares
Causes of L axis deviation
LBBB, LVH
Causes of R axis deviation
RBBB, RVH/ cor pulmonale
How big should a P wave be?
2 squares tall, 3 squares wide
Tall P wave
Large RA
P pulmonale
Broad or bifid P wave
Large LA
P mitrale
What does the PR interval represent? How big should it be?
AV node to bundle of His
5 small squares or fewer
How big should the QRS complex be?
3 small squares across - wider is bundle block
What are you looking for in the ST segment?
STEMI/ NSTEMI
In which leads should T waves be negative?
AVR and V1
+V2-V3 in blacks
Describe the position of ECG leads on the paper
Anterior Inferior Lateral High lateral Septal
I avR V1 V4
II avL V2 V5
III avF V3 V6
Which vessels are affected in the following infarctions?
Anterior Inferior Lateral High lateral Posterior
Anterior: RCA Inferior: LAD Lateral: circumflex High lateral: circumflex Posterior: RCA or circumflex
Rate if 1 large square
300
Rate if 2 large squares
150
Rate if 3 large squares
100
Rate if 4 large squares
75
Rate if 5 large squares
60
Rate if 6 large squares
50
Describe atrial flutter ECG
Saw-tooth (f waves)
ventricular rate usually 2:1 or 3:1
narrow QRS
Causes of ST elevation
STEMI
Prinzmetal’s angina
Pericarditis (saddle-shaped)
Ventricular aneurysm
Causes of ST depression
Ischaemia (flat)
Digoxin (down-sloping)
Definition of ST elevation
> 1 mm in limbs
> 2 mm in chest
Definition of ST depression
> 0.5 mm
Causes of inverted T waves
Strain Ischaemia Ventricular hypertrophy BBB Digoxin
How does hyperkalaemia present on ECG?
Peaked T waves
flattened T waves in hypo
Definition of angina
Pain on exertion that is relieved in 5 minutes by GTN
Which pain is resolved by nitrates?
angina and oesophageal pain
What causes a sudden increase in exertional angina?
rupture of atheromatous plaque - may progress to MI
causes of angina
usually atheroma
also: thrombosis, spasm (Prinzmetal), inflammation (arteritis)
Investigations for angina
ECG: t wave flattening/ inversion, ST depression, partial/ complete LBBB
Bloods: FBC, TFTs, glucose, lipids, U&Es, LFTs (before starting statins)
Exercise ECG: ST depression > 1 mm
Stress echo (exercise or dobutamine)
Gold standard: coronary angiography
Mx angina
Conservative: Lifestyle/ manage risk factors
Aspirin (75 mg)
Statin
First-line: GTN spray, beta-blocker OR rate-reducing CCB (eg verapamil)
Second-line: beta-blocker AND CCB (non rate-limiting, eg nifedipine)
third-line other nitrates, KCBs (eg nicorandil), new anti-anginals (ivabridine, ranolazine)
Revascularisation
What are the options for revascularisation?
PCI (will need long-term aspirin + clopi)
CABG (preferred if 3 vessel disease, LAD, diabetic, PVD)
MICABG (uses mammary)
Definition unstable angina
Angina at rest
or
Exertional angina that does not respond to max meds
Histological definition of STEMI/ NSTEMI
MI: cell death secondary to ischaemia
NSTEMI: confined to endocardium
STEMI: full-thickness
How may elderly present with MI?
maybe little pain, present with sudden LVF (profound SOB/ syncope)
How does STEMI present on ECG?
ST > 1 mm in 2 consecutive chest leads
How does a STEMI ECG change over 24h?
ST elevation begins to resolve
T waves begin to invert
pathological Q waves (deflect)
What should be considered if ST elevation persists after 1 week?
reinfarction
LV aneurysm
Investigations in MI
Bloods:
FBC: often leucocytosis, anaemia can precipitate
U&Es: monitor K+, renal function can worsen with hypoperfusion
Blood glucose
Lipids
Troponin
ECG CXR: widening mediastinum = aortic dissection (X thrombolysis) HF: pulm oedema, cardiomyopathy Echo: not first-line, but helpful
Rise and fall of troponin
Rises within 6-14hrs, falls after 2 weeks
Non-acute management of MI
3-5 days in hospital, examined daily by cardiologist
all have statin
all have 75 mg aspirin indefinitely
clopi 300 mg for 4 weeks (long, eg year if stents)
if large MI/ HF, ACEi after 3 days
if EF poor, spiro
nitrates
Early complications of MI (0-48h)
arrhythmias: VT, VF, SVT, heart block cardiogenic shock (from LVF, RVF)
Medium complications of MI (2-7 days)
arrhythmias
PE
rupture of papillary muscles*
rupture of IV septum/ free wall rupture
*usually present as acute failure/ death
Late complications of MI (7 days+)
Sudden death on PRAED Street
arrhythmias cardiac failure Dressler syndrome (secondary pericarditis) LV aneurysm mural thrombosis + systemic embolisation
What does a cardiologist examine for following MI?
Chest pain: ? further MI - urgent coronary angio
Signs of cardiac failure/ new murmurs: ?mitral regurg secondary to papillary musc rupture - diuretics + urgent echo
Pericarditis
Hypotension: ?drug-induced or cardiogenic shock
Bradycardia: ?heart block after inferior MI/ or v large anterior MI with septal necrosis
What follow-up should occur after MI?
Cardiac rehab
exercise tolerance test after 6 weeks
DVLA rules about MI
no driving for 1 week (4 weeks if not had surgery)
Managing cardiogenic shock
If reversible, eg MI, can treat with IABP (intra-aortic balloon pump) - using ECG for timing, inflates during diastole –> forcing blood back to coronary arteries and forward to renal arteries
Causes of sinus tachy
Physiological Fever Thyrotoxicosis Hypotension Hypoxia
Causes of atrial tachy
structural abnormality, CAD, digitalis toxicity
Atrial rate in atrial tachy
150 - 200 bpm (origin not SA node)
What might be needed to view atrial tachy on ECG?
Adenosine
Carotid sinus massage
How may atrial tachy appear on ECG?
Abnormal P waves
1:1 or slower
Atrial rate in atrial flutter
250 - 350 bpm
Causes of atrial flutter
alcohol, caffeine, structural abnormality, pulmonary disease (PE, infection, pneumothorax)
Presentation of atrial flutter
palpitations, dizziness, HF
Atrial rate in AF
300 - 600 bpm
variable ventricular response
Classifications of AF
Transient (paroxysmal)
Persistent (> 1 week)
Chronic (permanent)
Causes of AF
heart: IHD, atrial septal defect, mitral stenosis, rheumatic heart disease
lungs: lung disease, hypercapnia, hypoxia
hypertension, thyrotoxicosis, metabolic abnormalities, alcohol, sepsis
Clinical features of AF
palpitations, dizziness, SOB –> HF
Signs of AF
irreg irreg pulse (+/- haemodynamic compromise), no a waves (JVP)
Investigations for AF
ECG
Bloods: FBC, TFTs, U&Es, LFTs, coagulation screen (pre-warfarin)
CXR: cardiac structural causes
consider echo
ECG findings for AF
no p waves, variable R-R interval
Management AF
Treat underlying cause, if poss
RATE CONTROL: beta-blockers or CCBs, consider digoxin monotherapy if sedentary RHYTHM CONTROL (if rate control doesnt work): cardioversion (or meds, eg flecanide) ANTICOAGULATION: Chadvasc score will advise warfarin or apixiban/ rivaroxaban/ others
Complications of AF
increased risk of stroke/ embolic disease
premature death
may be DVLA precautions
What is Wolff-Parkinson-White Syndrome?
Atrial re-entry tachycardia: accessory excitatory pathway (Bundle of Kent) linking atrium to ventricle
Signs of WPW syndrome
Tachycardia
Symptoms of WPW syndrome
palpitations, dizziness, collapse, sudden death (tachyarrhythmia)
How does WPW show on ECG?
Short PR interval, delta wave (slurred upstroke to QRS)
NB normal when impulse not via Bundle of Kent
Management of WPW
Needs ablation.
Meds complicated: some don’t affect accessory pathway
How many people experience ventricular ectopics?
About 50%
How do ventricular ectopics present?
Asymptomatic or ‘heavy thump’ followed by compensatory pause
Management of ventricular ectopics
Beta-blockers if symptomatic
Causes of ventricular ectopics
Idiopathic, increased caffeine, hypokalaemia, fever, underlying cardiac abnormality
How do ventricular ectopics appear on ECG
not preceded by p wave, weird shape, compensatory pause
Definition of ventricular tachy
Lasts over 30 secs or causes haemodynamic compromise - >120 bpm
Causes of ventricular tachy
IHD (+/- MI) - cardiomyopathy - metabolic abnormalities - drug toxicity - long QT syndrome
Symptoms of ventricular tachy
palpitations, chest pain, syncope
Signs of ventricular tachy
tachycardia with hypotension, varying 1st HS, occasional cannon waves (giant a waves)