Cardiology Flashcards
ECG territories: vessel and area for II, III, aVF
inferior, right coronary
Can affect AV node so complete heart block
also in 40% RV infarction also occurs…nitrates are contraindicated!
ECG territories: vessel and area for V1-V4
anteroseptal, Left anterior descending
ECG territories: vessel and area for V4-6, I, aVL
Anterolateral, left anterior descending or left circumflex
ECG territories: vessel and area for I, aVL +/- V5-6
Lateral, left circumflex
ECG territories: vessel and area for Tall R waves V1-2
posterior, left circumflex/right coronary
ECG changes for posterior MI
Tall R waves in V1-2
where is B-type natriuretic peptide produced
cardiomyocytes mainly left ventricular myocardium in response to strain
effects of BNP
similar to ANP vasodilator decreases sodium resorption diuretic and natriuretic suppresses renin-angiotensin system supprsesses sympathetic tone
ECG changes of brugada
Auto dominant condition, more common in Asians. ST elevation of >2mm on >1 v1-3 leads with inverted t wave and partial RBBB
What ECG abnormality do you need to monitor for in endocarditis
Prolonged pr… Sign of aortic abscess, which is an indication for surgery
When would you consider coronary angiography post NSTEMI
consider within 96 hours if predicted 6 month mortality above 3%… So if high risk and comorbid
BP is 135/85, who do you treat?
If under 80 yr AND organ damage, cardiovascular disease, renal disease, diabetes, 10-yr risk greater than 10%
Which vessel supplies AV node
Posterior interventricular artery, branch of Right coronary
Complete heart block following MI, causative vessel
Right coronary
Genetics of hypertrophic obstructive cardiomyopathy
Auto dominant (1 in 500) Due to disorder in muscle tissue caused by defect in coding for beta myosin heavy chain protein or myosin binding protein c - sarcomere protein
Echo of hypertrophic obstructive cardiomyopathy
MR SAM ASH
mitral regurgitation
Systolic anterior motion of anterior mitral valve
Asymmetric hypertrophy
Purpose of drug eluting stents
Coated with paclitaxel or rapamycin rich inhibits local tissue growth. So lower restonosis rate but higher thrombosis rate (so longer clopi)
factors favouring rate controlling AF vs rhythm
age of 65 and ischaemic heart disease,,,rate
younger symptomatic, reversible causes ,Congestive heart failure… rhythm (sotalol, amiodarone)
but if it’s secondary to infection just give Abx
Electrolyte causes of VT
hypokalemia and hypomag, hypocalcemia
specific ECG changes for Acute pericarditis
PR depression is most specific.
Also ST saddle ST elevation
What is the time window for primary PCI
Presents with STEMI within 12hr and PCI can be reached within 120 minutes, if not then thrombolysis
What is role of troponin in cardiac muscle
Component of the thin filaments
Most important drug in stable angina for best long term prognosis
Aspirin
most common cardiac defect in Turner’s syndrome
Bicuspid valve -soft ejection systolic murmur
Increased risk of developing aortic valve problems- AS, AR and aortic valve infective endocarditis
Patient on angina treatment….
aspirin 75mg od, simvastatin 40mg on, atenolol 50mg od and a GTN spray prn
Still requiring regular gtn. What is next step?
When treating angina, if there is a poor response to the first-line drug (e.g. a beta-blocker), the dose should be titrated up before adding another drug…so increase atenolol up to 100mg daily in 1 or 2 dosesbefore adding ISMN
Young patient with AF for more than 48hr, stable rate, what’s the plan
2, 3, 4
If more than 2 days, then 3 weeks of anticoagulant before electrical cardioversion, then 4 weeks of anticoagulant after. Obv carry on if risk factors
If high risk of failure (i.e. previous failed cardioversion) then 4 weeks amiodarone or sotalol
Stop exercise tolerance test if…
3 mm ST depression , 2 mm ST elevation, SBP more than 230 mmHg , SBP falling more than 20mmHg , HR falling more than 20%.
U waves on ecg
Hypokalemia (severe)
Also bradycardia according to LITFL
J waves on ECG
hypothermia
Delta waves on ECG
Wolff Parkinson white
Management for VT during angiogram
Secondary to irritation of myocardium so withdraw catheter. If this resolves it then can be discharged with no extra mx
Epsilon waves on ECG - a notch at the end of QRS complex
DIAGNOSIS
Arrythmogenic right ventricular cardiomyopathy
Second most common inherited cause of sudden death
May present as syncope
Most common cause of restrictive cardiomyopathy
Amyloidosis
Difference between constrictive pericarditis and restrictive cardiomyopathy
Similar features
Low voltage ECG
Cardiomyopathy has prominent apical pulse
Enlarged heart
BBB , q waves
Absent pericardial calcification
The most important factor predicting outcomes post-STEMI is…
the presence of new systolic heart failure. It suggests that a large amount of myocardial damage.10x more likely to die than those without Mi
Broad complex tachy… Management if adverse features Vs nil
Electrocardioversion if adverse features (syst <90)
Amiodarone if no signs of shock
What is esseinmengers syndrome
Reversal of left to right shunt in congenital heart defect due to pulmonary hypertension…
E.g. In downs
Talk through valsalvae physiology
Increased intra thoracic pressure
Increased venous pressures so decreased venous return
Fall in cardiac output
What type of valve would someone who’s 75 probably get Vs 55yr
Bioprosthetic biologic valve for older, as they don’t need long-term anticoag (except aspirin)
Mechanical for younger, because they last longer.. need warfarin though (aortic: 3.0, mitral: 3.5)
Indications for a temporary pacemaker
Post anterior mi complete heart block (contrastingly, post inf this is common so managed conservatively)
Haemodynamically Unstable/symptomatic bradycardia
Trifasicular block pre surgery
Effect of squatting on heart murmurs
Squatting increases M + A stenosis
But decreases HOCM + mitral valve prolapse
Opposite is true in valsalvae
Aortic stenosis marker of severity on examination
Fourth heart sound
Narrow pulse pressure
Slow rising
Contraindication of exercise tolerance test
exercise tolerance test would be contraindicated in a patient with suspected aortic stenosis.
most accurate method to determine his left ventricular function?
MUGA scan
Patient with infection causing heart block
Diphtheria, chagas, Rocky Mountain
blood test to demonstrate re-infarction within a week of another MI ?
CK-MB
this cardiac enzyme returns to normal with 2-3 days, unlike trop T which is 10d
Drugs to avoid in HOCM
DANI has HOCM Diuretics and digoxin ACEi Nitrates Inotropes
Management of HOCM
Amiodarone Beta blocker Cardioverter defib (could be first line!) Dual chamber pacemaker Endocarditis prophylaxis
Prosthetic heart valves - antithrombotic therapy:
bioprosthetic: aspirin
mechanical: warfarin + aspirin
aortic: 3.0
mitral: 3.5
Cardiac complication in Lyme’s disease
Myocarditis / heart block are late features
where is Atrial Natriuretic Peptide (ANP) produced
myocytes in right atrium and ventricle (a bit in left too) in response to increased volume
what does Atrial Natriuretic Peptide (ANP) do
Similar to BNP
promotes Na excretion,
decreases BP
antagonises angiotensin II and aldosterone
vasodilator
causes of raised b-type natriuretic pepetide BNP
anything that causes LV dysfunction... Heart failure MI valvular disease CKD due to decreased excretion Age >70yr Hypoxia - COPD, PE sepsis
causes of reduced b-type natruiretic peptide (BNP)
BMI >35
HF drugs - ACEi, A2RB, Diuretics
African-carribbean origin
Management for BNP levels
CKS say >2000 then refer and echo in 2/52
400-2000 then echo in 6/52 and refer
What scoring system can classify risk post MI?
Killip class, ranked 1-4, predicts 30 day mortality 1 no HF , 6% 2 lung crackles, S3, 17% 3 frank pulmonary oedema, 38% 4 cardiogenic shock 80%!
first cardiac enzyme to rise post MI
Myoglobin
what do Troponin T, C and I bind to?
T binds to tropomyosin (another component of thin filament )
C binds to Calcium
I binds to actin
which heart sound is normal under 30 yr ?
Third heart sound can be normal in under 30yr, and can persist in women up to 50yr
what anatomy and ECG do S1 and S2 heart sounds correlate with
what ecg do S3 and S4 heart sounds correlate with.
s1 closure of Mitral and Tricuspid (QRS wave)
s2 closure of aortic and pulmonary (end of T)
remember M + T and a + p look similar
S3 passive ventricular filling
S4 P wave
PR depression on ECG…diagnosis?
specific marker for pericarditis
what is Kussmaul’s sign?
a paradoxical rise in JVP on inspiration, found in constrictive pericarditis and restrictive cardiomyopathy
patient presents in community with chest pain three days ago…what’s management?
trop and ecg before referral if longer than 72hr ago
if 12-72hr then same-day hosp assessment
timeline of Dressler’s syndrome and pericarditis post MI
pericarditis is common in the first 48hr (10% of patients with transmural MI).
Dressler’s, which is an autoimmune pericarditis is 2-6weeks
(Dressler’s has fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs
Causes of heart failure post MI
1week (1-2%) - intraventricular septum rupture - acute HF w pan sys murmur
1-2 weeks (3%) - LV free wall rupture - acute HF w cardiac tamponade
Acute MR - hypotension/pulmonary oedema - often inferopost infarct
Chronic HF - treat with Eplerenone if LVSD
what is management post thrombolysis?
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation.
If <50% then rescue PCI
If >50%, PCI has been shown to be beneficial. The optimal timing of this is still under investigation
management of diabetic post MI
Metformin may cause lactic acidosis if taken during time of tissue hypoxia
so stop and start insulin IV infusion
management of Dressler’s
NSAIDs - Colchicine
remember: usually 2-6weeks post MI
management of Prinzmetal angina
dihydropyridine calcium channel blocker like felodipine/amlodipine
(rare vasospasm pain at rest)
angina not controlled by atenolol 100mg, what is next step?
As Atenolol is at max dose, add Nifedipine MR
(remember Verapamil contra w beta due to complete heart block)
(diltiazem “used with caution due to the risk of bradycardia)
angina and sexual dysfunction…
Nitrates or nicorandil and phosphodiesterase inhibitors (Sildenafil etc) are contraindicated
Don’t take Sildenafil within 24hr of Nitrates
Anticoagulation management before and after catheter ablation for AF
need to be anticoag for 4 weeks before and 2 months after, then following this it is down to CHA2DS2-VASc score
-counterintuitively, ablation doesn’t reduce stroke risk even if sinus rhythm
how successful is catheter ablation for AF?
doesn’t seem to reduce stroke rate
55% of patient wiht single procedure remain in sinur rhythm at 3yr
80% of patient with multiple procudures
70yr old man with persistent atrial fibrillation, type 2 diabetes mellitus and treated for hypertension and on Warfarin comes in with 3 falls in 6 months…what do you do?
If CHADSVASc is 4 risk is 4.8% annually… You would have to have 295 falls a year for the risk to require stopping Warfarin
what drug should not be given in VT
Verapamil - can precipitate VF
treat with Amiodarone (ideally through central line) or immediately cardiovert if there are any adverse signs
how do you differentiate between the type A and type B wolff-parkinson White?
Type A (left sided accessory pathway) has dominant R waves in V1... basically right axis deviation Type B (right-sided) does not. left axis deviation
causes of dilated cardiomyopathy
Alcohol
Beriberi wet - thiamine deficiency
Coxsackie B
Doxorubicin
poor prognostic genetic mutations in HOCM
myosin binding protein C
troponin T
USUALLY caused by Myocin heavy chain-beta (15-25%) and myosin binding protein C (15-25%).
What wall thickness is poor prognostically for HOCM?
wall thickness > 30mm
triad of Arrhythmogenic right ventricular cardiomyopathy, palmoplantar keratosis, and woolly hair
Naxos disease
- autosomal recessive variant of ARVC
patient with fatigue and SOB on exertion. He has pulsing nailbed…what is this sign called?
Quinke’s sign - in Aortic Regurge, so early Diastolic murmur
patient has a mid-systolic click that moves later as she squats. Diagnosis?
Mitral valve prolapse.
Also should move earlier with valsalvae
Patient with Mitral Valve prolapse. What heart sounds would you expect?
Mid-systolic click which moves later with squat and earlier wiht valsal
Late systolic murmur
long-term management of atrial flutter
radioablation of tricuspid valve isthmus is curative in most
medication is less effective than with AF
It is sensitive to cardioversion though
most common heart defect in Marfans
dilatation of aortic sinuses
Most common heart defect in Turners
Bicuspid aortic valve (15%)
but also get coarctation of the aorta (5-10%)
patient presents with ejection systolic murmur over carotid area… what is the most like cause, if he is 55yr or 75yr ?
aortic stenosis…caused by:
<65yr , most likely bicuspid aortic valve
>65yr calcification
What value of pulmonary artery pressure is considered diagnostic of pulmonary arterial hypertension?
> 25mmHg at rest
—-measured by cardiac catheterisation
how do you determine management for patient with pulmonary hypertension?
Acute vasodilator testing if pt has signif fall in pul pressure
- -> positive response then calcium channel blockers
- -> negative response then prostacyclin analogues, endothelin R antag, or phosphodiesterase inhib
which congenital defect is more common: ventricular septal defects or atrial septal defects?
VSDs are more common, and the most common acyanotic defects
however, ASD are more common as a new diagnosis in adults as they generally present later
important thing to warn woman with pulmonary hypertension…………..
pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality
how common is patent foramen ovale?
20% of population!
patient post NSTEMI with normal Echo gets started on aspirin, ticagrelor and fondaparinux.
He develops dyspnoea a few days later, what is the likely cause of this?
ticagrelor can cause dyspnoea, due to the impaired clearance of adenosine
Heart failure unlikely due to normal Echo
74yr old with T2DM, and BP 146/88 mmHg. what would yuo use to treat her blood pressure?
Hypertension in diabetics - ACE-inhibitors are first-line regardless of age
patient has AAA and needs immediate surgery. His last INR was taken 2 weeks ago and was 2.5. How should you proceed?
As surgery immediate, treat with 25-50units of four-factor prothrombin complex
if it can wait 6hr then can give 5mg Vit K IV
ECG signs of hypokalaemia
U waves
PR lengthening
Small / absent T waves (occasionally inversion)
ST depression
Afrocaribbean patient on amlodopine 10mg with persistent hypertension, what do you add?
an angiotensin receptor blocker in preference to an ACE inhibitor
Which occurs sooner post PCI stent - stent thrombosis or restenosis?
Stent thrombosis = first month
Restenosis = 3 to 6 months
First line investigation for stable chest pain in suspected coronary artery disease
contrast-enhanced CT coronary angiogram
What is the most specific sign for left ventricular failure?
Gallop rhythm… Also an early sign.
S3 and/or S4
Considered normal if under 30yr, or sometimes up to 50y in women
Management of malignant hypertension with papilloedema
PO atenolol
But if severe/ encephalopathy:
IV lebetalol or nitroprusside
“Push down pressure”
What are Aschoff bodies the histological sign of
granulomatous nodules found in rheumatic heart fever
What is cardiac syndrome X
Aka microvascular angina
Normal ECG at rest, normal angiogram, but st depression on exercise stress test
Can treat with nitrates
Factors that increase and decrease BNP falsely
Obesity and HF drugs decrease it
Everything else increases .. eg copd, lvh diabetes ischaemia age >70
Distinguish between constrictive pericarditis and cardiac tamponade
PaY TaX
X and Y descent on the JVP for pericarditis
Absent Y in tamponade
Pulsus paradoxus present in tamponade absent in peri
Signs of severe AS
Slow-rising pulse and a S4 heart sound are signs of severe aortic stenosis.
Patient has inferior mi… Severe hypotension after starting nitrate. Cause
Right ventricular infarct (occurs in 30-50% of inf MI)… Nitrates would reduce V filling and systemic circ
most common cause of restrictive cardiomyopathy in the Uk
Amyloidosis (e.g. secondary to myeloma) - most common cause in UK
Prevention of svt
beta-blockers
radio-frequency ablation
Infective endocarditis - strongest risk factor
Previous inf endocarditis
Heart sound in dilated cardiomyopathy and in HOCM
DCM & LVF has three letters - S3
HOCM has four letters - S4
SCN5A gene mutation
Brugada
KCNQ1 mutation
Romano ward LQT
Mx of atrial flutter
Similar to AF but meds are less successful
..radiofrequency ablation of the tricuspid valve isthmus is curative for most patients
Pulsus alternans -
seen in left ventricular failure
Where does furosemide act
thick ascending limb of the loop of Henle
inhibits the Na-K-Cl cotransporter
General mechanism of drug induced LQT
blocking cardiac potassium channels
- excessive lengthening of cardiac re-polarisation
Persistent Vs paroxysmal AF
last greater than 7 days then persistent
Right ventricular enlargement with estimated PASP (pulmonary arterial systolic pressure) of 44mmHg
Heart sounds
Loud S2 in pulmonary hypertension
Drugs that affect adenosine
DE-AR Adenosine
Dipyridamole - enhances
Aminophylline - reduces
Adenosine MOA
transient heart block in the AV node
By A1 R agonist on AVnode
Drugs to avoid in WPW
Verapamil and digoxin —may precipitate VT or VF
Which vessel is affected in Takayasu’s
Aorta
Vessels affected in Buerger’s disease
Small/medium vasculitis - arteries of hands/feet
Assx with smoking
Osium primium vs ostium secondum BBB?
Primary LBBB (left by your parents in primary school) Secondum RBBB
Risk factors for aortic dissection
Hypertension (most important) Trauma? Bicuspid aortic valve (increases risk X6) Collagens Syndromes Preg Syphilis
AF pharmacological cardioversion… No structural heart disease Vs structural heart disease
Flecainide if nil
Amiodarone if structural HD
Risk factors for stent restenosis
Diabetes, renal impairment..
Usually Presents with angina symp 3-6m later
WPW associations
HoT As ME HOCM Thyroxicosis ASD secondum Mitral valve prolapse Ebsteins ab
Signs of severity in AS
S for Severity
Slow rising pulse
Soft S2
S4
ECG sign on hyperkal that precedes arrest
QRS longation
Where does S4 correlate with on ECG
After p wave
Unwell, AF, collapse, k 2.6, management
Correct potassium first
Where has the wire touched if you cause VF arrest
Coronary sinus
