Cardiology Flashcards
1
Q
Causes Acute Pericarditis
A
Idiopathic
Secondary to infection, autoimmune (SLE, RA, Takayasu, IBD), drugs (eg isoniazid, hydralazine), uraemia, anorexia nervosa, MI
2
Q
Central chest pain worse on inspiration/lying flat, relieved by sitting forwards
A
Acute pericarditis
3
Q
ECG Acute Pericarditis
A
concave/saddle shaped ST elevation and PR depression
4
Q
Management Acute Pericarditis
A
NSAIDs/Aspirin 1-2wks
Colchicine reduces risk of recurrence
5
Q
What is Pericardial Effusion
A
Accumulation of fluid in the pericardial sac
6
Q
Causes of Pericardial effusion
A
pericarditis, myocardial rupture, aortic dissection, malignancy
7
Q
ECG + CXR + Echo finding pericardial effusion
A
ECG: low-voltage QRS
CXR: enlarged globular heart
Echo: echo-free zone surrounding heart
8
Q
Management pericardial effusion
A
Treat the cause
Pericardiocentesis (+culture, stain, cytology)
9
Q
What is Cardiac Tamponade?
A
A pericardial effusion that increases intrapericardial pressure, reducing ventricular filling, dropping cardiac output, can cause cardiac arrest
10
Q
Signs on examination of Cardiac tamponade
A
Tachycardia, Hypotension, Pulsus paradoxus, raised JVP
11
Q
Diagnostic criteria of Cardiac Tamponade
A
Beck’s triad:
- Falling BP
- Rising JVP
- Muffled heart sounds
12
Q
ECG + Echo finding of Cardiac Tamponade
A
ECG: low-voltage QRS
Echo: diagnostic, echo-free zone around heart +/- diastolic collapse of RA + RV
13
Q
Management of Cardiac Tamponade
A
Urgent drainage- Pericardiocentesis
14
Q
What size defines AAA?
A
> 3cm across
15
Q
What is the aetiology of AAA?
A
Degeneration of elastic lamellae and smooth muscle loss
16
Q
Screening for AAA?
A
All men aged 65+ offered screening with USS
17
Q
Management of AAA?
A
Surgery for large/rapidly expanding/symptomatic >5.5cm
Endovascular stenting
Emergency if rupture
18
Q
Presentation of ruptured AAA
A
Intermittent/continuous abdominal pain radiates to back/iliac fossa/groin
Expansile abdominal mass
Shock
19
Q
Management ruptured AAA
A
Rapid surgery
20
Q
Define critical ischaemia in PAD
A
Ulceration + Gangrene + Foot pain at rest
21
Q
Fontaine classification of Peripheral arterial disease
A
- Asymptomatic
- Intermittent claudication
- Ischaemic rest pain
- Ulceration/Gangrene
22
Q
Investigations of PAD
A
Ankle-brachial pressure index
Colour Doppler USS 1st line
23
Q
Management PAD
A
RF modification (smoking, treat HTN + cholesterol, antiplatelet eg Clopidogrel)
Claudication: supervised exercise programme, Vasoactive drugs eg Naftidofuryl oxalate
Percutaneous transluminal angioplasty
Surgical reconstruction
Amputation
24
Q
Mid-diastolic murmur, with AF and malar flush
A
Mitral Stenosis
25
Causes of Mitral Stenosis
Rheumatic heart disease, infective endocarditis
26
Pansystolic high-pitched murmur, radiates to left axilla, 3rd heart sound
Mitral regurgitation
27
Causes of Mitral regurgitation
Age, ischaemic heart disease, infective endocarditis, rheumatic heart disease, Ehler-Danlos, Marfan's
28
Ejection-systolic murmur with crescendo-decrescendo character, radiates to carotids, slow rising pulse and narrow pulse pressure
Aortic Stenosis
29
How might Aortic Stenosis present?
Exertional Syncope
30
Causes of Aortic Stenosis?
Age, Rheumatic heart disease
31
Early diastolic soft murmur, collapsing pulse
Aortic Regurgitation
32
Causes of Aortic Regurgitation
Age, Ehler-Danlos, Marfan's
33
What is Dilated Cardiomyopathy associated with?
Alcohol, haemochromatosis, autoimmune thyrotoxicosis, congenital (X-linked)
34
What is the possible inheritance of congenital DCM?
X-linked
35
Presentation of DCM
Fatigue, dyspnoea, pulmonary oedema, RVF, emboli, AF, VT
36
Signs on examination of DCM
Tachycardia, Hypotension, raised JVP, displaced apex, ascites
37
Possible blood test in DCM
Raised BNP
38
CXR findings of DCM
Cardiomegaly, Pulmonary oedema
39
ECG findings of DCM
Tachycardia, T wave changes, poor R wave progression
40
Echo findings of DCM
Globally dilated hypokinetic heart
41
Management of DCM
Diuretics, Beta blockers, ACEi, anticoagulation, biventricular pacing, ICDs
42
What is Hypertrophic cardiomyopathy?
LV outflow obstruction from asymmetric septal hypertrophy
43
What is the leading cause of cardiac death in the young?
Hypertrophic cardiomyopathy
44
What is the inheritance pattern of Hypertrophic cardiomyopathy?
Autosomal Dominant
45
Presentation of Hypertrophic cardiomyopathy
Sudden death
| Angina, dyspnoea, palpitations, syncope, CCF
46
Examination findings of Hypertrophic cardiomyopathy
Ejection systolic murmur, systolic thrill at left lower sternal edge
47
ECG findings of Hypertrophic cardiomyopathy
Progressive T wave inversion, deep Q waves, AF, WPW, VT
48
Echo findings of Hypertrophic cardiomyopathy
Asymmetrical septal hypertrophy
49
Management of Hypertrophic cardiomyopathy
Implantable defibrillator
Amiodarone for arrhythmias
BB/Verapamil for symptoms
50
Investigations in chest pain
ECG, Blood glucose, Lipid profile, U&E, FBC, TFT, LFT, ESR/CRP, CXR
51
Cardiac causes chest pain
ACS, stable angina, pericarditis, acute congestive cardiac failure, arrhythmias
52
Pulmonary causes of chest pain
PE, pneumothorax, CAP, Asthma, lung Ca, Pleural effusion
53
Complications of MI
Cardiac arrhythmias, LV failure, Heart block, VT/VF, RV failure, Pericarditis, mitral regurg, ventricular septal defect, Dressler's syndrome
54
What is Dressler's syndrome?
Late-onset post-myocardial infarction pericarditis, usually occurring one to six weeks after the initial event
55
How does Dressler's syndrome present?
Pleuritic chest pain, low-grade fever and pericarditis
56
Presentation of Aortic Dissection
Sudden tearing chest pain radiating to back
| Branches of aorta occlude --> hemiplegia, unequal arm pulses/BP, acute limb ischaemia
57
Types of Aortic Dissection and their management
Type A- ascending aorta- surgical Mx
| Type B- not ascending aorta- medical/surgical Mx
58
Causes of Hypertension
```
95% Essential Hypertension
ROPE
Renal disease- renal artery stenosis
Obesity
Pregnancy
Endocrine- Conn's (renin:aldosterone ratio)
```
59
Complications of Hypertension
Retinopathy, Nephropathy, HF, CVA
60
Stages of Hypertension
Stage 1: clinic > 140/90 or home > 135/85
| Stage 2: clinic > 160/100 or home > 150/95
61
Steps of Hypertension management
1. Age < 55 non-black- ACEi OR >55 black- CCB
2. Non-black ACEi + CCB; Black ARB + CCB
3. ACEi + CCB + Thiazide-like diuretic
4. ACEi + CCB + 2 thiazide-like diuretics
62
Name ACE inhibitors
Ramipril, Lisinopril, Enalapril
63
Name Calcium channel blockers
Amlodipine, Nifedipine, Verapamil
64
Name ARBs
Candesartan, Losartan, Valsartan
65
Main side effect of thiazide-like diuretic (blood result)
Hyperkalaemia
66
Name thiazide-like diuretics
Indipamide, Bendroflumethiazide
67
Blood pressure targets for managing hypertension
<80yrs: < 140/90
>80yrs: < 150/90
Diabetic: < 130/80
68
Presentation of angina
Contricting chest pain +/- radiation to arms or jaw
69
Difference between stable and unstable angina
Stable always relieved by GTN or rest
| Unstable come on randomly at rest - ACS
70
4 Types of Angina
Stable- on exertion, relieved by rest/GTN
Unstable- at rest
Prinzmetal- coronary artery vasospasm
Decubitus- lying flat
71
Diagnosis of Angina
CT Coronary angiogram
72
Medical management of Angina
Acute: GTN spray- vasodilates
Long-term: Beta blocker or CCB
Secondary prevention: 3As: Aspirin 75mg, Atorvastatin, ACEi
73
Surgical management of Angina
Percutaneous coronary intervention with coronary angioplasty
| Coronary artery bypass graft (CABG) if severe stenosis
74
What is Cor Pulmonale?
Right heart failure caused by respiratory disease- causes increased pressure and resistance in pulmonary arteries
75
Causes of Cor Pulmonale
COPD, PE, interstitial lung disease, CF
76
Presentation of Cor Pulmonale
SOB, peripheral oedema, syncope, chest pain
77
Examination findings of Cor Pulmonale
Hypoxia, cyanosis, raised JVP, 3rd heart sound, hepatomegaly
78
Blood supply heart
LCA splits into circumflex + LAD
- Circumflex supplies LA and posterior LV
- LAD supplies anterior LV and anterior septum
RCA supplies RA+RV, inferior LV + posterior septum
79
3 Types of ACS
1. Unstable angina
2. NSTEMI
3. STEMI
80
Presentation of ACS
Central crushing chest pain radiating to jaw/arm, N&V, sweating, clammy, SOB, impending doom, palpitations
81
Which group of people are more likely to have a 'silent MI'?
Diabetics
82
ECG changes in STEMI
ST elevation or new LBBB
83
ECG changes in NSTEMI
ST depression, T wave inversion, Pathological Q waves
84
What are pathological Q waves?
> 40ms wide
> 2mm deep
> 25% depth of QRS
Seen in leads V1-3
85
ECG territories in MI and blocked artery
I, aVL, V3-V6: Anterolateral: LCA
V1-4: Anterior: LAD
I, aVL, V5-V6: Lateral: Circumflex
II, III, aVF: Inferior: RCA
86
When is troponin testing in ACS?
Baseline + 6-12hrs after
87
Causes of raised troponin?
ACS, chronic renal failure, sepsis, myocarditis, aortic dissection, PE
88
Management of acute STEMI
If present within 12hrs:
- Primary PCI (within 2hrs)
- Thrombolysis if not- Streptokinase/Alteplase
89
Management of acute NSTEMI
BATMAN
- Beta blockers unless CI
- Aspirin 300mg stat
- Ticagrelor/Clopidogrel
- Morphine
- Anticoagulant- LMWH Tx dose
- Nitrates
90
Secondary Prevention after ACS
```
6As:
Aspirin 75mg
Another antiplatelet- Ticagrelor
Atorvastatin
ACEi- Ramipril
Atenolol
Aldosterone antagonist eg Eplerenone (if HF)
```
91
Presentation of AF
Palpitations, SOB, syncope, symptoms of VTE
92
Examination findings of AF
Irregularly irregular pulse
93
What are the 2 causes of an irregularly irregular pulse?
AF
| Ventricular ectopics
94
ECG findings of AF
absent p waves
irregularly irregular
narrow QRS tachycardia
95
What is valvular AF?
AD + severe mitral stenosis or mechanical heart valve
96
Causes of AF
```
(Mrs) SMITH:
Sepsis
Mitral stenosis/regurgitation
Ischaemic heart disease (MI)
Thyrotoxicosis
Hypertension
```
97
Management of AF
Rate control: aim <100
- 1st line
- Beta blocker/CCB/Digoxin (only sedentary people)
Rhythm control:
- Cardioversion: Pharmacological (flecanide/amiodarone) or Electrical with sedation
- Long term- Beta blockers or Dronedarone
Anticoagulation:
- Warfarin/NOAC
- HASBLED + CHADSVASC Score
98
What is target INR for Warfarin used in AF?
2-3
99
Name some NOACs
Apixaban, Dabigatran, Rivaroxaban
100
Complications of AF
Heart failure, VTE, Stroke
101
HASBLED Score
```
Major bleeding risk for anticoagulation of patients with AF:
Hypertension
Abnormal renal/liver function
Stroke
Bleeding
Labile INRs
Elderly
Drugs/Alcohol
```
102
CHA2DS2VASc Score
```
Stroke risk for patients with AF:
Congestive heart failure
Hypertension
Age > 75 (2)
Diabetes
Stroke/TIA previously (2)
Vascular disease
Age 65-74
Sex (female)
```
103
Name the 4 cardiac arrest rhythms and split them into shockable and non-shockable
```
Shockable:
1. Ventricular tachycardia
2. Ventricular fibrillation
Non-shockable:
3. Pulseless electrical activity
4. Asystole
```
104
What is the aetiology of atrial flutter?
Re-entrant rhythm --> atrial contraction at 300 bpm and ventricular contraction at 150 bpm
105
Characteristic appearance of atrial flutter on ECG?
Saw-tooth
106
What is atrial flutter associated with?
Hypertension, Ischaemic heart disease, cardiomyopathy, thyrotoxicosis
107
Management of atrial flutter?
Rate/Rhythm control: BB or Cardioversion
Radiofrequency ablation of re-entrant pathway
Anticoagulation
108
Aetiology of SVT
Electrical activity in ventricles re-enters the atria
109
3 types of SVT
1. AV node re-entrant tachycardia
2. AV re-entrant tachycardia- accessory pathyway (WPW)
3. Atrial tachycardia- electrical signal comes from somewhere other than SA node
110
Acute Management of SVT
- Valsalva maneouvre
- Carotid sinus massage
- Adenosine fast bolus --> momentary asystole
- Verapamil
- DC cardioversion
111
Long-term prevention of SVT
BB, CCB, Amiodarone
| Radiofrequency ablation
112
What is Wolff-Parkinson-White Syndrome?
Extra electrical pathway connecting atria and ventricles
113
ECG findings in WPW syndrome?
Short PR interval, wide QRS, delta wave- slurred upstroke of QRS
114
Treatment of WPW syndrome
Radiofrequency ablation
115
ECG findings in PE
S1Q3T3
Deep S wave in I
Pathological Q waves in III
Inverted T waves in III
116
What is Torsades de Pointes?
Polymorphic ventricular tachycardia which occurs in patients with a prolonged QT
117
Causes of Torsades de Pointes?
Inherited long-QT syndrome
Meds- anti-psychotics, citalopram, flecanide, amiodarone, macrolide Abx
Electrolyte disturbances- hypokalaemia, hypomagnesaemia, hypocalcaemia
118
Causes of long-QT
Inherited long-QT syndrome
Meds- anti-psychotics, citalopram, flecanide, amiodarone, macrolide Abx
Electrolyte disturbances- hypokalaemia, hypomagnesaemia, hypocalcaemia
119
Acute management of Torsades de Pointes
Correct cause
Magnesium infusion
Defib if VT
120
Long-term management of Torsades de Pointes
Correct electrolytes
Beta Blockers
Pacemaker/implantable defib
121
Prognosis of Torsades de Pointes
Will either spontaneously resolve or progress to VT
122
Describe the 3 levels of heart block
1st degree: delayed AV conduction through AV node- PR > 0.2s
2nd degree: some impulses do not make it through AV node
- Mobitz type 1: Wenkebach's, increasing PR until 1 QRS missed then starts again
- Mobitz type 2: set ratio of P to QRS eg 2:1 or 3:1
3rd degree/complete: no relation of P to QRS
123
Presentation of acute LV failure
Rapid onset breathlessness, exacerbated by lying flat - Pulmonary oedema
Cough of frothy white/pink sputum
124
Triggers for acute LV failure
iatrogenic (fluids), sepsis, MI, arrhythmias
125
What type of respiratory failure is seen in acute LV failure?
Type 1
126
Signs on examination of acute LV failure
Tachypnoea, Hypoxia, Tachycardia, 3rd heart sound
| Bilateral basal crackles
127
Specific blood result in acute LV failure
Raised BNP
128
Investigations in acute LV failure
Raised BNP
Echo for ejection fraction
CXR
129
CXR findings in acute LV failure
```
Cardiomegaly
Upper lobe venous diversion
Pleural effusions
Interlobar fissures
Kerley B lines
```
130
Management of acute LV failure
```
Pour SOD
Pour away (stop) fluids
Sit up
Oxygen
Diuretics- IV Furosemide
```
131
Presentation of chronic heart failure
SOB worse on exertion, cough with frothy white/pink sputum, orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema
132
Investigations in chronic heart failure
BNP
Echo
ECG
133
Causes of chronic heart failure
Ischaemic heart disease, AS, hypertension, AF or other arrhythmias
134
Management of chronic heart failure
```
Conservative: stop smoking
Medical: ABAL:
- ACE inhibitor: Rampipril
- Beta Blocker: Bisoprolol
- Aldosterone antagonist: Spironolactone
- Loop diuretic: Furosemide
Surgical: for AS or MR
Flu + Pneumococcal vaccines
```
135
Classification of chronic heart failutr
New York Heart Association (NYHA) Classification:
- Stage 1: no limitation on ordinary activity
- Stage 2: normal at rest, ordinary activity causes breathlessness
- Stage 3: normal at rest, less than normal activity causes breathlessness
- Stage 4: symptoms at rest
136
2 features to suspect Infective endocarditis
Fever + New Murmur
137
Patient presents with fever and new murmur. Think...
Infective Endocarditis
138
What are the most common organisms in Infective Endocarditis
Streptococcus viridans most common
Then Staph aureus
Prosthetic valves: Staph epidermidis
139
RFs for Infective Endocarditis
Skin breaches, immunosuppression, prosthetic valves, renal failure, DM, IVDU
140
Presentation of Infective Endocarditis
Fever, rigors, night sweats, malaise, weight loss, new murmur
141
Signs on examination of Infective Endocarditis
```
Vasculitis
Microscopic haematuria
Roth spots
Splinter haemorrhages
Osler's nodes
Janeway lesions
```
142
What are Roth Spots?
Boat shaped retinal haemorrhages with pale centre
143
What diagnostic criteria is used for Infective Endocarditis?
Modified Duke Criteria
144
What investigations in Infective Endocarditis?
3 x blood cultures
Urinalysis for microscopic haematuria
TOE/TTE
145
What antibiotics for Infective Endocarditis?
Local trust guidelines
Native valve: Ampicillin + Flucloxacillin + Gentamicin
Prosthetic valve: Vancomycin + Gentamicin + Rifampicin
146
Management of Infective Endocarditis
Antibiotics
| Surgery
147
What is Brugada Syndrome?
A cause of sudden cardiac death in the young
| Faulty sodium channels which predispose to fatal arrhythmias eg VF
148
What is the inheritance pattern of Brugada Syndrome?
Autosomal dominant
149
Management of Brugada syndrome
Implantable defibrillator
150
Signs of an ischaemic limb
```
Pain
Pale
Pulseless
Perishingly cold
Paraesthesia
Paralysis
```
151
What score is used for classification of acute limb ischaemia?
Rutherford score- 1, 2a, 2b, 3
152
What are the 7 parameters to check for an acutely ischaemic limb?
1. Pain
2. Pedal pulse palpation
3. Pedal pulse doppler
4. Skin- colour, temp, CRT
5. Nerves- sensory deficit
6. Nerves- motor deficit
7. Muscle tenderness
153
Management of an acutely ischaemic limb
IV Heparin
