Cardiology Flashcards
Which artery is most likely to be affected if post M.I there is a brady arrhythmia? and what type of arrhythmia is most common?
Inferior M.I due to RCA blockage
1st degree AV block
What are some common causes of tachy arrhythmias that can be reversed without shock or anti-arrhythmia drugs?
high K+ / Low K+
Hypoxia
Hypercapnia
Acidosis
Hypercalcaemia
What scoring system is used for NSTEMIs to predict risk of another MI or stroke within 6 months of a NSTEMI?
GRACE score
> 10% = surgical intervention
What are the causes of Acute De Novo heart failure?
ICHAMP - iatrogenic fluid overload - Coronary syndrome - Hypertension - Arrhythmias - M.I - P.E -
What are the key symptoms for heart failure?
Breathlessness
Fatigue
Oedema
What is the greatest risk factor for endocarditis?
Previous endocarditis
What important electrolyte abnormalities can cause VT>
Hypokalemia
Hypomagnesemia`
What is first line management for diabetic patients with hypertension? regardless if they are above or below 55?
ACE inhibitor
In patients with a provoked P.E (i.e. recent surgery) how long should they be warfarinised following the P.E?
for those who have an unprovoked P.E, how long should they be?
And how long for someone with active cancer?
provoked: 3 months
Unprovoked: >3 months
Cancer: 6 months
What is needed to have trifascicular block?
Anterior or posterior fascicular block \+ RBBB \+ 1st degree heart block
(remember to have left anterior fascicular block you need left axis deviation + rS wave in leads II,III, aVF)
(to have left posterior fascicular block you need right axis deviation + rSV wave in leads II, III, aVF) *rare
After initial bloods and ECG what investigations should be done into palpitations?
Holter monitor
What may be seen with hypothermia on the ECG?
Prolonged QT interval
J waves
Which type of heart rhythm is always abnormal?
LBBB
In order for there to be a STEMI what must be present?
> 2mm change in two consecutive leads in V1 - V6
or
1mm change in two consecutive leads in limb leads
+/-
LBBB
What is a sign of constrictive pericarditis?
Raised JVP during inspiration
What defect is typically seen with Down’s syndrome babies?
Ventricular septal defect
What should be offered to all heart failure patients annually?
Influenza Vaccine
If someone has a stroke due to AF, following the initial aspirin for 2 weeks, what medication should they be started on afterwards?
Warfarin
What is the biggest risk factor towards aortic dissection?
hypertension
What disease is most likely if a young female present with episodes of dizziness and lethargy and has an absent pulse on one side - usually left.
Takayusa’s vasculitis
- causes inflammation of the large vessels which can cause occlusion on one side
What two rhythms cannot be shocked?
Pulseless electrical activity
asystole
If a patient has suspected P.E but has renal disease, what investigations should be done?
V/Q miss match
- not CTPE
because renal function cannot handle the contrast
In the setting of infective endocarditis that is causes heart failure, what is the definitive management?
Immediate surgical intervention for valvular replacement
Where is the QT interval measured from?
From the start of the Q wave to the end of the T wave
Where is the PR interval measured from?
Start of the P wave to the start of the Q wave
What is an abnormal QT interval?
It should be half the cardiac cycle.
at 60bpm it should be
<440m/s in males
<460m/s in females
QTc needs to be established though because as the HR increases the QT reduces.
Breathing problems with dropping sats and a clear chest one should think?
P.E
What tests are important to do prior to starting amiodarone?
TFTs - thyrotoxicosis
LFTs - hepatitis
U&Es - detect hypokalamia which may cause the arrhythmias
CXR - underlying fibrosis or pneumonia
What type of breath sound may be heard with acute heart failure? outwith things such as crackles
Polyphonic wheeze
- due to oedema build up
What are the reversible causes of a cardiac arrest?
Hypothermia
Hypoxia
Hypovolaemia
Hypokalaemia / hyperkalaemia / hypoglycaemia
Tension pneumothorax
Toxins
Tamponade
Thrombosis
If there is systolic murmur which radiates to the back with splitting of S2, what is likely defect?
Atrial septal defect
List some differentials for ST elevation:
Myocardial infarction pericarditis Takotsubo cardiomyopathy Intracranial hemorrhage Left ventricular aneurysm
In a thoracic arotic disection, what ECG findings would you likely see?
ST elevation in inferior leads
- aVF
- II
- III
What does T wave inversion suggest?
Ischemia
Left ventricular hypertrophy
If a patient requires emergency surgery and is on warfarin, what should be done?
Prothrombin complex concentrate
What is the most common ECG finding of a P.E?
Sinus Tachycardia
What is the drug of choice for chemical cardioversion if there is no structural heart disease?
Flecainide
What is the most common cause of sudden death syndrome in young people, how is it inherited and name some clinical findings:
Hereditary obstructive cardiomyopathy
Autosomal dominant
- Exertional syncope
- systolic ejection murmur
How is Torsades de Pointes treated?
IV magnesium sulphate
In cardiac asystole what is the management?
Chest compression. stop every 2 mins and reasss. Adrenaline given every 3-5mins
What are the indications for transcutaneous cardiac pacing?
Complete AV block
- and M.I with instability
Secondary degree heart block
- with M.I and instability
First degree
- with instability
Bradycardia with adverse signs when atropine has been ineffective
In orthostatic hypotension, what drop in blood pressure is needed?
> 20mmHg
What drug is contraindicated in aortic stenosis?
GTN
Which two beta blockers have been showing to reduce mortality in heart failure?
Carvedilol
Bisoprolol
Statins can induce an increase in liver enzymes, when should they be discontinued?
LFTs need to be >3x normal limit before being discontinued.
Following an M.I, how long until you can drive again?
4 weeks
Which commonly used anti- hypertensive is contraindicated in pregnancy?
ACE inhibitors
How long should a patient be observed for following an anaphlyatix reaction?
6-12 hours
- due to biphasic reaction
In bradycardia if there is a risk of asystole or the patient is unstable, what is the first line? and what is second line?
First line:
* Atropine 500mcg IV
No improvement:
- Atropine 500mcg IV repeated to 3mg
- Other inotropes
- Transcutaneous cardiac pacing (using defibrillator)
What is the immediate management for NSTEMI?
Clopidogrel Aspirin Heparin \+/- Beta blockers \+/- Nitrates \+/- Oxygen
Following an NSTEMI a grace score should be calculated, if >10% what should be done?
inpatient coronary angiography
CABG
PCI
- if symptomatic
2-3 weeks following an MI a patient develops pleuritic chest, pericardial rub and fever.
ECG shows global ST elevation and bloods increased CRP and ESR.
what does this patient have? and how is it managed?
Dressler’s syndrome
- post immune mediated
- NSAIDs
- Steroids
- pericardiocentesis
What are some aetiologies to AV block?
Congenital
Idiopathic fibrosis
MI/ Ischemia - Right coronary artery
Inflammation
- infective endocarditis
- Sarcoidosis (chronic), Chaga’s disease
Trauma
Drugs
- Beta blockers
- digoxin
What are some aetiologies of RBBB?
Normal variant
Right Ventricular hypertrophy/ strain
- P.E
Coronary heart disease
Atrial septal defect
What are some aetiologies of LBBB?
Coronary heart disease
Hypertension
Cardiomyopathy
Aortic Valve disease
What are some of the conditions/ states that are associated with atrial flutter?
Cardiomyopathy
thyrotoxicosis
Hypertension
Ischemic heart disease
What is the management for Atrial flutter?
Rhythm/ Rate control
Radiofrequency ablation
Anti-coagulation
What does AVNRT stand for?
Atrial ventricular nodal reentry tachycardia
What are the three main types of SVT?
AVNRT
AVRT
Atrial Tachycardia (tachy originates in atrium)
What is the long term management for SVT?
Medication
- beta blockers, Ca2+ blockers, Amiodarone
Radiofrequency ablation
What is the accessory pathway in wolf -parkinson white syndrome called? and what medications are contraindicated in this condition?
Bundle of Kent
Calcium channel blockers, Beta blockers and adenosine are contraindicated.
- they significant increase the risk of slowing conduction through the AV node, encouraging the current through the bundle’s of kent.
- this can put the patient in a polymorphic wide complex tachycardia
Briefly outline the pathophysiology behind Torsade de Pointes:
Prolonged repolarization of the ventricles leads to some myocytes to undergo spontaneous depolarisation - called [afterdepolarisations].
These then trigger further depolarisations prior to ventricles fully repolarizing
What is the management for torsades de pointes?
Remove causative medications
- macrolides
- citalopram
- amiodarone
IV magnesium infusion
Defib if VT develops
How big are the boxes in 1st degree heart block?
5 small or 1 big box
- 0.2m/s
Which types of heart block increase the risk of asystole?
Mobitz type II
3rd degree heart block
What are some side effects of atropine?
Pupil dilation/ mydriasis
Dry mouth
Dry eyes
Urinary retention
What are some x-ray signs of heart failure?
Upper lobe venous diversion
Kerley B lines
Fluid within the intralobular fissures
Bat-wing sign
Bilateral pleural effusions
What is the management of severe pulmonary oedema that is not responding to diuretics, sitting up and oxygen alone?
CPAP Dilators - morphine ITU admission \+ Diuretics Sitting up
How many small squares should the QRS be?
< 3 = <120m/s
What is the criteria used for rheumatic fever?
Jone criteria: Evidence of Strep infection + 1 major + 1 Minor or 2 Majors
Step infection:
- Streptolysin O antigen
- recent strep throat
Major:
Pericarditis
- murmur
- pericardial rub
Polyarthritis
Subcutaneous nodes
Erythema Marginatum
Chorea movements
Minor:
- fever
- arthralgia
- Raised ESR
- Previous Rheumatic fever
How is rheumatic fever treated?
Benzylpenicillin STAT
followed by:
- phenoxymethylpenicillin 10 days
NSAIDs
+/-
prednisolone
Haloperidol
What are the blood pressure targets:
<80: <140/90
> 80: <150/90
Diabetics: <130/80
What score is used to assess if a P.E patient should be managed in hospital?
PESI
What are the clinical findings of infective endocarditis?
Janeway lesions Osler's nodes Splinter Hemorrhages Roth Spots Finger clubbing Anaemia Splenomegaly Haematuria Murmur
What is the adrenaline dose given to patients:
0-6 years = 0.15ml in 1 in 1000 = 150 micrograms
6 - 12 years = 0.3ml in 1 in 1000 = 300 micrograms
> 12 years = 0.5ml in 1 in 1000 = 500 micrograms
What are the two broad types of heart failure?
Reduced ejection fraction:
- Coronary heart disease
- Younger patients
- Males
Preserved ejection fraction:
- elderly
- females
- Hypertension
- Ventricular hypertrophy
High Output failure:
- Anaemia
- pregnancy
- Hyperthyroidism
How is acute heart failure managed?
Sit patient up
100% oxygen
Slow titrated morphine
+/- antiemetic
Furosemide
x2
- if needing more referral to senior staff
GTN
Consider:
- CPAP
- referral to senior staff in ICU
PODMAN
- Position up right
- oxygen
- Diuretics
- Morphine
- Anti emetics
- NItrates
What are some contraindications to CPAP?
BP <90mmHg Facial trauma Pneumothorax Type II respiratory failure Reduced consciousness - not responding to pain
What are some complications of CPAP?
Hypotension
Aspiration
Gastric distention
Anxiety
What investigations should be done into angina?
CT angiography
ECG
Stress ECG
What are the secondary prevention medications used for angina?
Aspirin
ACE
Statins
Atenolol (although will usually be on for symptom control)
What are some causes of tachyarrhythmias?
Cardiac:
- MI
- Long QT syndrome
- Cardiomyopathy
Non cardiac:
- Hypoxia
- Hypomagnesemia
- Hypokalemia
- Sepsis
- Hypoglycaemia
Drugs:
- Cocaine
- TCAs
- Amphetamines
What investigations should be done into tachycardia?
Bloods:
- FBC
- U&Es - K? Mg?
- Bone profile - Ca2?
- TFTs
- coagulation studies
Orifices:
X-ray:
- Chest x-ray
ECG - essential
What are some causes to bradyarrhythmias?
Physiological normal in young and extremely fit
Cardiac:
- post MI
- Sinus Node disease
- AV block
Non - cardiac
- vasovagal
- Hypothermia
- hypothyroidism
- raised ICP - cushing’s effect
Drug induced
- Calcium channel
- beta blockers
- Digoxin
What are the causes of cardiac shock?
M.I Arrhythmias P.E Tension pneumothorax Aortic dissection
How is cardiogenic shock managed?
ABCDE approach
Investigate the cause and look to reverse
Management often requires ICU
- Oxygen
- Morphine for anxiety
- Correction of cause (arrhythmias etc)
- Optimize filling pressures - plasma expanders/ dobutamine if to low
What must be present in order to diagnose an M.I?
ECG changes + troponins
Signs and symptoms + troponins
What are the other causes which can cause troponins to rise?
Congestive heart failure Sepsis Chronic renal failure Tachyarrhythmias P.E Infiltrative cardiomyopathies - Sarcoidosis - Amyloidosis
If there is a posterior wall infarction which vessel has been occluded?
Left circumflex
What are the stages of hypertension?
Stage 1: >140-160 or >135
Stage 2: >160 - 180 or 155
Stage 3: >180/110
What are the causes to hypertension?
Primary
- idiopathic
- low birth weight
- Environmental factors
Secondary
- Primary aldosteronism
- Pheochromocytoma
- Cushing’s disease
- Hyperthyroidism
- Renal stenosis
- Drugs - oral contraception
How is the diagnosis of hypertension made?
Clinic - 2 reading, 5 mins apart over 2 appointments
- >140/90
Home Ambulatory: >135/85
Night time measuring: >120/80
Who always gets treated for hypertension?
> 160/100 - stage 2
or
150/90 Home ambulatory
What tests should be conducted in hypertension to exclude secondary causes?
Bloods:
- U&Es
- TFTs
- Lipid profile
- Fasting glucose
Orifices:
- Urine analysis - kidney damage
- Urine metadrenaline - Chromocytoma
- Urinary free cortisol
X-ray
- Echocardiogram
- Renal ultrasound - renal stenosis
ECG
- LVH?
If a patient is being thrombolysed following an MI and are on diabetic medication, what should happen with regard to their medication?
Stopped and placed on a insulin infusion
What electrical activity can be seen on ECG with a cardiac tamponade?
Electrical alternans
- QRS fluctuates in size
What other symptoms outwith chest pain are associated with angina?
Sweatiness
Dyspnea
Faintness
Nausea
What is the management for Angina?
Lifestyle advice
Referral to cardiology
Symptom relieve:
- GTN spray
Symptom control:
- Beta blocker
- Ca2+
- Combined
- Nicorandil
Secondary prevention:
- Aspirin
- ACE
- Atorvastatin
Surgical input
- CABG
- PCI
What investigations should you do into postural hypotension?
Sit to rising - Taking times at 2,3,7 mins
Table tilt test
Valsalva maneuver
24 hour blood pressure monitoring
Name non- pharmacological ways of reducing falls in orthostatic hypotension:
Stand slowly
Sit cross legged
Increase Salt intake
Referral to falls clinic
What is the medication that be used in orthostatic hypotension?
Fludrocortisone
What are the complications of untreated hypertension?
Stroke Heart failure M.I PVD Renal stenosis Aortic dissection Retinopathy
In coronary heart disease, what score can be done to assess the risk of an adverse advent?
QRISK 3
What symptoms may someone with coronary heart disease have and how is it managed?
Angina Strokes MI PVD Mesenteric ischemia
Primary:
- QRISK 10% > aspirin and atorvastatin
Secondary - previous adverse event Aspirin 80mg Atorvastatin ACE Beta blocker
What are some causes to pericarditis?
Recent viral infection
Dressler’s syndrome
Uraemia
Autoimmune
- RA
- SLE
Radiotherapy
How is pericarditis managed?
NSAIDs
Steroids
Colchicine
severe:
- pericardial paracentesis
Life threatening:
- Pericardiectomy
What does a lipid profile include?
Total levels of cholesterol
Triglycerides
HDL
What is the management of hyperlipidaemia?
Lifestyle changes
Lowering of BMI
1st line: Atorvastatin
2nd line: Ezetimibe (cholesterol absorption inhibitor)
3rd line: Alirocumab (PCSK9 inhibitor - blocks LDL)
What are the main categories of dyslipidemia?`
Hypercholesterolaemia
Hypertriglyceridemia
Mixed hyperlipidaemia
What are some secondary causes to hypercholesterolaemia and hypertriglyceridemia?
Hypercholesterolemia:
- hypothyroidism
- pregnancy
- cholestatic liver disease
Hypertriglyceridemia:
- DM type 2
- Chronic renal disease
- abdominal obesity
- Excess alcohol
What are some clinical manifestations of hypercholesterolaemia?
Xanthelasma - around the eyes
Corneal arcus
Xanthomas
- achilles
- Knee
- Extensors
What are the clinical signs of hypertriglyceridemia?
Lipaemia retinalis
Lipaemic and blood
Eruptive Xanthomas
Signs and symptoms of AF?
Palpitations
Hypotension
Chest pain
Dizziness
Breathless
Evidence of a stroke
What are some symptoms of heart failure?
Breathless
fatigue
Paroxysmal nocturnal dyspnoea
Nocturnal cough
Wheeze
Cold peripheries
Congestion - if right sided
Poor exercise in tolerance
What investigations should be done into angina?
ECG
Exercise ECG
Angiography - CT Angiography or Transcatherter angiography - which allows for therapeutic intervention as well
What are the signs of Mitral regurgitation? and what is the definitive diagnosis?
Displaced - hyperdynamic apex beat
Pansystolic murmur heard at apex - radiates to axilla
Splitting of S2 due to pulmonary oedema
Tests:
- initially Transesophageal echo
- cardiac catheterisation to confirm diagnosis - measure pressures
What are the complications of mitral regurgitation?
Arrhythmias
Stroke
Sudden death syndrome
What are the signs of Mitral stenosis? and how is it diagnosed? and treated?
Usually presents with signs of pulmonary oedema
Mid-diastolic snap Heard on apex - best in expiration Malar flush on cheeks - low cardiac output Low volume pulse RV heave
Diagnosis:
- echocardiogram
Management:
- control AF - rate limiting
- Anticoagulation
- Balloon dilation
- valvular replacement
What are the classical presentational symptoms of aortic stenosis?
Chest pain Exertional syncope Heart failure Dyspnoea Dizziness
Signs:
- Ejection systolic murmur - crescendo decrescendo
- slow rising pulse
- narrow pulse pressure
- Heaving
- LBBB
- Complete AV block
- LVH strain
Management:
- valvular replacement
- TAVI
Name some signs seen with aortic regurgitation:
Externational dyspnoea
palpitation
Syncope
High pitched early diastolic murmur Collapsing pulse Wide pulse pressure Hyperdynamic apex beat Head nodding - Musset's sign Pistol shot over the femorals
Cardiomegaly
pulmonary oedema
How is aortic regurgitation assessed?
How is it managed?
Diagnosed via echocardiogram with doppler
Assessed for severity using cardiac catheterization
Control hypertension - ACE Echo every 6-12 months Valvular replacement - if severe - enlarging - Deterioration in LV functioning
What are features of pericarditis pain?
What are some clinical findings of pericarditis?
Direct retrosternal pain Pain relieved by sitting forward No Pain related to activity Pain is worse on deep inspiration Fever may also accompany
Pericardial Rub
ECG - ST elevation across all leads
QRS Alterna
