Cardiology Flashcards
What are the causes of bradycardia?
DIVISION Drugs - beta blockers - Digoxin - Ca2+ blockers
Iscehmia
Vagal tone
Infection
- Infective endocarditis
Sick Sinus Syndrome
Infiltrative
- sarcoidosis
- Amyloid
O
- Hypothyroidism
- Hypokalemia
Neuro
- ICP
If a person is only started on rate control for AF, what else must the be prescribed?
Anti-coagulation
DOAC
or
Warfarin for valvular disease
What is the target HR in AF?
<90bpm
What are the complications of hypertension?
CANER
- Cardio
- Aorta
- Neuro
- Eyes
- Renal
What clinical signs may you find of hypertension?
Ventricular heave 4th heart sound Abdominal bruits enlarged kidneys Radiofemoral delay
What is the management for Mitral stenosis?
Balloon Valvotomy
Anticoagulation
Beta blockers
Diuretics - to reduce pressure on atrium
What are the major causes of Dyslipidemia?
Predominantly hypercholesterolaemia
- primary: - Familial - loss of ApoB100
- Secondary: Nephrotic syndrome And Hypothyroidism
Predominantly Triglyceridemia/ mixed:
- primary: - Lipoprotein Deficiency
- Secondary: - Diabetes, central obesity
In a lipid profile, what is investigated?
Total cholesterol
HDL
LDL
Fasting triglycerides
What is the treatment for hyperlipidaemia?
Remove underlying causes
- hypothyroidism
- Diabetes
Lifestyle changes
1st: Atorvastatin
2nd: Ezetimibe
3rd: alirocumab
Hypertriglyceridemia:
1st: Fibrates
Which Valvular abnormality gets a TAVI?
Aortic Stenosis
What additional tests should be done into HTN?
Bloods:
• U&Es
- Assess renal damage
- Low K+ would also suggest primary aldosteronism
* Serum total cholesterol and HDL cholesterol * TFTs * Serum glucose
Orifices: • Urinalysis - Proteins - Blood - Glucose
ECG:
Consider secondary causes:
- Cortisol
- metadrenalines
- renal ultrasounds
Following a PCI, if a patient develops severe chest pain, what should be done?
There can be failure of the procedure.
CABG needs to be considered
What measuring device can be put in place to measure the filling pressures of the heart - which are useful for assessing the type of shock someone is in?
Pulmonary artery catheter
Name some differentials for a P.E:
Pneumothorax
Pneumonia
Unstable Angina
Asthma
Pericarditis
What are some potential findings of P.E on x-ray?
Wedge shaped opacity
Enlarged pulmonary artery
Pulmonary opacities
Pleural effusion
What is the ABG likely to show on a P.E?
Respiratory alkalosis
In massive P.Es you may get mixed metabolic acidosis due to hemodynamic collapse
What are the complications of mitral stenosis?
Pulmonary hypertension
AF
Dysphagia
laryngeal palsy
What are the symptoms of a mitral valve prolapse and what are some complications of it?
Sudden onset breathlessness
Atypical chest pain
Palpitation
Anxiety attack
Complications:
- Mitral regurgitation
- Arrhythmias
What are the causes to cardiogenic shock?
MI HEART
MI Hyperkalemia Endocarditis Aortic dissection Rhythm disturbance Tamponade
What are the signs of a cardiac tamponade?
Beck’s signs:
- raised JVP - during inspiration
- Muffled heart sounds
- Low BP
Kussmaul’s breathing
Pulsus paradoxus
What additional investigation can be done in AF to rule out thrombosis formation?
Transesophageal echocardiogram
Why is spironolactone used in heart failure?
Has been showing to increase life expectancy
- 30% reduced mortality
What should be checked prior to starting someone on an ACE inhibitor?
Renal function
- not recommended in AKI
- Renal stenosis contraindicated
- if serum creatinine rises should be withheld
Electrolytes
- increases K+
What are the cardinal changes on ECG that are seen for a full thickness MI?
ST elevation in two continuous leads
- Chest leads > 2mm (2 small boxes)
- Limb leads >1mm (1 small box)
Q - waves
T Waves
Reciprocal are not cardinal
In heart failure what are you looking for on ECHO?
Ejection fracture and peak velocity
Valvular abnormalities
Wall thickness
Heart size
Other than medications, what treatments should be implemented into heart failure?
Low Salt intake Low restriction Rehabilitation exercise programs Low fat diet Weight loss Education
Why should IV drugs be used in severe hypotension?
Reduced absorption from SC or G.I or Rectal if low perfusion
What are the features of pericarditis?
Sharp
Central
Worse when leaning back
What are some causes of pericarditis?
Autoimmune
Dressler’s
Infection
Uraemia
With acute onset breathlessness in LV failure, what questions do you want to ask?
Is it made worse lying down? Normal level of exercise? Sputum? Syncope? Chest pain?
What will an ECG of aortic stenosis show on ECG?
Left ventricular hypertrophy
Left axis deviation
What are the two types of electric shock delivered, and when is what given?
DC synchronised cardioversion
- timed with QRS - for downslope of Q wave
Defibrillation
- given at any point through cardiac cycle.
Cardioversion used when:
- AF
- Atrial flutter
- VT WITH pulse but unstable
Defibrillation
- VF
- VT WITHOUT a pulse
How long does Dressler’s take to present?
Few weeks.
- there will be fever as well
If there is symptoms consistent with pericarditis following M.I within a few days it is simply pericarditis
How can you differentiate between JVP and carotid and what things will cause it to rise?
2 waves form
Hepatojugular reflux
Non- palpable pulse
Heart failure
Fluid overload
Constrictive pericarditis
Tamponade
What are the signs of Pericarditis?
Pleuritic central pain
Worse on:
- inspiration
- Lying back - lean forward for relieve
Pericardial friction rub
Fever
ECGs:
- ST saddle shape
- PR depression
Why do heart failure patients get worse symptoms at night?
- Lying flat allows fluid to build up
- Reduced respiratory effort due to sleep - allows saturations to change more drastically and more shallow breathes
- Less adrenaline levels - less cardiac output - worse heart failure
Specifically what BNP is monitored for in heart failure? and what additional tests should be done?
N terminal Pro-B type natriuretic / NT proBNP
ECG
Echocardiogram
In heart failure, who should not get ACE inhibitors?
Valvular disease patients
What are the grades of a murmur?
Grade 1: Difficult to hear
Grade 2: Quiet
Grade 3: Easy to hear
Grade 4: Easy to hear with palpable thrill
Grade 5: Can hear it with stethoscope just touching
Grade 6: Without stethoscope
Outwith CT angiogram what other investigations can be done into angina?
Stress echo
Stress ECG
Myocardial perfusion scans
CT calcification
List some causes of non cardiac progressive breathlessness
Anemia COPD Lung cancer Interstitial lung disease Pleural effusion Sarcoidosis
In HTN, what does Left ventricular hypertrophy demonstrate?
End organ failure
- heart is struggling
What is the INR target for AF when anticoagulation with warfarin?
2-3
What can falsely lower BNPs?
Beta blockers
ACE
Aldosteronism antagonists
Obesity
What are the shockable rhythms?
VT - which will be pulseless
VF - which will also be pulseless
What are some causes of RBBB?
Can Be normal
Pulmonary hypertension
P.E
M.I
Cardiomyopathy
Fibrosis
Chagas disease
What are some causes of LBBB?
Aortic stenosis
Hypertension
M.I
Severe coronary artery disease
When shocking someone, why is the shock delivered on the QRS?
It is an easily definable mark to be shocked on and ensure not shocking on T wave - which would cause VF
What is the management for long term VT?
Implantable cardiac defibrillator
What drugs can be used for rhythm control of AF?
Beta blockers
Flecainide
Sotalol - actually works by class III action - K+
Amiodarone
What are the different classifications of AF?
Acute - first presentation
Paroxysmal - terminates within 7 days
Persistent - requires cardioversion to stop
Permanent - does not terminate. Requires rate control
What factors should be considered when thinking about cardioverting someone from AF?
How well the arrhythmia is tolerated
Whether anticoagulation is required
Whether spontaneous cardioversion is likely
Whether cardioversion is likely to work
If AF >48 hours what is the anticoagulation times?
3 weeks before
4 weeks afterwards
Who is typically considered for rhythm control in AF?
Younger patients
Symptomatic patients
Active patients
Recurrent paroxysmal
How can the rate limiting effect in AF be assessed?
ECG holder
Exercise stress test
What maneuver can be done to expose F waves seen in atrial flutter?
Carotid massage
or
Adenosine
If a young person has RBBB and stroke what is the likely defect?
Patient Foramen ovale
A raised JVP during inspiration is called? and is associated with what?
Kussmaul sign
Cardiac tamponade
What are the first signs on ECG of M.I?
Hyperacute T waves
- the T waves will then flip afterwards - usually within 24 hours.
Q waves begin usually after 24 hours and last for a long time
Why should statins be stopped during pregnancy?
Cholesterol is essential for the fetus
Whats the most common cause of death in M.I?
VF
What are some causes of Prolonged QT?
Hypokalaemia Hypomagnesaemia Hypocalaemia Macrolides Quinolones Amiroadone M.I
What is the presentation of mitral stenosis? and how should it be investigated?
AF Pulmonary hypertension - dyspnea - frothy bloody sputum Right heart failure
Investigations:
- CXR
- ECG
- Echocardiogram
How can the murmur of mitral stenosis be described?
Splitting of the S2 with diastolic low rumble
The 2nd S2 sound is actually the snapping opening of the mitral valve.
What is the most common cause of aortic stenosis?
Calcific Aortic Valvular Disease
Bicuspid Aortic Valve
Rheumatic fever
When analysing an echocardiogram for aortic stenosis, what things are you looking for?
Valvular calcification
Left ventricular hypertrophy
Peak velocity of outflow
What is pulsus alternans? and what does it signify?
It is where there is a strong contraction and then a weak contraction.
- associated with severe myocardial failure.
May seen on blood pressure monitoring changes as much as 50mmHg
What things may cause a soft S1 sound?
Mitral regurgitation Shock Heart Failure Obesity Emphysema
What murmur may be associated with aortic stenosis and what is it? and what can it be mistaken for and how is that resolved?
Gallavardin phenomenon
- where there is a musical like radiation to the apex
Often mistaken for Mitral regurgitation
Can be differentiated because mitral regurgitation radiates to the axilla
What are the signs of aortic regurgitation?
Collapsing pulse Wide pulse pressure Capillary Pulsation Head nodding with each heart beat Pistol shot femoral
**high pitched over the left sternal edge 4th intercostal space
What murmur is associated with Aortic regurgitation?
Austin Flint murmur
How does aortic dissection present?
Sever pain radiating to the back Hypertension **differentiates from AAA Reduced pulses peripherally Different pulses on limbs Aortic regurgitation (present with type A)
What is the diagnostic investigation and what medical management for an aortic dissection?
CT angiogram of thorax and abdomen
Maintain a low blood pressure
- beta blocker - labetalol IV
- GTN IV
- Contact cardio-thoracic surgeons
What blood tests do you want for a suspected P.E?
FBC - infection? ABG D-dimers U&Es - for contrast use Coagulation screen ESR
Prevention of a P.E can be achieved via:
LMWH
Enoxaparin
Stockings
Early mobilisation
ERAS
IVC filters
When should diabetics be started on hypertensive medication?
Home ambulatory >135/85
What are some of the complications of infective endocarditis?
Stroke
Congestive heart failure
P.E
AKI
- with nephritic syndrome
Splenic infarction
Septic arthritis
When is surgery indicated for Infective endocarditis?
Signs of heart failure
Multiple septic emboli
Abscess formation
Obstruction of the valve
Persistent positive cultures
What is the wanted antibiotics for prosthetic valve endocarditis?
Vancomycin \+ Gentamicin \+ Rifampin
How can you distinguish a pericardial rub from a pleuritic rub?
Ask the patient to hold their breath
When is a cardiac rupture most likely to occur following an M.I?
3-7 days
- due to macrophage involvement of the removal of necrotic tissues
**most common an anterior rupture due to LAD involvement
Why is there pain to the left arm during an MI?
T1 dermatomal distribution
Who receives eplerenone following an M.I?
Diabetic patients
Ejection fraction <40%
