Cardiology Flashcards
1
Q
Order for presenting ECGs (11 steps)
A
- Pt details, time of ECG, presenting complaint
- Paper speed
- Rate
- Rhythm
- Axis
- P waves
- PR interval
- QRS complex
- ST segment
- T waves
- QT interval
2
Q
ECG paper speed
A
25 mm/s
3
Q
Rate on ECG
A
300/big squares
4
Q
Causes of L axis deviation
A
LBBB, LVH
5
Q
Causes of R axis deviation
A
RBBB, RVH/ cor pulmonale
6
Q
How big should a P wave be?
A
2 squares tall, 3 squares wide
7
Q
Tall P wave
A
Large RA
P pulmonale
8
Q
Broad or bifid P wave
A
Large LA
P mitrale
9
Q
What does the PR interval represent? How big should it be?
A
AV node to bundle of His
5 small squares or fewer
10
Q
How big should the QRS complex be?
A
3 small squares across - wider is bundle block
11
Q
What are you looking for in the ST segment?
A
STEMI/ NSTEMI
12
Q
In which leads should T waves be negative?
A
AVR and V1
+V2-V3 in blacks
13
Q
Describe the position of ECG leads on the paper
Anterior Inferior Lateral High lateral Septal
A
I avR V1 V4
II avL V2 V5
III avF V3 V6
14
Q
Which vessels are affected in the following infarctions?
Anterior Inferior Lateral High lateral Posterior
A
Anterior: RCA Inferior: LAD Lateral: circumflex High lateral: circumflex Posterior: RCA or circumflex
15
Q
Rate if 1 large square
A
300
16
Q
Rate if 2 large squares
A
150
17
Q
Rate if 3 large squares
A
100
18
Q
Rate if 4 large squares
A
75
19
Q
Rate if 5 large squares
A
60
20
Q
Rate if 6 large squares
A
50
21
Q
Describe atrial flutter ECG
A
Saw-tooth (f waves)
ventricular rate usually 2:1 or 3:1
narrow QRS
22
Q
Causes of ST elevation
A
STEMI
Prinzmetal’s angina
Pericarditis (saddle-shaped)
Ventricular aneurysm
23
Q
Causes of ST depression
A
Ischaemia (flat)
Digoxin (down-sloping)
24
Q
Definition of ST elevation
A
> 1 mm in limbs
> 2 mm in chest
25
Definition of ST depression
> 0.5 mm
26
Causes of inverted T waves
```
Strain
Ischaemia
Ventricular hypertrophy
BBB
Digoxin
```
27
How does hyperkalaemia present on ECG?
Peaked T waves
| flattened T waves in hypo
28
Definition of angina
Pain on exertion that is relieved in 5 minutes by GTN
29
Which pain is resolved by nitrates?
angina and oesophageal pain
30
What causes a sudden increase in exertional angina?
rupture of atheromatous plaque - may progress to MI
31
causes of angina
usually atheroma
also: thrombosis, spasm (Prinzmetal), inflammation (arteritis)
32
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
33
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
34
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)
35
Definition unstable angina
Angina at rest
or
Exertional angina that does not respond to max meds
36
Histological definition of STEMI/ NSTEMI
MI: cell death secondary to ischaemia
NSTEMI: confined to endocardium
STEMI: full-thickness
37
How may elderly present with MI?
maybe little pain, present with sudden LVF (profound SOB/ syncope)
38
How does STEMI present on ECG?
ST > 1 mm in 2 consecutive chest leads
39
How does a STEMI ECG change over 24h?
ST elevation begins to resolve
T waves begin to invert
pathological Q waves (deflect)
40
What should be considered if ST elevation persists after 1 week?
reinfarction
| LV aneurysm
41
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
```
42
Rise and fall of troponin
Rises within 6-14hrs, falls after 2 weeks
43
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
44
Early complications of MI (0-48h)
```
arrhythmias: VT, VF, SVT, heart block
cardiogenic shock (from LVF, RVF)
```
45
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
46
Late complications of MI (7 days+)
Sudden death on PRAED Street
```
arrhythmias
cardiac failure
Dressler syndrome (secondary pericarditis)
LV aneurysm
mural thrombosis + systemic embolisation
```
47
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
48
What follow-up should occur after MI?
Cardiac rehab
| exercise tolerance test after 6 weeks
49
DVLA rules about MI
no driving for 1 week (4 weeks if not had surgery)
50
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
51
Causes of sinus tachy
```
Physiological
Fever
Thyrotoxicosis
Hypotension
Hypoxia
```
52
Causes of atrial tachy
structural abnormality, CAD, digitalis toxicity
53
Atrial rate in atrial tachy
150 - 200 bpm (origin not SA node)
54
What might be needed to view atrial tachy on ECG?
Adenosine
| Carotid sinus massage
55
How may atrial tachy appear on ECG?
Abnormal P waves
| 1:1 or slower
56
Atrial rate in atrial flutter
250 - 350 bpm
57
Causes of atrial flutter
alcohol, caffeine, structural abnormality, pulmonary disease (PE, infection, pneumothorax)
58
Presentation of atrial flutter
palpitations, dizziness, HF
59
Atrial rate in AF
300 - 600 bpm
| variable ventricular response
60
Classifications of AF
Transient (paroxysmal)
Persistent (> 1 week)
Chronic (permanent)
61
Causes of AF
heart: IHD, atrial septal defect, mitral stenosis, rheumatic heart disease
lungs: lung disease, hypercapnia, hypoxia
hypertension, thyrotoxicosis, metabolic abnormalities, alcohol, sepsis
62
Clinical features of AF
palpitations, dizziness, SOB --> HF
63
Signs of AF
irreg irreg pulse (+/- haemodynamic compromise), no a waves (JVP)
64
Investigations for AF
ECG
Bloods: FBC, TFTs, U&Es, LFTs, coagulation screen (pre-warfarin)
CXR: cardiac structural causes
consider echo
65
ECG findings for AF
no p waves, variable R-R interval
66
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
```
67
Complications of AF
increased risk of stroke/ embolic disease
premature death
may be DVLA precautions
68
What is Wolff-Parkinson-White Syndrome?
Atrial re-entry tachycardia: accessory excitatory pathway (Bundle of Kent) linking atrium to ventricle
69
Signs of WPW syndrome
Tachycardia
70
Symptoms of WPW syndrome
palpitations, dizziness, collapse, sudden death (tachyarrhythmia)
71
How does WPW show on ECG?
Short PR interval, delta wave (slurred upstroke to QRS)
NB normal when impulse not via Bundle of Kent
72
Management of WPW
Needs ablation.
| Meds complicated: some don't affect accessory pathway
73
How many people experience ventricular ectopics?
About 50%
74
How do ventricular ectopics present?
Asymptomatic or 'heavy thump' followed by compensatory pause
75
Management of ventricular ectopics
Beta-blockers if symptomatic
76
Causes of ventricular ectopics
Idiopathic, increased caffeine, hypokalaemia, fever, underlying cardiac abnormality
77
How do ventricular ectopics appear on ECG
not preceded by p wave, weird shape, compensatory pause
78
Definition of ventricular tachy
Lasts over 30 secs or causes haemodynamic compromise - >120 bpm
79
Causes of ventricular tachy
IHD (+/- MI) - cardiomyopathy - metabolic abnormalities - drug toxicity - long QT syndrome
80
Symptoms of ventricular tachy
palpitations, chest pain, syncope
81
Signs of ventricular tachy
tachycardia with hypotension, varying 1st HS, occasional cannon waves (giant a waves)
82
ECG apperance of ventricular tachy
Graves
wide QRS, > 120 bpm
monomorphic or polymorphic
83
Complications of ventricular tachy
VF
84
Management of anti-arrhythmics
amiodarone, DC cardioversion, implantable cardiac defib
85
What can be confused with VT?
SVT with BBB (use carotid sinus massage/ adenosine - these have no effect on VT)
both are fatal
86
What is torsades de pointes?
specific type of polymorphic VT
ECG: irreg + rapid, twisting around axis
87
Complications of torsades?
usually self-limiting but can lead to VF
88
Causes of VF
IHD, post-infection, torsades, prolonged QT, severe hypoxia
89
Presentation of VF
syncope, cardiac arrest
90
What does ECG show with VF?
wide QRS
| squiggly mess
91
Causes of bradyarrhythmias
Physiological (young athletes, sleep), sinus node disease (esp elderly), IHD affecting SA (RCA), drugs (beta-blockers, CCBs), sepsis, hypothyroidism, increased ICP, tumours (cervical, mediastinal), myocarditis, sarcoid
92
How do bradyarrhythmias present?
usually asymptomatic
or: syncope, dyspnoea, hypotension
93
How are bradyarrhythmias managed?
asymptomatic: no treatment
symptomatic: IV atropine, isoprenaline, pacing wire
94
Two main classes of bradyarrhythmia
AV Block (first degree, second, third)
Bundle branch block
95
Describe ECG for different degrees of AV block
First degree: slow, but all impulses are conducted - 40% will progress to other degrees
Second degree: not all impulses conducted between atria + ventricles
```
Mobitz I (Wenkebach): progressive prolongation of PR interval, dropped QRS
- can be benign (kids, athletes), or inferior MI
```
Mobitz II: P-R interval constant, QRS occasionally dropped
- risk of CHB, needs pacing
Third degree: P waves + QRS are independent
96
Causes of BBB
ischaemia, infarction
97
ECG findings for BBB
axis deviation
wide QRS
V1 and V6: WilliaM MarroW
98
Which valves close: S1 and S2?
S1: AV valves (tricuspid and mitral)
S2: pulmonary + aortic
99
What is rheumatic fever?
Group A strep pharyngeal infection
| antibody-mediated immune response (type II hypersensitivity)
100
Name of criteria for diagnosing rheumatic fever?
Duckett-Jones
1) evidence of beta-haemolytic strep infection (eg ASOT titre)
2) 1 major or 2 minor
MAJOR
carditis
arthritis
Sydenham's chorea
erythema marginatum (red rash on trunk, clear centre)
nodules (pea-sized, extensor surfaces, painless)
```
MINOR
fever
high ESR/ CRP
long PR interval
arthralgia
```
101
Describe the arthritis that usually accompanies rheumatic fever?
migrating polyarthritis affecting larger joints
102
Management of rheumatic fever
High-dose benzylpenicillin
Anti-inflammatories for immune response
Abx (usually penicillin) ~5 years
103
Main cause of mitral stenosis
Rheum fever
104
Clinical features of mitral stenosis
Lungs: dyspnoea (pulm oedema), haemoptysis
Heart: AF (enlarged atria) + emboli
Compression due to large L atrium: hoarseness, dysphagia, L lung collapse (on L bronchus)
105
Describe the murmur of mitral stenosis
Low-rumbling murmur at apex: hard to hear (reposition)
106
What might you find on examination of someone with mitral stenosis or mitral regurg?
```
Maybe AF
Raised JVP
Pulm oedema
Loud palpable murmur
Abdo: ascites, hepatomegaly
Peripheral oedema
```
107
Causes of mitral regurgitation
PROBLEMS WITH MITRAL ANNULUS: senile calcification, LV dilatation (enlagement of annulus), abscess formation during IE
MITRAL VALVE LEAFLETS: IE, rheumatic fever, mitral valve prolapse
CHORDAE TENDINAE: idiopathic rupture, IE, CD tissue disorders
PAPILLARY MUSCLE: MI, infiltration, myocarditis
108
Clinical presentation of mitral regurg
Acute: can be fatal - blood back to pulm veins
Chronic: heart has chance to decompensate - fatigue, dyspnoea
109
Describe the murmur of mitral regurgitation
Loudest at apex, radiating to axilla
Murmur is pansystolic (high pitched blowing), soft first heart sound
Apex displaced (down+out) + thrusting
110
Causes of aortic stenosis
Usually valvular:
senile calcification, severe atherosclerosis, congenital, rheum fever
Can be subvalvular, eg HOCM, or supravalvular
111
Which test is absolutely contraindicated in AS?
Exercise test
112
Clinical features of AS
may be asymptomatic
```
Dyspnoea (may lead to orthopnoea + paroxysmal nocturnal dyspnoea as LV fails)
Angina
Dizziness + syncope (esp exertional)
Sudden death
Emboli
```
113
Examination findings in AS
Pulse: low volume
Carotid pulse: slow rising, small volume
BP: low with narrow pulse pressure
Lungs: bilateral basal creps (as LV fails)
114
Describe the murmur of aortic stenosis
Radiates to carotids
Ejection systolic murmur
Palpable thrill + heave
115
Causes of aortic regurg
VALVULR DISEASE: congenital, rheum fever, IE, RA, SLE, CD disease
AORTIC ROOT DISEASE: Marfan's, osteogenesis imperfecta, ank spond
116
Clinical features of aortic regurg
Asymptomatic
| or dyspnoea
117
Examination findings AR
Collapsing pulse, Quincke's sign (visible capullary pulsation in nailbed)
Wide pulse pressure
De Musset sign (head bobbing), Corrigan sign (prominent neck veins)
Pistol shot femoral arteries
118
Describe the murmur of AR
Early diastolic murmur
119
Causes of tricuspid regurg
Mostly from dilatation of RV (RVF or pulmonary HTN)
| Sometimes IE, congenital malformations
120
Clinical presentation of TR
symptoms of RVF
121
What is diff HF and CHF?
CHF = HF with fluid retention
122
What is the key blood test for HF?
BNP (protective)
123
Causes of HF
Heart disease: ischaemic, valvular, congenital, cardiomyopathy, myocarditis, endocarditis
Strain: PE, HTN
Precipitating factors: MI, infection, arrhythmia, anaemia, thyrotoxicosis, electrolyte disturbance, PE, pregnancy, vitamin deficiencies
KEY: NON-CONCORDANCE WITH MEDS
124
What is diastolic HF?
Preserved systolic function
More common in old women
Due to impaired relaxation/ stiffening of myocardium
125
Describe HF symptoms in terms of forward and backward effects
Forward: failure to pump to provide adequate perfusion
Backward: systemic + pulmonary oedema
126
Clinical features of LVF
LUNGS
Dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, lung creps, pleural effusions, pink frothy sputum, cyanosis
Cough: cardiac asthma (bronchoconstriction due to oedema) and bronchial oedema
Fatigue
127
Clinical features of RVF
FLUID OVERLOAD
Peripheral oedema, ascites, tender pulsatile hepatomegaly, raised JVP
128
Examination findings of severe CHF
cold peripheries, reduced pulse pressure, hypotension, gallop rhythm/ 3rd + 4th HS
cachexia
129
Investigations for HF
FBC:
?anaemia
?leukocytosis in acute exacerbation
U&Es:
?low Na due to increased vasopressin (dilutional hyponatreaemia)
?low K common: diuretics
?high K common: K-sparing diuretics/ ACEi/ ARBS
BNP and cardiac enzymes
LFTs
TFTs
lipids
glucose
ABG: hypoxia, hypocapnia, metabolic acidosis
ECG: hypertensive changes, ischaemia, arrhythmias
Echo
CXR
Cardiac catheterisation: explore as mx may improve things!
130
Management of HF
Risk factors
HF nurse
ACEi (monitor renal failure/ hypotension)
Beta-blockers
Diuretics (furosemide + thiazides) - symptomatic only
Aldosterone antagonists (spiro potentiates ACEi, can cause K-retention)
Nitrates
Digoxin (AF + HF)
Hydralazine: potent vasodilator - better in blacks than ACEi - or additional therapy/ if ACEi/ARBS not tolerated
PACEMAKER
131
Who does NICE recommend should get a pacemaker in HF?
Conduction problems
| EF <35%
132
Normal volume of pericardial fluid
50 mL
133
Causes of acute pericarditis
Viral (Coxsackie, EBV, HIV), bacterial, fungal, TB, rheum fever (when acute)
acute MI,
autoimmune disease (SLE, RA, sarcoid),
malignancy
uraemia [usually a haemorrhagic pericarditis, rapidly leading to tamponade - needs dialysis]
134
Symptoms of acute pericarditis
Sharp retrosternal pain, relieved on leaning forward/ worse on lying, coughing, swallowing
Dyspnoea (pain on deep inspiration)
135
Signs of acute pericarditis
Pericardial friction rub
Fever
Tachycardia
136
Management of acute pericarditis
Treat underlying cause
Bed rest
NSAIDs
137
Management of Dressler syndrome
NSAIDS + aspirin
| Maybe CS
138
Signs of Dressler Syndrome
Fever, pericarditis, pleurisy
1 week after MI
May have arthritis
tamponade not uncommon
139
Pathophysiology of Dressler syndrome
Can only occur if pericardium exposed to blood - autoantibodies form - Type III
140
What causes constrictive pericarditis?
Pericardium becomes fibrosed + thickening, restricting filling of heart during diastole
Any cause of acute pericarditis can persist
141
How is constrictive pericarditis diagnosed?
Cardiac catheterisation is diagnostic (raised and equal end-diastole pressures)
142
Causes of pericardial effusion
Acute pericarditis, MI with ventricular wall rupture, chest trauma, aortic dissection, cardiac surgery, neoplasia
143
Symptoms of pericardial effusion
If acute, even small volumes can cause tamponade - HF signs
If gradual, even 2 L can be asymptomatic - may just be dull ache, dysphagia
144
What is Light's criteria? What measurements do you need?
For pericardial effusion
| Need serum protein + LDH
145
Causes of transudative pericardial effusions
CCF, hypoalbuminaemia
146
Causes of exudative pericardial effusions
Infection, post-MI, malignancy, SLE, Dressler
147
Causes of haemorrhagic pericardial effusions
Uraemia, aortic dissection, trauma, post-cardiac surgery
148
Where to withdraw pericardial fluid?
Below xiphoid at 45 degrees towards shoulder
| send fluid for cytology, microscopy, culture + biochemical analysis
149
Where do infective vegetations usually occur?
usually valves but any area of turbulence (eg VSD)
150
All cases of IE start with a sterile fibrin-platelet vegetation as a prerequisite for adhesion development. What does development depend upon?
Presence of anatomical abnormalities in heart's surface
Haemodynamic abnormalities in heart
Host immune response
Virulence of pathogen
Presence of bacteraemia (transient bacteraemia is common: but healthy person should be ok)
151
Causes of IE
```
Rheum fever
Prosthetic valves
Pts with congenital heart disease surviving
Elderly
More IV drug use?
More abx resistance
```
at risk if invasive vasc procedures
152
Most commonly affected valves in IE
mitral - aortic - others
153
Common causative microbes in IE
Staph aureus: now most common
Strep viridans: prev most common (rheum fever)
Staph epidermidis: most common in pts with new prosthetic valves (under 2 months)
also enterococci, pseudamonas, fungi etc
154
Usual classification of IE
```
Acute IE (rapidly progressive)
Subacute IE (slowly progressive)
Non-bacterial thrombotic endocarditis: CKD, neoplasia, SLE, malnutrition
```
155
Criteria for IE
Duke criteria
156
How does IE present?
Fever + systemic symptoms (maybe not in elderly)
New heart murmur in 50%
If subacute/ chronic, maybe non-specific symptoms like myalgia, flu-like symptoms
Presenting complaint may be CVA or other signs of microemboli, or splenectomy
157
Investigations for IE
```
Urine dip (microscopic haematuria - v sensitive)
Urinalysis for casts
```
Daily ECG: risk of heart block if affects aortic root
Blood cultures: 3 sets (ideally 1 before abx)
```
FBC: leucocytosis, thrombocytopenia (DIC), thrombophilia (acute phase response)
ESR/ CRP
U&Es
LFTs
RhF + immune-complex titre
```
CXR: pulm oedema
Echo weekly (valve damage)
158
Management of IE
Abx
| Monitoring
159
Complications of IE
Local destructive effects: valve incompetence, paravalvular abscess, prosthetic valve dehiscence, myocardial rupture
these can lead to (sometimes rapid) CCF and cardiogenic shock
Emboli/ non-infected fragments: stroke, cerebral abscess, ischaemic bowel, renal infarcts, digital infarcts, renal + hepatic abscesses (hepatic infarct rare: dual supply)
160
Which are systolic and diastolic murmurs?
SYSTOLIC: stenosis of opp
DIASTOLIC: regurg of same
SYSTOLE:
AS, PS
MR, TR
DIASTOLE:
MS, TS
AR, PR
161
Recommended daily calories
1800 men and women
162
Recommended BMI
18.5 to 24.9
| in S Asian, Chinese + Japanese: 18 to 23
163
When sex after MI?
When comfortable to do so, usually 4 weeks
164
Safety netting for cardiac pain
Red flags: refer to A&E by ambulance
Cardiac pain within last 12h: emergency referral
Cardiac chest pain within last 72h: same day referral
Cardiac chest pain stopped over 72h ago/ no complications: Rapid access chest clinic
165
When should patient call ambulance after trying GTN spray?
```
Dose
wait 5 mins
Dose
wait 5 mins
still pain: ambulance
```
166
Contraindications of GTN
Phosphidoesterase inhibitors
24h between Viagra
48h for others
can cause severe hypotension/ death
167
Cardio causes of clubbing
Cyanotic congenital heart disease
| Infective endocarditis
168
Closed foramen ovale
Fossa ovalis
169
Major anatomical site for thrombus formation in AF
left atrial appendage
170
Difference low-output and high-output HF
In low output the compensatory mechanisms fail, resulting in reduced cardiac output. Cool peripheries and weak pulses. Eg IHD, AS
In high-output the heart has normal/ increased cardiac output but cannot meet increased metabolic demands. Warm peripheries and normal pulses. Eg thyrotoxicosis, AV fistula, beriberi, pregnancy, severe anaemia
171
General principle for introducing HF meds
One at a time until stable, use clinical judgement to decide which to start with
172
Mx pericarditis
NSAIDs or aspirin until symptoms/ CRP resolves (usually 2 weeks)
Colchine usually used as adjunct to prevent recurrence
CS if connective-tissue or other rare cause (or others contra-indicated)
**NB post-MI pericarditis shouldnt be managed with NSAIDs as may intefere with healing of pericardium
173
What should be investigated it IE caused by Strep gallolyticus (Strep bovis)
Colonoscopy for colorectal ca
174
Empirical abx for IE
Native valves: vanc (or fluclox) with gentamicin (4-6 weeks)
Prosthetic valves: also rifampicin
175
What causes Stokes-Adams attacks?
Paroxysmal arrhythmias, eg third-degree heart block
176
What is holiday heart syndrome?
Binge-drinking causing self-limiting AF
177
INR target in AF
2-3
2.5 to 3.5 if recurrent thromboembolic events on anticoag or metallic valves
178
Murmur grades
Grade VI: audible without steth
Grade V: loud ++, audible with rim of steth, thrill
Grade IV: loud + thrill
Grade III: clearly audible (no thrill)
179
Signs of constrictive pericarditis
KKK
Knock
Kussmaul Sign (paradoxical rise in JVP with inspiration)
180
What is CHADSVasc for?
Assess risk of stroke (whether to start anticoag)
181
What is HAS-BLED score for?
Assess risk of bleeding if on therapy
182
What are the dysfunctions related to the different cardiomyopathies?
Dilated cardiomyopathy (systolic dysfunction - dad bods, can't lift weights)
Hypertrophic cardiomyopathy (diastolic dysfunction - hulked up, can't relax)
Restrictive cardiomyopathies (diastolic dysfunction - stiff, can't relax)
183
What is thought to cause Takotsubo cardiomyopathy?
'broken heart syndrome'
| ctecholamine-mediated response to severe stress events
184
Symptoms of digoxin toxicity
Lethargy, N&V, delirium, xanthopsia (yellow flashes/ discolouration of vision)
185
ECG changes in digitalis toxicity
Bradycardia, prolonged QT, AV block
| Downsloping ST depression
186
Mx digitalis toxicity
Typically hypokalaemia: so manage U&Es
Digibind (digoxin antibodies) available but seldom used
187
How to differentiate L sided and R sided murmurs O/E
L sided loudest on exhalation
| R sided loudest on inspiration
188
Midline sternotomy + leg scar
CABG
| +/- valve replacement
189
Midline sternotomy without leg scar
valve replacement most likely
| maybe CABG without vein graft, LIMA or radial artery graft
190
Causes of raised JVP
RHF, volume overload, PE, constrictive pericarditis
191
Causes of raised JVP with low BP
Tension pneumothorax, cardiac tamponade, massive PE, severe asthma
192
Causes of elevated and fixed JVP
SVC obstruction
193
Causes of cannon A waves
complete heart block, VEBs, VT
194
Causes of giant V waves
TR (look for ear wiggling and pulsatile hepatomegaly)
195
Causes of central cyanosis
Hypoxic lung disease
R-to-L cardiac shunt (cyanotic congenital heart disease, Eisenmenger's)
Methaemoglobinaemia
*if severe, can cause blue hands but usually warm*
196
Causes of peripheral cyanosis
```
PVD
Raynaud's sx
Heart failure
Shock
(severe central cyanosis causes)
```
197
Causes of irreg irreg pulse
AF
VEBs
Complete HB + variable ventricular escape
198
Causes of absent radial pulse
```
Congenital (usually bilateral)
Arterial embolism (eg due to AF)
Atheroma (usually subclavian)
Previous arterial line
Previous coronary angio
Cervical rib
Coarctation of the aorta
```
199
Features of JVP (vs carotid)
```
Double pulsation
Non-palpable
Obliterated when pressure applied at base of neck
Height changes with respiration
Height changes with angle of pt
Rises with hepatojugular reflux
```
200
indication for adenosine
first-line to diagnose and treat SVT
201
contra-indications of adenosine
hypotension, coronary ischaemia, asthma (bronchospasm)
| careful in heart transplant + COPD
202
Describe digoxin's moa
reduces HR and increases force of contraction
203
Abx associated with long QT
erythroMycin
204
how does hypercalcaeMia present on ecg
short QT
