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Medicine finals > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Define heart failure

A

The inability of the heart to pump adequate amounts of blood to meet the body’s metabolic demands

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2
Q

What are the signs and symptoms of heart failure?

A

SOB (esp lying flat and on exertion)
Fatigue
Ankle oedema
Cough - frothy pink sputum

Hepatomegaly
Tachycardia
Tachypnoea
Raised JVP

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3
Q

What are the two main types of heart failure?

A

HF-PEF (preserved ejection fraction)

HF-REF (reduced ejection fraction)

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4
Q

What blood test is used to diagnose HF?

A

NT-proBNP (>2000 requires urgent referral)

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5
Q

What investigations are needed in patients with HF?

A

ECHO
ECG
CXR
NT-proBNP

(FBCs, U&Es, LFTs, TFTs, HbA1c)

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6
Q

What are the signs of heart failure that are seen on CXR?

A

Cardiomegaly
Kerly B lines
Upper lobe diversion
Pleural effusions

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7
Q

How can heart failure be classified?

A

New York Heart Association (NYHA) Classification of Heart Failure

Grade 1: No limitation of function
Grade 2: Slight limitation - moderate exertion causes symptoms
Grade 3: Marked limitation - mild exertion causes symptoms
Grade 4: Severe limitation - any exertion causes symptoms (may have symptoms at rest)

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8
Q

What are the complications of heart failure?

A

Muscle undwrperfusion - muscle weakness and atrophy –> fatigue, exercise intolerance and dyspnoea

Increased risk of thromboembolism and stroke

Arrhythmias - AF is most common, VT can occur in advanced HF

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9
Q

Describe the management of heart failure

A

Exercise, smoking cessation, salt and fluid restrict

ACEi and B-blocker
Aldosterone antagonist (spironolactone)
Loop diuretics - furosemide improves symptoms

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10
Q

For patients with HF, what needs to be routinely checked and why?

A

U&Es

Diuretics, ACEi and aldosterone antagonists can cause electrolyte disturbances

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11
Q

What treatments in HF improve prognosis?

A

ACEi

Beta-blocker

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12
Q

What can be used to treat AF in patients with HF?

A

Digoxin

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13
Q

Although Ca channel blockers are no longer routinely used in the management of HF, what Ca channel blocker can be used?

A

Amlodopine

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14
Q

What is the step-wise approach in the management of HF?

A 
ACEi/ARB 
\+ Diuretic
\+ Beta-blocker
\+ Aldosterone antagonist
\+ Digoxin
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15
Q

Describe the management of acute heart failure

A 
Sit up 
100% O2 flow
2 puff GTN 
IV opiates - reduce anxiety, reduce preload
IV furosemide - reduce fluid retention
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16
Q

What implantable devices can be used in the management of HF?

A

Pacemaker
ICD
Left ventricular assist devices

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17
Q

What are the effects of AF?

A

Irregularly irregular ventricular contraction
Tachycardia
Heart failure due to poor filling of the ventricles during diastole
Risk of stroke

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18
Q

How can AF present?

A 
Asymptomatic 
Palpitations
SOB
Syncope
Symptoms of associated conditions (stroke, sepsis, thyrotoxicosis)
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19
Q

What two differential diagnoses are there for an irregularly irregular pulse?

A

AF

Ventricular ectopics

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20
Q

How can AF and ventricular ectopics be differentiated between?

A

Ventricular ectopics will disappear when the HR goes above a certain threshold

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21
Q

What are the signs associated with AF seen on an ECG?

A

Absent T waves
Narrow QRS complex tachycardia
Irregularly irregular ventricular rhythm

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22
Q

What is valvular AF?

A

Patients with AF who also have moderate/severe mitral stenosis or a mechanical heart valve

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23
Q

What are the most common causes of AF?

A 
Sepsis
Mitral valve pathology (stenosis/regurgitation)
Ischaemic heart disease
Thyrotoxicosis
Hypertension
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24
Q

What are the two principles of treating AF?

A

Rate/rhythm control

Anticoagulation to prevent stroke

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25
Q

Why is rate control important in the management of treating AF?

A

Atria normally pump blood into ventricles

In AF, atrial contractions are uncoordinated therefore ventricles have to fill up by suction and gravity

The higher the heart rate, the less time available for the ventricles to fill with blood and the lower the cardiac output

Reducing the heart rate below 100 increases the time in diastole which increases the time available for the ventricles to fill with blood

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26
Q

What group of patients should not have rate control as first line management of their AF?

A

Reversible cause of their AF
Their AF is new onset (within last 48 hours)
Their AF is causing heart failure
They remain symptomatic despite being effectively rate controlled

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27
Q

What are the options for rate control?

A 
Beta blocker (atenolol) 
Calcium channel blocker (diltiazem)
Digoxin
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28
Q

What is the aim of rhythm control?

A

Return patient to normal sinus rhythm

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29
Q

When can immediate cardioversion be considered?

A

AF has been present for less than 48 hours or severely haemodynamically compromised

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30
Q

When is delayed cardioversion required?

A

AF has been present for >48 hours and they are stable

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31
Q

Prior to delayed cardioversion, how long should a patient be anti coagulated for?

A

3 weeks

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32
Q

What are the pharmacological options of cardioversion?

A

Flecanide

Amiodarone

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33
Q

What are the possible longterm medical rhythm control options?

A

Beta blockers
Dronedarone
Amiodarone

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34
Q

Define paroxysmal AF

A

AF comes and goes in episodes, usually last <48 hours

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35
Q

Describe the ‘pill in the pocket’ approach to managing paroxysmal AF

A

Take flecanide when they feel the symptoms of AF starting

must have no underlying structural heart disease

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36
Q

Why must flecanide be avoided in atrial flutter?

A

Can cause 1:1 AV conduction

Results in significant tachycardia

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37
Q

Why is anticoagulation important in AF?

A

Uncontrolled and uncoordinated movement of atria causes blood to stagnate in the left atrium - particularly atrial appendage

Stagnant blood –> thrombus

Thrombus –> embolus

Embolus: atria –> ventricles –> aorta –> carotid arteries –> ischaemic stroke

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38
Q

What measure of the clotting cascade is extended by warfarin?

A

PT

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39
Q

What has to be measured routinely in patients taking warfarin?

A

INR

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40
Q

What is the targeted INR in patients taking warfarin for AF?

A

2-3

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41
Q

What are the potential benefits of DOACs compared to Warfarin?

A

No monitoring required
No major interaction problems
Equal/slightly better at prevent strokes in AF
Equal/slightly less risk of bleeding

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42
Q

What score is used to assess whether a patient with AF requires anticoagulation?

A

CHA2DS2-VASc

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43
Q

What are the components of the CHA2DS2-VASc score?

A 
Congestive heart failure
Hypertension
Age > 75 (score 2) 
Diabetes
Stroke/TIA previously (score 2)
Vascular disease
Age 65-74
Sex (female)
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44
Q

What CHA2DS2-VASc score recommends coagulation?

A

> 1

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45
Q

What assessment tool can be used to assess the risk of a patient bleeding whilst taking anticoagulation?

A

HAS-BLED

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46
Q

What are the components of the HAS-BLED score?

A 
Hypertension
Abnormal renal/liver function
Stroke
Bleeding
Labile INRs
Elderly
Drugs or alcohol
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47
Q

What does the left coronary artery become?

A

Circumflex artery

Left anterior descending artery

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48
Q

What areas of the heart are supplied by the right coronary artery?

A

Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area

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49
Q

What areas of the heart are supplied by the circumflex artery?

A

Left atrium

Posterior aspect of left ventricle

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50
Q

What areas of the heart are supplied by the left anterior descending artery?

A

Anterior aspect of left ventricle

Anterior aspect of septum

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51
Q

What are the ECG changes associated with a STEMI

A

ST segment elevation

New LBBB

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52
Q

What ECG changes are associated with a NSTEMI

A

ST segment depression
Deep T wave inversion
Pathological Q waves

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53
Q

What area of the heart is supplied by the Left Coronary Artery?

A

Anterolateral

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54
Q

What ECG leads depict the left coronary artery?

A

I, aVL, V3-6

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55
Q

What area of the heart is supplied by the LAD?

A

Anterior

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56
Q

What ECG leads depict the LAD?

A

V1-4

57
Q

What area of the heart is supplied the circumflex artery?

A

Lateral

58
Q

What ECG leads depict the circumflex artery?

A

I, aVL, V5-6

59
Q

What area of the heart is supplied by the right coronary artery

A

Inferior

60
Q

What ECG leads depict the right coronary artery?

A

II, III, aVF

61
Q

What is a rise of troponin consistent with?

A

myocardial ischaemia

62
Q

What are potential causes of raised troponins?

A 
ACS
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
63
Q

In a patient with suspected ACS, what investigations should you organise?

A 
Bloods: FBCs, U&amp;Es, LFTs, lipids, TFTs, HbA1c
ECG
CXR
ECHO
CT angiogram
64
Q

What are the two options for treating an acute STEMI?

A

Primary PCI

Thrombolysis

65
Q

What is the premise for the treatment of an acute STEMI

A 
Morphine
Oxygen (if O2 sats <95%)
Nitrates (GTN)
Aspirin 300mg
Tricagrelor (180mg)
66
Q

What score can be used to assess the 6-month risk of a patient dying or having a repeated MI after having a NSTEMI?

A

GRACE score

medium to high risk consider early PCI

67
Q

What are complications of MI?

A 
Death
Rupture of heart septum/papillary muscles
Oedema
Arrhythmia and aneurysm
Dressler's syndrome
68
Q

What is Dressler’s syndrome?

A

Post-myocardial infarction syndrome

Occurs 2-3 weeks post MI

Localised immune response –> pericarditis

69
Q

How may a patient present with Dressler syndrome?

A

Pleuritic chest pain
Low grade fever
Pericardial rub

70
Q

What can Dressler syndrome cause?

A

Pericardial effusion

Pericardial tamponade

71
Q

How can a diagnosis of Dressler syndrome be made?

A

ECG (global ST elevation an T wave inversion)
ECHO (pericardial effusion)
Raised CRP and ESR

72
Q

How can Dressler syndrome be managed?

A

NSAIDs
Steroids

May require pericardiocentess

73
Q

What are the secondary prevention methods of MIs?

A 
Aspirin (75mg)
Another antiplatelet 
Atorvastatin
ACE inhibitors
Atenolol 
Aldosterone antagonist (clinical heart failure)
74
Q

What is a type 1 MI?

A

Acute coronary event

75
Q

What is a type 2 MI?

A

Ischaemia secondary to increased demand or reduced supply of oxygen

76
Q

What is a type 3 MI?

A

Sudden cardiac death

77
Q

What is a type 4 MI?

A

Associated with PCI, coronary stenting, CABG

78
Q

What is the most common cause of left axis deviation?

A

Defects of the conduction system

79
Q

The duration of the PR interval is noted to become increasingly prolonged. In addition, the QRS complexes appeared to be dropped at regular intervals. What diagnosis does this suggest?

A

Second degree Mobitz type 1

80
Q

What is the normal duration of a PR interval?

A

0.12-0.2 seconds (3-5 small squares)

81
Q

What can a shortened PR interval suggest?

A

Accessory pathway between the atria and the ventricles (Wolff Parkinson White Syndrome)

82
Q

What is the normal duration of the QRS complex?

A

0.12 seconds (3 small squares)

83
Q

What is a common cause of right axis deviation?

A

Right ventricular hypertrophy

84
Q

What is the often the earliest sign seen in an ECG during a myocardial infarction?

A

Tall peaked T waves

85
Q

Give some risk factors for the development of infective endocarditis

A

Valvular damage:
Previous rheumatic heart disease
Age related valvular degeneration
Prosthetic valve

IV drug user

86
Q

In what circumstances is a diagnosis of endocarditis given until proven otherwise?

A

New murmur and fever

87
Q

Describe the acute presentation of endocarditis

A 
Fever and new heart murmur
Petechiae
Haematuria
Rigors
Night sweats
Splinter haemorrhages
Nail fold infarcts
Roth spots
Embolic incidents
Malaise
88
Q

What type of people are likely to present with a subacute presentation of infective endocarditis?

A

Known congenital or valvular disease

89
Q

What type of organism can cause a subacute presentation of endocarditis along with hepatosplenomegaly?

A

Coxiella

90
Q

What are the potential causative agents of infective endocarditis?

A 
S. vidians - most common 
S.aureus
S.bovis - need colonoscopy ?tumour 
Q fever 
HACEK (haemophilus, actinobacillus, Cardiobacterium, kingella, eikenella) 
Brucella 
Yeasts
91
Q

How can infective endocarditis be diagnosed?

A

Duke Criteria

92
Q

What are the Major Duke Criteria?

A

Positive blood culture for infective organism (on 2 separate tests)
Evidence of IR from other tests (Echo - strictures, unusual blood flow, implanted/unusual material)
New valve regurgitation

93
Q

What are the minor Duke criteria?

A 
Fever >38
Predisposed to IE
Unusual ECHO 
Immunological factors present (Roth spots, Osler nodes, GN, RF)
Blood cultures positive 
Vascular abnormalities
94
Q

What type of ECHO should be used if a patient has prosthetic valves?

A

TOE

95
Q

What antibiotics can be given in an acute presentation of IE?

A

Flucloxacillin

Gentamicin

96
Q

What antibiotics an be given in a sub-acute presentation of IE?

A

Benzylpenicillin

Gentamicin

97
Q

What antibiotics can be given If a patient has a prosthetic valve or resistant organism in IE?

A

Vancomycin
Gentamicin
Rifampicin

98
Q

What are indications for surgery in patients with IE?

A 
IE resistant to antibiotic treatment
Fungal disease resistant to treatment
IE causing embolic events
IE causing CHF
Severe structural damage on echo
99
Q

What is the aetiology of IE?

A

Damaged endocardium –> platelet and fibrin deposition –> organism adhere and grow –> infective vegetation

100
Q

What valves are most commonly affected in IE?

A

Aortic and mitral valves

101
Q

In IVDU, what side of the heart is most commonly affected in IE/

A

Right

102
Q

What are the 4 cardiac arrest rhythms and which are shockable?

A

VT and VF - shockable

Pulseless electrical activity and asystole

103
Q

How should an unstable patient with a tachycardia be treated?

A

Up to 3 synchronised shocks

Consider amiodarone infusion

104
Q

What are the three narrow QRS complex tachycardias?

A

Atrial fibrillation
Atrial flutter
SVT

105
Q

How should a stable patient with tachycardia due to atrial fibrillation be treated

A

Rate control with beta-blocker or diltiazem

106
Q

How is atrial flutter treated?

A

Rate control with beta blocker or cardioversion
Treat underlying cause
Radiofrequency ablation of the re-entry rhythm
Anticoagulation depending on CHA2DS2VASc score

107
Q

How should a ventricular tachycardia causing a broad QRS complex tachycardia be treated?

A

Amiodarone infusion

108
Q

What is the atrial contraction rate in atrial flutter?

A

300bpm

109
Q

What is the ventricular contraction rate in atrial flutter?

A

150bpm

110
Q

What is the classical appearance of atrial flutter on ECG?

A

Saw tooth

111
Q

What conditions are associated with atrial flutter?

A

HTN
Ischaemic heart disease
Cardiomyopathy
Thyrotoxicosis

112
Q

What is the process behind SVT?

A

Electrical signal re-enters the atria from the ventricles

Signal travels back through the AV node into ventricles

113
Q

What is paroxysmal SVT?

A

SVT reoccurs and remits in the same patient over time

114
Q

What are the three main types of SVT?

A
  1. Atrioventricular nodal re-entrant tachycardia - re-entry point is through the AV node
  2. Atrioventricular re-entrant tachycardia - re-entry is through an accessory pathway
  3. Atrial tachycardia - electrical signal originates in the atria but somewhere other to the SA node
115
Q

How should a stable patient with SVT be managed?

A

Continuous heart monitoring

  1. Valsalva manoeuvre
  2. Carotid sinus massage
  3. Adenosine (or verapamil if contraindicated)
  4. Direct current cardioversion
116
Q

In what patients should adenosine be avoided?

A 
Asthma
COPD
Heart failure
Heart block 
Severe hypotension
117
Q

What doses of adenosine can be used in the management of SVT’;

A

6mg –> 12mg –> 12mg

118
Q

How can patients with paroxysmal SVT be managed on a LT basis?

A

Medication - beta-blocker, ca channel blockers, amiodarone

Radiofrequency ablation

119
Q

What is the accessory pathway in Wolff-Parkinson-White commonly known as?

A

Bundle of Kent

120
Q

What is the definitive treatment of Wolff-Parkinson-White syndrome?

A

Radiofrequency ablation of the accessory pathway

121
Q

What ECG changes are associated with Wolff-Parkinson-White Syndrome?

A

Short PR interval (<0.12s)
Wide QRS complex (>0.12s)
Delta wave

122
Q

When can radio frequency ablation be curative?

A

AF
Atrial flutter
SVT
WPW syndrome

123
Q

What type of tachycardia is Torsades des pointes?

A

Polymorphic ventricular tachycardia

124
Q

What happens to the height of the QRS complex in Torsades des Pointes?

A

Progressively get shorter then longer

125
Q

In what patients can Torsades des Pointes occur?

A

Prolonged QT

126
Q

What can Torsades des Pointes revert into?

A

VT

127
Q

What are causes of a prolonged QT?

A

Long QT syndrome
Drugs
Electrolyte disturbances - hypokalaemia, hypomagnesaemia, hypocalcaemia

128
Q

What drugs can cause prolonged QT?

A 
Anti psychotics
Citalopram
Flecainide
Sotalol
Amiodarone
Macrolide antibiotics
129
Q

What is the acute management of Torsades des Pointes?

A

Correct the cause
Magnesium infusion
Defib if VT occurs

130
Q

What is the long term management of Torsades des Pointes?

A

Avoid medications that prolong QT interval
Correct electrolyte disturbance
Beta blockers
Pacemaker or implantable defibrillator

131
Q

What is the appearance of a ventricular ectopic on ECG?

A

Individual random, abnormal, broad QRS complexes on a background of a normal ECG

132
Q

Describe first degree heart block

A

Delayed atrioventricular conduction through AV node
Every atrial impulse leads to a ventricular contraction
PR interval >0.2s

133
Q

Describe second degree heart block

A

Some of the atria impulses do not make it through the AV node
There are instances where p waves do not lead to QRS complex

134
Q

Describe Mobitz type I heart block

A

Atrial impulses get weaker until it doesn’t pass through the AV node
The cycle then repeats

135
Q

Describe Moritz type 2 heart block

A

Intermittent failure or interruption of AV condition
Missing QRS complexes
Usually a set ratio of p waves to QRS complexes
Risk of asystole

136
Q

What is 3rd degree heart block

A

Complete heart block
No observable relationship between p waves and QRS complexes
Significant risk of asystole

137
Q

What is the treatment of bradycardia/AV node blocks if the patient is stable?

A

Observe

138
Q

What is the treatment of bradycardia/AV node blocks if the patient is unstable or at risk of asystole?

A

Atropine IV

Atropine up to 6 doses, other inotropes, transcutaneous cardiac pacing

139
Q

What are some side effects of atropine?

A

(Antimuscarinic - inhibits PNS)

Constipation
Urinary retention
Pupil dilatation
Dry eyes

Medicine finals (12 decks)

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