Cardiology Flashcards
Which conditions does ACS refer to
Unstable angina
NSTEMI
STEMI
What is the gold standard investigation of ACS
CT coronary angiogram
A STEMI can be defined as
ACS with ST elevation or new LBBB on ECG
How could you describe the difference between STEMI and NSTEMI to patients
STEMI is full vessel occlusion and ischaemia/infarction of the entire myocardial thickness
NSTEMI is partial vessel occlusion that caused ischaemia/infarction part of the myocardium wall (not the full thickness)
How can you differentiate unstable angina from MI
Trop rise - present in MI, absent in unstable angina
Which are the most cardiospecific troponins?
I and T
How long should you wait between repeating troponin levels?
4-6 hours
Causes of raised troponin levels
MI HF Renal failure/CKD PE Arrhythmias
How long after an MI do troponins stay raised
7-10 days
Describe the sequence of ECG changes during a STEMI
Hyperacute T waves ST elevation/new LBBB Pathological Q waves T wave inversion ST normalisation T wave normalisation
Possible ECG changes in NSTEMI/unstable angina
ST depression
T wave inversion
Loss of R wave
Normal
Which are the inferior leads on ECG
II + III + aVF
Which are the lateral leads on ECG
I + aVL + V5 + V6
Which are the septal leads on ECG
V1 + V2
Which are the anterior leads on ECG
V3 + V4
Which vessel supplies the inferior territory on ECG
Right coronary artery
Posterior descending branch
Which vessel supplies the lateral territory on ECG
Left coronary artery
Circumflex branch
Which vessel supplies the septal and anterior territories on ECG
Left anterior descending artery
Septal branch = septal
Diagonal branch = anterior
How soon after an MI do troponins rise
6-8 hours
Differentials for ST elevation on ECG
STEMI LBBB Pericarditis Hyperkalaemia PE Tricyclic antidepressants
General management for all ACS
Morphine + metoclopramide
Nitrates (GTN, not if inferior)
Oxygen (if sats <94%)
Aspirin 300mg
Describe the specific management of STEMI
If symptoms started >12 hours ago then give fondaparinux
If symptoms started <12 hours ago then for reperfusion therapy: if can get to PCI within 120 mins the PCI. If cant get to PCI within 120 mins then thrombolyse
What is the time window from symptom onset for a STEMI to qualify for reperfusion therapy
<12 hours
If a STEMI had symptom onset <12 hours ago, how long do you have to get them to the cath lab to be able to perform PCI?
120 minutes
Contraindications to thrombolysis
Previous intracranial bleed Ischaemic stroke <6 months ago Cerebral malignancy or AVM Major trauma or surgery <3 weeks ago GI bleed <1 months ago Known bleeding disorder Aortic dissection Recent biopsy/lumbar puncture (<24hrs ago)
What cardioprotective medication do you initiate after ACS
Aspirin for life + Ticagrelor/Clopidogrel for 12 months
Beta blocker
ACEi
High dose statin
MI complications most common in the first 0-24hrs
Ventricular arrhythmia - VT, AV block - causes sudden cardiac death
Acute left heart failure
Cardiogenic shock
MI complications most common 1-3 days after
Early infarct associated pericarditis - can cause haemopericardium/pericardial tamponade
MI complications most common 3-14 days after
Papillary muscle rupture - acute mitral regurgitation
Ventricular septal rupture
Left ventricular free wall rupture
MI complications most common two week-months after
Atrial/ventricular aneurysms Dressler syndrome Arrhythmia/AV block Congestive heart failure Reinfarction
What is the GRACE score used for
Inpatient and 6 month mortality risk following ACS
What is the CRUSADE score used for
Predicts risk of major bleeding in patients diagnosed with ACS, especially NSTEMI - used to help inform about risk of thrombolysis
What is the HAS-BLED score used for
To assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation
What is the QRISK2 score used for
Risk of MI or stroke over the next 10 years
What is the CHADSVASC score used for
Assesses embolic risk in patient with AF
Causes of angina
Atheroma
Anaemia
Aortic stenosis
Tachyarrhythmias
Describe stable angina
Induced by effort, relieved by rest
Describe unstable angina
Angina of increasing frequency/severity/occuring on minimal exertion/at rest
What 3 features need to be present for angina to be classed as typical?
- Constricting discomfort in the front of the chest, or in the neck/shoulders/jaw/arms
- Precipitated by physical exertion
- Relieved by rest or GTN in 5 mins
What advice do you give to patients on what to do when they have an angina attack?
Stop and rest
Use GTN and wait 5 mins
Second dose of GTN and wait 5 min
Call 999 (or earlier if pain is intensifying/feel unwell)
How do you manage angina
Address causative/exacerbating factors (anaemia, thyroid)
Secondary prevention of CVD - lifestyle modification, control of HTN and DM
GTN for symptom relief
Beta blocker +/ calcium channel blocker
Name some narrow complex tachycardias
Sinus tachycardia
Atrial flutter
Atrial fibrillation
Narrow complex tachycardias represent the electrical signal being initiated where?
Supraventricular
Broad complex tachycardias represent the electrical sign being initiated where?
Ventricular
Name some broad complex tachycardias
Premature/ectopic ventricular beats
VT
Torsade de pointes
VF
Name some bradycardias
Sinus bradycardia
First degree heart block
Second degree heart block
Third degree heart block
Endocrine causes of secondary HTN
Primary hyperaldosteronism (Conn syndrome) Primary hyperparathyroidism Pheochromocytoma Cushings syndrome Hyperthyroidism Acromegaly Congenital adrenal hyperplasia
Renal causes of secondary HTN
Renal artery stenosis
ADPKD
Renal failure/decreased GFR
Glomerulonephritis
Fundoscopic features of hypertensive retinopathy
Cotton wool spots Flame haemorrhages Hard exudates AV nicking Papilloedema
How do you assess for hypertensive end-organ damage?
ECG/echo
Fundoscopy
Renal function + Urinalysis
What is the difference between hypertensive urgency and hypertensive emergency
Hypertensive urgency does have signs of end-organ damage
Hypertensive urgency has signs of end-organ damage
How do you manage hypertensive urgency?
Oral antihypertensives
How do you manage hypertensive emergency?
IV antihypertensives
How do you go about diagnosing hypertension
2 readings in clinic 140/90 or above then ABPM or HBPM average reading of 135/85 or more
How often does ABPM take readings
2 measurements every hour
How often does HBPM take readings
2 measurement twice a day
Describe the pathway for treating with antihypertensives
Step 1: ACEi/ARB if <55, CCB if >55 or Afro-Caribbean
Step 2: ACEi/ARB + CCB
Step 3: ACEi/ARB + CCB + Thiazide diuretic
Step 4: A + C + D + alpha/beta blocker
Side effects of calcium channel blockers
Flushes/headache
Ankle oedema
Fatigue
Side effects of ACE inhibitors
Dry cough
High K
Angioedema/rash
Dizziness/headache
Side effects of ARBs
Dizziness/headache
Urticaria/pruritus
High K
Cough
Side effects of beta blockers
Dry mouth/skin/eyes
Cold peripheries
Dizziness
GI upset
Causes of left heart failure
Hyperdynamic circulation - anaemia, thyrotoxicosis Arrhythmia - AF Valvular disease - MR, AR, AS HTN MI Congenital defects - ASD, VSD
Signs/symptoms of left heart failure
Dyspnea Orthopnea Pulmonary oedema Bilateral basal crackles Paroxysmal nocturnal dyspnea Cool peripheries Sweating Cerebral/renal dysfunction
Causes of right heart failure
Left heart failure COPD Pulmonary hypertension Tricuspid regurgitation Atrial septal defect
Signs/symptoms of right heart failure
Peripheral pitting oedema
Raised JVP with hepatojugular reflex
Hepatosplenomegaly
Ascites
NYHA classification of heart failure
I. no limitation/sx with normal physical activity
II. slight limitation/sx of normal physical activity
III. marked sx with less than normal physical activity e.g. getting dressed
IV. sx at rest, can’t really do any physical activity
Which blood test can assess for heart failure?
BNP
Which medications improve mortality in heart failure
ACEi/ARBs
Beta blockers
Spironolactone (aldosterone antagonist)
Which medications just give symptom relief in heart failure
Furosemide
Digoxin
Describe ECG findings of AF
Irregularly irregular rhythm
Narrow QRS
Absent/indiscernible P waves
Increased rate
If AF has been present for >48 hours or an unknown duration, how long would you ideally anticoagulate before cardioversion?
3 weeks
Which medications are used for rhythm control in AF
Amiodarone
Flecainide
Which medications are used for rate control in AF
Beta blocker
Non-dihydopyridine calcium channel blockers - Diltiazem, Verapamil
Digoxin
Which two scores can you use to assess risk/benefit of starting anticoagulation in AF
CHADSVASC and HAS-BLED
Causes of pericarditis
Viral infection Bacterial infection MI Trauma/surgery SLE/RA Uraemia Radiation
Symptoms of pericarditis
Pleuritic chest pain, improved by sitting forwards
Tachypnoea
Dyspnea
Flu like symptoms/low grade fever
ECG changes in pericarditis
Diffuse ST elevation - with ST depression in aVR and V1
Inverted T waves
Management of acute pericarditis
Usually self limiting and resolves in 2-6 weeks
NSAIDs/Aspirin
Restrict physical activity
Colchicine to reduce risk of recurrent
Which valve is most commonly affected by infective endocarditis in IVDU’s
Tricuspid valves
Signs/symptoms of infective endocarditis
Fever/chills, malaise, B sx New murmur, arrhythmias, HF Oslers nodes Splinter haemorrhages Janeway lesions Clubbing Signs/sx of emboli - kidney, lungs, brain
What is the name of the criteria used to diagnose infective endocarditis?
Modified Duke’s criteria
Rheumatic fever occurs after infection with what?
Group A beta-haemolytic streptococcal pharyngitis
Clinical features of rheumatic fever
Fever, malaise, fatigue Large joint polyarthritis Pancarditis Valvular disease Sydenham chorea Subcutaneous nodules Erythema marginatum
What is the name of the criteria used to diagnose rheumatic fever
Jones criteria
Systolic murmurs
AS PS MR TR MVP
Diastolic murmurs
AR
PR
MS
TS
Describe how you grade a murmur
1 - heard only if you listen hard for ages
2 - faint but heard easily
3 - loud no thrill
4 - loud with thrill
Describe the murmur of aortic stenosis
Opening click + ejection harsh systolic murmur
Describe the murmur of pulmonary stenosis
Ejection systolic
Describe the murmur of mitral regurgitation
Pansystolic
Describe the murmur of tricuspid regurgitation
Pansystolic
Describe the murmur of mitral valve prolapse
Mid systolic click + mid/late systolic murmur
Aortic stenosis findings
Opening click + harsh ejection systolic murmur
Slow-rising small volume pulse, narrow pulse pressure
Displaced heaving apex beat if LVH
Systolic thrill in aortic area
Reduced/absent S2
Radiates to carotids
Pulmonary stenosis findings
Ejection systolic murmur
Right-sided heart failure (RV heave, tricuspid regurgitation, raised JVP)
Widely split S2
Right ventricular dilation (right ventricular heave, peripheral signs of right heart failure)
Radiates to left shoulder/infraclavicular
Aortic regurgitation findings
Decrescendo early diastolic murmur
Collapsing pulse, wide pulse pressure. Corrigan’s, Quincke’s, de-Musset’s
Displaced hyperdynamic apex beat
Radiates to left sternal edge
Mitral stenosis findings
Opening snap + low pitched rumbling mid-diastolic murmur
Loud S1
Tapping apex beat
Low volume pulse
AF
Signs of pulmonary HTN (malar flush, right sternal heave, engorged neck veins)
Describe the murmur of aortic regurgitation
Decrescendo early diastolic murmur
Describe the murmur of pulmonary regurgitation
Early decrescendo diastolic murmur
Describe the murmur of mitral stenosis
Opening snap + low pitch rumbling mid-diastolic murmur
Describe the murmur of tricuspid stenosis
Mid-diastolic
Getting a patient to sit forward and hold expiration exaggerates which murmur?
Aortic stenosis
Getting a patient to lie on their left and hold expiration exaggerates which murmur?
Mitral regurgitation
Causes of a third heart sound
Left ventricular failure - dilated cardiomyopathy
Constrictive pericarditis
Mitral regurgitation
