cardiology Flashcards
how does GTN spray relieve symptoms of angina?
Vasodilates
How should patients be advised to use their GTN spray?
Take spray, rest, wait 5 mins, take again if still have sx, then if not relieved sx after a second 5 mins, call 999
which vein commonly used in CABG?
Great saphenous vein (leg)
also used for venous cutdown.
anterior to med malleolus
what makes up a thrombus in a fast flowing artery (ACS)?
Platelets
What does the LCA become?
Circumflex artery
LADA
What does RCA supply?
RA
RV
Inferior LV
Posterior septal area
what does circumflex artery supply?
LA
post LV
what does LADA supply?
Ant LV
Ant septum
ACS - 3 conditions?
Unstable angina
STEMI
NSTEMI
How are the 3 ACS differentiated?
ECG -
if ST elevation/new LBBB - STEMI
if no ST elevation - trop levels, other ecg changes
How does ACS present?
cardiac sounding chest pain
non-pleuritic
non-positional
non-tender
How is NSTEMI identified?
Raised troponin levels
ST depression, T wave inversion, pathological Q waves
If troponins normal, and ECG normal - dx?
unstable angina
MSK chest pain
cardiac chest pain?
central constricting/crushing ass with n/v, sweating, clamminess SOB feeling impending doom palpitations, radiates to jaw/left arm - numbness continues at rest >20mins
which patients may experience a silent MI?
DM
where is ST elevation seen in STEMI?
in leads corresponding with particular area of heart
new LBBB
What indicates a late presentation of ACS?
path Q waves
anteriolateral area of heart (front/L side of heart) - which artery?
LCA
which leads affected in anteriolateral area infarct?
1
AVL
V3-6
which artery affected in anterior (front) area of heart
LADA
which leads affected in anterior area infarct?
V1-4
Which artery supplies the lateral aspect of heart? (Left side)
circumflex artery
which leads affected in lateral aspect infarct?
1
AVL
V5-6
Inferior aspect of heart - which artery?
RCA
which leads affected in inferior aspect infarct?
2
3
AVF
What are troponins?
proteins found in cardiac muscle
when would you measure troponins?
baseline
6 hours
12 hours
after onset of sx
What does raised troponins indicate and why?
myocardial ischemia - the troponins are released from the ischemic muscle in the heart
Other causes of raised trops (non-spec):
chronic RF sepsis - cap myocarditis aortic dissection PE
Other cardiac ix for ACS:
Ex BMI ECG FBC - anaemia U/E - ACEi LFT - statin Lipid profile TFT HbA1c \+ CXR - other causes (pneumonia), also oedema - HF ECHO - functional damage CT coronary angiogram
Acute STEMI treatment:
<2 hours presentation - primary PCI (‘cath’) / CABG
Thrombolysis if not
which arteries is catheter fed into in PCI?
Brachial or femoral
Thrombolysis - what kind of medication?
fibrinolytic agent - breaks down fibrin
risk of what in thrombolysis?
bleeding
can’t use if had a recent stroke
examples of thrombolytic agents? (TPA)
streptokinase
alteplase
tenecteplase
Acute NSTEMI tx:
BBs
Aspirin 300mg stat
Ticagrelor 180mg stat (alt clopidogrel 300mg)
Morphine titrated for pain (ony if SEVERE)
Anticoagulant - LMWH (eg enoxaparin BD for 8/7)
Nitrates - GTN to relieve CA spasm
O2 only if drop sats
what is the GRACE score used for?
to decide if PCI in NSTEMI
what does Grace score measure?
6 month risk of death/repeat MI following NSTEMI
how is grace score graded?
low risk <5%
med risk 5-10
high risk >10%
Who gets early PCI <4 days based on grace score?
medium and high risk patient
Cx of MI:
Death Rupture of septum or papillary muscles Edema - HF onset Arrhythmia/aneurysm Dressler's syndrome
What is Dressler’s Syndrome?
post MI syndrome
2-3 weeks post MI
due to localised immune response
pericarditis
Dressler’s syndrome presentation:
pleuritic chest pain
low grade fever
pericardial rub on auscultation
can cause pericardial effusion/tamponade
How is Dressler’s syndrome diagnosed?
ECG - GLOBAL ST elevation, T wave inversion (SADDLE ST) (also referred to as concave st)
ECHO - pericardial effision
raised inflamm markers - ESR, CRP
Mx: Dressler’s syndrome:
NDAIDs (aspirin/ibuprofen)
steroids if severe (pred)
pericardiocentesis if tamponade
Secondary prevention of MI:
6As
Aspirin 75mg OD
Another AP - clopidogrel 3/12, ticagrelor 12/12 (P2Y12)
Atorvastatin 80mg OD
ACEi
Atenolol/BB
Aldosterone antagonist - if clinical evidence of HF (eplerenone)
Secondary prevention lifestyle advice:
stop smoking reduce alcohol healthy med diet cardiac rehab - specific exercises for MI optimise other meds - DM, HTN
Types of MI: 1-4
1 - traditional due to ACS
2 - ischemia secondary due to decreased supply of 02 to heart (anaemia, tachy, Hypotension)
3 - sudden cardiac death/arrest suggestive of ischemic event
4 - MI ass with PCI/stunt/CABG
LV failure definition: (pathophys)
LV unable to adequately move blood through the left side of the heart and out into the body
causes a backlog of blood behind LV - LA/PVs, lungs
Vessels become engorged - increased vol and P - leak fluid - oedema
Leads to SOB, 02 desats
Triggers for LVF:
Iatrogenic - IV fluids in elderly patients with already impaired LV function
Sepsis
MI
Arrhythmias
Presentation acute LVF:
Acute SOB - worse by lying flat, better sitting up
T1RF - low sats, w/o hypercapnia
look/feel unwell
cough up frothy pink/white sputum
Examination LVF:
Increased RR Decreased sats tachycardia 3rd heart sound apex beat moves down/laterally bilat basal crackles - wet crackling if severe - hypotension - cardiogenic shock abdo pain, weight gain
signs of RHF:
Raised JVP (jugular venous distension) - backlog on RH peripheral oedema (ankles, legs, sacral) hepatosplenomegaly congestive hepatopathy dyspnoea OE
Ix of acute LVF:
hx/ex ECG - ischemia - ACS/arrhythmias (AF) ABG - RF? CXR bloods - inf, renal function, BNP, trops ECHO - function
what is BNP?
Hormone released from the ventricles when cardiac muscle is stretched beyond normal range
High BNP?
heart overloaded beyond its ability to pump effectively
Normal action of BNP?
to relax the smooth muscle in BVs
reduces systemic vascular resistance
acts on kidneys as diuretic
BNP - sens/spec??
Sensitive, not specific
other causes of high BNP?
tachycardia sepsis PE renal impairment COPD
how will echo inform LVF dx?
Echo assesses function of ventricles, anatomical abnormalities
measures ejection fraction (>50% normal)
pulmonary artery pressure
diastolic function
what is an ejection fraction?
the percentage of blood in the LV squeezed out with each ventricular contraction
CXR acute LVF:
Cardiomegaly (>0.5 ratio) Upper lobe venous diversion bilat pleural effusions fluid in interlobar fissures fluid in septal lines - Kerley B lines
Mx Acute LVF:
Poor sod Pour away IV fluids Sit patient up Oxygen if sats <95% Diuretics - furosemide 40mg stat
also LMNOP Lasix / furosemide Morphine (venodilators) Nitrates (venodilator) O2 Position
2 loop diuretic examples:
furosemide
bumetinide
other management options if severe pulmonary oedema/cardiogenic shock: (HF)
IV opiates - morphine vasodilates
CPAP
Inotropes - NAd
ICU/HDU
causes of chronic heart failure:
impaired LV contraction - systolic
impaired LV relaxation - diastolic
both lead to chronic backlog of blood trying to flow through the L side of heart (increase pressure LA, PVs, lungs)
presentation chronic HF:
breathlessness worse on exertion cough - frothy pink white sputum orthopnoea paroxysmal nocturnal dyspnoea peripheral oedema
orthopnoea?
worsening SOB on lying flat - how many pillows?
PND?
patients experience sudden waking in night with acute SOB, cough, wheeze, suffocating sensation
Open window- fresh air. sx improve over mins
Diagnosis chronic HF?
hx/ex - bibasal crackles, periph oedema
NTproBNP
ECHO
ECG
causes of chr HF?
Ischemic HD
Valvular HD - AS
HTN
arrhythmias - af
Mx Chr HF?
- BNP
- Refer to cardiology (urgently if BNP>2000ng/L)
- Medical mx
- surgical mx (AS/MR)
- HF specialist nurse
additional chr HF mx:
yearly flu jab stop smoking advice fluid restrict, salt load down (<2L, <2g) optimise tx of comorbidities exercise as tolerated
medical chr HF mx:
ABAL ACEi (ramipril up to 10mg OD) BB (bisoprolol up to 10mg) Aldosterone antag (spironolactone, eplerenone) Loop diuretics (furosemide, bumetinide)
If can’t tolerate ACEi in chr HF mx:
use ARB (candesartan up to 32mg OD)
which type of HF patients should ACEis be avoided in?
valvular HD until specialist has seen them
what needs measuring when pts on ACEis, loop diuretics, aldosterone antagonists?
U/Es
what is cor pulmonale?
RHF caused by respiratory disease
increased pressure and resistance in PAs - PHTN -> RV insufficiency -> back pressure blood RA, vena cava, systemic circulation
respiratory causes of cor pulmonale?
copd PE interstitial lung disease CF primary pulm HTN
presentation of cor pulmonale?
early - asymptomatic SOB peripheral oedema syncope chest pain
signs of cor pulmonale?
hypoxia cyanosis raised JVP peripheral oedema 3rd HS murmur - tricuspid regurgitation - pansystolic murmur hepatomegaly (pulsatile if TR)
Mx cor pulmonale:
underlying cause
LTOT
Hypertension NICE 2019: dx:
140/90 clinic
135/85 home readings
causes of HTN:
essential 95% - primary
secondary causes 5%
secondary causes HTN: ROPE
Renal disease (Renal artery stenosis)
Obesity
Pregnancy (preeclampsia)
Endocrine (hyperaldosteronism - Conn’s syndrome)
conns is commonest cause of secondary htn
Ix: Conn’s syndrome:
renin:aldosterone ratio blood test
HTN cx:
IHD Cerebrovascular accident retinopathy nephropathy HF
stages of HTN:
1 - >140/90
2- >160/100
3 - >180/120
end organ damage: investigations for those newly dx with HTN:
urine albumin:creatinine ratio (proteinuria) dipstick - microscopic haematuria Bloods - HbA1c, renal, lipid levels fundus ex ECG
HTN medications:
ACEis (ramipril)
BBs (bisoprolol)
CCBs (amlodipine)
Diuretics (indapamide) - thiazide-like
ARBs (candesartan) - if African/ACEi CI
lifestyle advice for HTN:
healthy diet stop smoking reducing alcohol, caffeine reduce salt regular exercise
who gets offered medical mx of HTN (stage related)
- stage 2 or higher
- stage 1 if under 80 with QRisk >10%, DM, CKD, CVD, end organ damage
if age <55 and white, what HTN first line drugs:
also T2DM pts
ACEi
if age >55 or black, what HTN first line drug:
CCB
step 2 of HTN mx:
ACE+CCB, if black ARB+CCB
or A+D or C+D
step 3 of HTN mx:
A+C+D
step 4 HTN mx:
If serum K<4.5mmol/L - K sparing diuretic - spironolactone
if serum K>4.5mmol/L - alpha blocker (doxazosin)
or BB (atenolol)
refer
how does spironolactone work:
K sparing diuretic
Aldosterone antagonist - blocks aldosterone in kidneys->Na excretion, K reabsorption
HTN treatment targets:
<140/90
if >80yo <150/90
what is the first heart sound:
closing of AV valves at the start of the systolic contraction of ventricles
what is the second heart sound:
closing of the semilunar valves at the end of systolic contraction
when is the third hs heard?
0.1 seconds after the second heart sound
what causes the third hs?
rapid ventricular filling leading to the chordae tendineaa to pull to their full length and twang like a guitar string
can be normal in 15-40yos (healthy) as the ventricles easily allow rapid filling
what is cause of third hs in pathology?
elderly - HF - ventricles and chordae stiff and weak and reach their limit much faster
(“galloping s3”)
when is 4th hs heard?
right before s1
is hs4 ever normal?
no
what does s4 indicate?
stiff or hypertrophic ventricle and caused by turbulent flow from atria contracting against a non-compliant ventricle
which part of stethoscope used to listen to low pitched sounds?
bell
which part of stethoscope used to listen to high pitched sounds?
diaphragm
where do you listen for pulmonary valve?
2nd ICS left sternal border
where do you listen for aortic valve?
2nd ICS right sternal border
where do you listen for tricuspid valve?
5th ICS left sternal border
where do you listen for mitral valve?
5th ICS midclavicular line (apex area)
where is Erb’s point?
3rd ICS Left sternal border - best place to listen to S1 and S2
how do you manouvre patient to listen for mitral stenosis?
left side
how do you manouvre patient to listen to aortic regurgitation?
sat up, leaning forwards, holding exhalation
assessing a murmur: SCRIPT
Site - where heard loudest
Character - soft, blowing, cresc, decresc
Radiation - heard over carotids (AS) or left axilla (MR)
Intensity - grade
Pitch - indicates velocity
Timing - systolic, diastolic
murmur grade:
1 difficult to hear s1,2> murmur
2 quiet s1,2=murmur
3 easy to hear s1,2
6 - can hear off chest
what does mitral stenosis cause in the muscle?
LA hypertrophy
what does aortic stenosis cause in the muscle?
LV hypertrophy
what does mitral regurgitation cause in the muscle?
LA dilation
what does aortic regurgitation cause in the muscle?
LV dilatation
what causes mitral stenosis?
Rh disease
Infective endocarditis`
mid-diastolic low pitched murmur? (rumbling)
with opening snap
mitral stenosis
lub drrrrrrrrr
which valvular condition is associated with malar flush and AF? also tapping apex beat?
mitral stenosis
what can mitral regurgitation cause long term?
congestive cardiac failure
pan-systolic high pitched whistling/blowing murmur?
(holo-systolic). louder on expiration
mitral regurgitation
brrrrrrrrr throughout systole
causes of mitral regurgitation?
idiopathic weakening of valve with age ischemic heart disease infective endocarditis rheumatic heart disease CT disorders: Ehlers Danlos/Marfan (Infection or infarction)
commonest valve disease?
Aortic stenosis
ejection-systolic high pitched, crescendo-decrescendo murmur? (louder on expiration)
Aortic stenosis
brrrr dub
which murmur radiates to carotids, has slow rising pulse and narrow pulse pressure, also has reporting of exertional sycope ?
Aortic stenosis
causes of Aortic stenosis?
atherosclerosis
idiopathic age related calcification
rheumatic heart disease
if <65 - bicuspid valve
early diastolic, soft murmur?
rumbling
aortic regurgitation
lub tarrrr
which murmur is associated with Corrigan’s pulse?
Aortic regurgitation
What is Corrigan’s pulse?
collapsing pulse
rapidly appearing and disappearing pulse at carotids
also brachial, femoral weak pulses
what does aortic regurgitation often lead to?
heart failure due to backlog of pressure in LV
What is an Austin-Flint murmur?
caused by Aortic regurgitation,
heard at apex, early diastolic rumbling - blood flowing through the aortic valve and over the mitral valve, causing it to vibrate
causes of aortic regurgitation?
idiopathic age related weakness
CT disorders - Ehlers Danlos/Marfan
infection or infarction
aortic dissection
what does midline sternotomy scar indicate?
mitral or aortic valve replacement or CABG
lateral right sided thoracotomy scar from?
mitral valve replacement
where do porcine bioprosthetic heart valves come from?
pigs
how long do bioprosthetic heart valves last?
10 years
how long do mechanical heart valves last and what do patients need to take?
> 20 years, lifelong anticoagulation - warfarin
what is the INR range for warfarin patients due to mechanical heart valves?
2.5-3.5
name 3 types of mechanical heart valve:
starr-Edwards
tilting disc
st jude
what is a problem with starr edward valves?
high thrombus formation risk
mechanical heart valves (3) major complications:
thrombus formation
infective endocarditis
haemolysis->anaemia
click replaces S1 for?
metallic mitral valve
click replaces S2 for?
metallic aortic valve
what does TAVI stand for?
Transcatheter Aortic Valve Implantation
who may have a TAVI?
high risk severe aortic stenosis patients, who can’t have open heart surgery
what type of valve is implanted in a TAVI?
bioprosthetic
which 3 organisms are most likely responsible for infective endocarditis?
staphylococcus (IVDU)
Streptococcus
Enterococcus
describe the pathophysiology of AF?
disorganised electrical activity overrides the normal activity from the SAN
contraction of atria is rapid, irregular and uncoordinated
-> irregular conduction of ventricles leading to irregularly irregular contractions, tachy, HF, stroke
ecg findings AF:
absence of p-waves
narrow QRS tachy
irregularly irregular ventricular rhythm
why is there a risk of stroke in AF?
tendency for blood to collect in LA and clot -> emboli which travel through LV, aorta, carotids, to brain, block cerebral arteries causing ischemic stroke
symptoms of AF:
asymptomatic
palpitations
SOB
Syncope
ddx for irregularly irregular pulse? (2)
AF
Ventricular ectopics
what is valvular AF?
AF in those who have a mod/severe mitral stenosis/mechanical heart valve
assumed that valvular pathology lead to AF
AF without valve pathology or with other valve pathology such as mitral regurgitation or aortic stenosis is classed as?
non-valvular AF
commonest causes of AF? Mrs Smith
Sepsis Mitral valve pathology IHD Thyrotoxicosis HTN
2 principles to treating AF:
rate control OR rhythm control
anticoagulation
why does rhythm control help AF patients?
allows ventricles more time to fill during diastole, maintaining a cardiac output
4 instances where rate control is NOT first line in AF tx?
There is reversible cause for their AF
Their AF is of new onset (within the last 48 hours)
Their AF is causing heart failure
They remain symptomatic despite being effectively rate controlled
younger than 65
rate control drugs (AF) 3:
- BBs (atenolol 50-100mg OD)
- CCBs (diltiazem - not in HF)
- Digoxin
what is offered to those AF patients unsuited to rate control drugs?
rhythm control drugs
2 ways of achieving rhythm control?
cardioversion
long term medical rhythm control
who is suitable for immediate cardioversion?
AF has been present for less than 48 hours or they are severely haemodynamically unstable.
what should happen to patient in delayed cardioversion (meds given as prep):
anticoagulated 3 weeks prior
rate control while waiting
2 options for cardioversion? (+egs)
AF
electrical cardioversion (GA+defib) chemical cardioversion (pharmacological) - flecanide -amiodarone (if structural heart disease)
long term medical rhythm control drugs (3):
BBs first line
dronedarone (maintaining cardioversion)
amiodarone (HF)
define paroxysmal AF:
where the AF comes and goes, usually episodes NOT lasting >48hrs
management of paroxysmal AF:
anticoagulated (based on chadsvasc)
pill in pocket approach
what is a pill in the pocket approach to paroxysmal AF management?
use of flecanide when patients experience AF sx, with no underlying structural heart disease
when should flecanide be avovided
atrial flutter -> extreme tachy
where does blood often stagnate in AF?
atrial appendage
risk of stroke in AF if no anticoagulation?
5%
risk of stroke with anticoagulation meds in AF?
1-2%
2/3 lower than if not anticoagulated
risk of anticoagulation meds ? (risk per year)
risk of serious bleed ( haemorrhage )
3% year
how is a patients bleeding risk on anticoagulation drugs measured?
HASBLED score
what type of drug is warfarin?
how does it act?
vitamin K antagonist
vitK is essential for clotting factors
prolongs prothrombin time
what is INR a measure of?
how anticoagulated someone is by warfarin
compares prothrombin time of warfarin patient with that of a healthy adult
1 is normal/ 2 indicates it takes double the time for blood to clot
target INR range for warfarin patients?
2-3
which system in the liver affects warfarin?
cytochrome p450 system
affected by antibiotics
dietary advice to warfarin patients?
leafy greens (high vit K) cranberry juice, alcohol (affect cp450)
what is the half life of warfarin and what can be used as an antidote?
1-3 days
vit K
what does DOAC stand for?
Direct Oral Anticoagulant
what is the half life of DOAC and what is the risk with doacs?
7-15 hours no antidote (but lower risk of bleeding overall)
name 4 advantages of DOACs over warfarin?
No monitoring is required
No major interaction problems
Equal or slightly better than warfarin at preventing strokes in AF
Equal or slightly less risk of bleeding than warfarin
what does chads2vasc measure?
whether an AF patient should be started on anticoagulation
what is no longer recommended for lowering stroke risk in AF?
aspirin
what chadsvasc score should consider/give anticoagulation?
1 - consider
2+ give
what does chads2vasc mnemonic stand for?
CCF HTN Age >75 (scores 2) DM Stroke/TIA prev (scores 2) Vascular disease Age (65-75) Sex (female)
what does hasabled assess?
risk of someone having a bleed/stroke while on anticoagulation medication
what does HASBLED mnemonic?
HTN Abnormal renal/liver function Stroke Bleeding Labile INRs Elderly Drugs/alcohol
name the 4 cardiac arrest rhythms?
ventricular tachycardia
ventricular fibrilation
pulseless electrical activity
asystole
which 2 cardiac arrest rhythms are shockable?
ventricular tachy
v fib
if unstable tachycardia, how do you manage?
up to 3 synchronised shocks
amiodarone infusion every 3 shocks
adrenaline 3-5mins 1mg
in a stable patient, what are the 3 possible arrhythmias causing narrow complex (<0.12s) tachycardia?
AF
Atrial flutter
Supraventricular tachycardia
how do you treat atrial flutter?
BB rate control
tx underlying
radiofrequency ablation of re-entry rhythm
anticoag
how do you treat SVT?
vagal manouvres and adenosine
(Valsava, carotid sinus massage)
cardioversion if BP <90
in a stable patient, what are the 3 possible arrhythmias causing broad complex tachycardia?
ventricular tachycardia
SVT with BBB
AF variation
how do you treat ventricular tachy>
amiodarone infusion 300mg
what causes atrial flutter?
pathophys
re-entry rhythm in either atria
aka re-entry loop
stimulates atrial contraction at 300bpm
signal makes its way to ventricles every second lap -> 150bpm ventricular contraction
sawtooth appearance on ecg with p wave after p wave?
atrial flutter
conditions associated with atrial flutter (4):
HTN
ischemia
cadiomyopathy
thyrotoxicosis
what causes SVT (pathphys)?
re-entry rhythm from ventricles to atria
self-perpetuating electrical loop
results in NARROW QRS
3 main types of SVT:
AV nodal re-entrant tachycardia
AV re-entrant tachycardia
Atrial tachycardia
how does adenosine work?
slowing cardiac conduction primarily through the AV node, interrupting the AVN/accessory pathway during SVT and resets to sinus rhythm
half life 8-10 seconds
which conditions should adenosine be avoided in?
asthma copd HF heart block severe hypotension
what causes Wolff-Parkinson White syndrome?
extra electrical pathway connecting the atria and ventricles, normally there is only one pathway - the AVN.
the extra pathway is called the bundle of kent
what is the bundle of kent?
extra electrical pathway connecting the atria and ventricles in WPW syndrome
definitive treatment for Wolff-Parkinson White syndrome ?
radiofrequency ablation of the accessory pathway
ecg changes in WPW syndrome?
short PR intervals
wide QRS
Delta wave
axis deviation depending on which accessory pathway (L/R)
what is torsades de pointes and what does it mean?
polymorphic ventricular tachycardia
means twisting of the tips
torsades de pointes ecg changes:
normal ventricular tachy
QRS twisted around the baseline
height of QRS get progressively smaller then larger then smaller…
prolonged QT interval
where are afterdepolarisations found?
torsades de pointes
what is the prognosis for torsades de pointes?
either spontaneously revert back to sinus or progress to VT (and maybe cardiac arrest)
causes of prolonged QT: from start of Q to end of T!
Long QT syndrome (inherited)
iatrogenic (APs, ADs, flecanide, sotalol, macrolides)
electrolyte disturbance (hypokalaemia, hypomagnesia, hypocalcaemia)
acute mx of torsades de pointes?
correct the cause - meds or electrolytes (macrolides - clari)
magnesium infusion
defib if VT
long term mx of torsades de pointes?
BBs
pacemaker
ECG changes for ventricular ectopics?
individual, random, abnormal broad QRS complexes on otherwise normal ECG
what is bigeminy?
ventricular ectopics are happening so commonly that they occur after every sinus beat
mx of bigeminy?
check bloods for anaemia, electrolyte disturbance, thyroid abnormalities
what is heart block generally referring to ?
AV node block
what is first degree heart block?
delayed AV conduction through AVN
every atrial impulse leads to a ventricular contraction
every p -> QRS
PRI>0.2s
what is second degree heart block?
some atrial impulses do not reach the ventricles
not all p -> QRS
several patterns of 2nd degree HB
what is Wenckebach’s phenomenon (Mobitz Type 1) HB? (description)
atrial impulses become gradually weaker until they don’t pass through the AVN
after failing to stimulate a ventricular contraction, the atrial impulse returns to being strong and cycle repeats
ECG changes Wenckebach’s phenomenon (Mobitz Type 1)?
increasing PRI until absent QRS, cycle
what is Mobitz type 2 HB? (description)
intermittent failure of AV conduction
results in absent QRS complexes, set ratio of p:QRS (eg 3:1 block)
PRI normal
what happens to PRI in Mobitz type 2 HB? what is there a risk of in this condition?
normal pri
risk of asystole
what causes 2:1 block?
either mobitz 1 or 2, hard to tell which
2 p waves to each QRS
3rd degree HB (description and ECG changes)
complete HB
no observable relationship between p and QRS
significant risk of asystole
treatment for stable bradycardia / AV blocks?
observe
tx for unstable bradycardia / AV blocks (risk of asystole in Mobitz type 2/ 3rd degree)?
- atropine 500mcg stat IV up to 6 doses
- other inotropes (NAd)
- transcutaneous cardiac pacing (using defib)
tx for high risk of asystole (M2/3rd):
temporary transvenous cardiac pacing
permanent implantable pacemaker when available
how does atropine work?
antimuscarinic - inhibits parasympathetic NS
sfx atropine:
dilated pupils,
urinary retention,
dry eyes,
constipation
how do pacemakers work?
deliver controlled electrical impulses to specific areas of the heart to restore normal rhythm and improve heart function
consist of pulse generator, pacing leads
where are pacemakers commonly implanted?
Left anterior chest wall/axilla
how long do pacemaker batteries last?
5 years
what can pacemakers be a contraindication for having:
MRI
TENS machines,
diathermy in surgery
indications for pacemaker (5):
Symptomatic bradycardias
Mobitz Type 2 AV block
Third degree heart block
Severe heart failure (biventricular pacemakers)
Hypertrophic obstructive cardiomyopathy (ICDs)
where are single chamber pacemakers implanted (2 options):
RA
RV
where are dual chamber pacemakers implanted?
RA+RV
where are biventricular pacemakers inserted?
triple chamber/cardiac resynchronisation pacemakers
RA, RV, LV
what continually monitor the heart and apply a defibrillator shock to cardiovert the patient back in to sinus rhythm if they identify a shockable arrhythmia.?
implantable cardioverter defibrilator
ECG changes in single chamber pacemaker?
line before each p/QRS in all leads
ECG changes in dual chamber pacemaker?
line before each p and QRS in all leads
which coronary artery disease is described as ‘supply ischemia’
STEMI
which coronary artery diseases are described as ‘demand ischemia’?
stable angina
unstable angina
NSTEMI
diamond classification for chest pain from HPI (3):
- left sided
- worse OE/relieved with rest
- relieved by nitroglycerin
if 3/3 diamond classification for chest pain from HPI: dx:
typical angina
if 2/3 diamond class HPI chest pain dx:
atypical angina
0/1 out of 3 of diamond classification for chest pain:
non-anginal chest pain
if assessing someone on ward who already had NSTEMI and ?another one, why can’t you use troponins and what can you use instead?
Can’t use troponins as they peak first during first MI, then stay elevated, so won’t be sensitive to second MI
Instead can check CPK-MB (creatine kinase myocardial band)
patient presents with cardiac sounding chest pain, normal ECG normal troponins, what is next in management pathway?
? unstable angina -> need PCI ‘cath’ anyway
is this cardiac coronary artery ischemia at all? - rule this out with cardiac stress test.
if stress test positive, what is the management?
f/u with cardiologist, will need PCI elective
how do you carry out stress test?
exercise or pharmacological
(exercise if they can exercise)
pharm - adenosine, dobutamine
how do you evaluate in cardiac stress test?
ECG (when baseline ECG normal)
ECHO (when baseline not normal)
MRI (when prev CABG/HF)
what are ECHO and MRI looking for during stress test?
dead tissue (doesn’t move) - scar tissue
at risk tissue (at rest and under stress - STUNNING)
AREA OF REVERSIBILITY
healthy tissue
what does angiography determine?
PCI (stent/balloon) - angioplasty
or CABG - if 3+ vessels involved
general medical management of ACS: (MONA BASH C)
*all
Morphine (worse prog if needed. SEVERE ONLY) O2 (during initial ex, nasal canula) Nitrates (if angina persists) Aspirin* BB* ACEi* Statin* Heparin (therapeutic dose) Clopidogrel (if post stent or high risk STEMI)
when in a rural setting, and cardiologist who can do PCI is far away, what do you give before transfer?
TPA if >60 mins away
BUT! The time from MI onset to PCI <2hours
if person is having a right sided STEMI (2,3,avf) - what tx don’t they get and why?
nitrates - right ventricle is pre-load dependent
investigations to diagnose heart failure: (3)
BNP
ECHO
Angiogram - ischemic or non-ischemic?
What is heart failure with preserved ejection fraction?
2 types of HF - systolic, diastolic
Diastolic the ventricle is thick, has trouble relaxing, ejection fraction normal or increased, but can’t relax to fill so well
classification of heart failure? how many classes?
New York Heart Association Classification
4
1 - asx
4 SOB rest
Heart failure step wise mx based on NYHACHF:
- BB and ACEi (or ARB)
- Loop diuretic (furosemide)
- Isosorbide dinitrate / spironalactone (to adddress pre load and afterload) / digoxin
- Inotropes
if HF, and have an ejection fraction <35% and not class 4, what is mx->
implantable cardiac defibrilator
if ejection fraction <30%, LBBB, mx:>
CRT with biventricular pacemaker
if ischemic cause of heart failure, in addition to other tx, what do they need:
aspirin, statin
how to investigate a murmur and which murmurs to ix?
ECHO
systolic g3+
any diastolic
how will Mitral stenosis present?
younger patients
CHF sx - dyspnoea OE, PND, crackles
A Fib
what treatment for Mitral stenosis?
balloon valvuloplasty
how will aortic regurgitation present?
acute - cardiogenic shock, flash pulmonary oedema
chronic - CHF, chest pain
tearing chest pain - classical dx?
aortic dissection
treatment for aortic regurgitation?
acute - urgent chronic - urgent/elective REPLACEMENT before onset of angina/HF remember to consider cabg
how will aortic stenosis present?
old man with atherosclerosis
chest pain, HF sx, syncope
bicuspid Aortic valve accelerates the pathology
treatment for Aortic stenosis:
NOT valvuloplasty -> REPLACEMENT
remember to consider CABG
mitral regurgitation presentation?
acute - cardiogenic shock, flash pulmonary oedema
chronic - CHF, AF
treatment for mitral regurgitation?
emergent valve replacement if acute
elective if chronic but before AF, HF sets in
why do you have to consider cabg in aortic valve replacements?
ostea of coronary vessels are in aortic valve
if lose an ostea - lose coronary flow
hypertrophic cardiomyopathy - what causes it?
unilateral septum hypertrophy
covers aortic opening -> LV outlet obstruction
who gets HCM?
patients with sarcomere mutations young athletic sudden death - due to ventricular arrhythmia SOB/syncope OE FHx sudden cardiac death
systolic murmur, but more blood->less murmur (better when they squat or leg-lift):
(like Aortic stenosis)
HCM
treatment for HOCM:
avoid dehydration Beta blockade transplant alcohol ablation myomectomy AICD
what is mitral valve prolapse:
leaflets of the mitral valve don’t touch well, too big
so during systole they blow through
systolic murmur but more blood->less murmur (better when squat or leg lift):
(like mitral regurg)
mitral valve prolapse
pathophysiology of mitral valve prolapse:
congenital
what type of person gets mitral valve prolapse:
young women
treatment of mitral valve prolapse:
avoid dehydration
BB
doesn’t need to be replaced
dilated cardiomyopathy: pathophys
chambers become dilated
minimal actin and myosin overlap
so no contractility
what generates contractility force in heart muscle?
actin and myosin overlap
causes of dilated cardiomyopathy:
virus - coxsackie, chagas wet beriberi alcohol ischemia chemo
how will patient with dilated cardiomyopathy present?
systolic CHF, 3rd HS
orthopnoea, PND, dyspnoea OE, crackles, peripheral oedema
reduced LVEF<55%, dilated LV
TR, MR
tx of dilated cardiomyopathy:
CHF sx: BB, ACEi, diuretics (furosemide)
definitive: transplant
stop alcohol/chemo
what should happen to relatives of HCM?
first degree relatives screened by echo
concentric hypertrophic cardiomyopathy: causes:
longstanding HTN
concentric hypertrophic cardiomyopathy: CP:
diastolic CHF
how to treat concentric hypertrophic cardiomyopathy/diastolic CHF:
avoid dehydration
BB/ccb
transplant
HTN control *** (1.)
restrictive cardiomyopathy: pathology:
no room for ventricle to relax due to interference in the wall of the ventricle, interfering with the myocyte normal function
causes of restrictive cardiomyopathy (3):
amyloid
sarcoid
haemachromatosis
cancers
idiopathic fibrosis
how will patient with restrictive cardiomyopathy present?
diastolic CHF
if restrictive cardiomyopathy + peripheral neuropathy -> dx
amyloidosis
if restrictive cardiomyopathy + pulmonary disease->
sarcoidosis
if restrictive cardiomyopathy + cirrhosis, bronze diabetes->
haemachromatosis
If suspect amyloidosis, which ix?
abdo wall fat pad biopsy
gingiva biopsy
is suspect sarcoidosis, which ix?
cardiac MRI then do endomyocardial biopsy
is suspect haemachromatosis, which ix?
screen ferratin (up) then get genetic test
tx restrictive cardiomyopathy:
diastolic chf so: rate control - BB, CCB gentle diuresis transplant definitive tx underlying disease
what will echo of HOCM show?
asymmetric hypertrophy of septum
in suspected chronic heart failure first line ix?
BNP
then echo
45-year-old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
low pulm artery occlusion pressure
low cardiac output
high systemic vascular resistance
cause?
hypovolaemia
causes low cardiac output due to low preload
75-year-old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
high pulm artery occlusion pressure
low cardiac output
high systemic vascular resistance
cause:
cardiogenic shock
in this, pulm pressures usually high
tx using venodilators as in pulm oedema
22-year-old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
low pulm artery pressure
high cardiac output
low systemic vasc resistance
cause?
septic shock
decresed SVR is often major feature of sepsis
hyperdynamic circulation often present
tx using vasoconstrictors
palpitations ix?
after bloods and ecg
next important is holter monitor
60-M -> ED shocked with sudden onset, severe chest pain at rest. radiates to his back and down his arms. PMH HTN, angina and DVT 4 years ago. His regular medications include ramipril, GTN and simvastatin. He has never smoked, doesn’t drink alcohol and has not had any recent travel. CXR: widened mediastinum and ECG: sinus tachycardia. Found some relief from the pain 20 minutes after using his GTN spray. dx?
aortic dissection
which classification for aortic dissection?
stanford
or debakey
Massive PE + hypotension - tx?
thrombolyse
what happens to DM meds when someone comes in having been thrombolysed post anterior MI to CCU?
stop metformin and gliclazide
start IV insulin infusion
what is kussmauls sign associated with ?
raised JVP on inspiration
associated with constrictive pericarditis
used to differentiate constrictive pericarditis from tamponade
calcification of pericardium?
constrictive pericarditis
if ?PE but can’t get a scan - mx?
start on treatment dose anticoagulant and wait for scan
PE: ECG changes (commonest)?
sinus tachycardia
T inversion v1-3 +/- inferior leads (RV strain)
s1Q3T3
right axis deviation
hypercalcaemia ecg?
short qt interval
J waves if severe
right ventricular strain ecg features:
ST depression and T wave inversion
v1-3 (+4)
2,3,avf
what does RBBB look like on ecg?
first part of QRS normal
secondary R wave in v1-3 (looks like M)
slurred ‘S’ in the lateral leads (looks like W)
ST depression, T wave inversion in R precordials
broad QRS >120ms
what does LBBB look like on ecg?
QRS broad >120ms
tall R waves in lateral leads (1,v5,v6) (looks like M)
deep S waves in R precordials (v1-3) - (looks like W)
LAD
dominant S wave in v1
Right axis deviation on ecg?
QRS is positive in 2,3,avf
QRS is negative in lead 1
left axis deviation on ecg?
QRS is positive in lead 1
QRS is negative in 2, 3, avf
which drugs can lead to hypocalcaemia?
furosemide
loop diuretics sfx
also can cause ototoxicity
85 yom, 142/84 BP. Q-Risk of 8% on no meds: tx?
lifestyle advice as risk not >10%, he’s over 80, no comorbidities
which anti-infective agent will cause the INR to increase?
fluconazole
INR 5.0-8.0 (no bleeding) - mx?
withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose
which complications do Type A aortic dissection patients sometimes present with?
hemiplegia
neuro complaints
71yof 147/92 BP confirmed on 2 readings - next step?
Ambulatory BPM
first line mx acute pericarditis?
NSAIDS AND colchicine
obvious MI hx with tall R waves in v1-3 - where is MI? ST depression in leads V1-V3 Tall R waves in leads V1-V3 Inverted T-wave in lead aVR All other T-waves are normally oriented
posterior MI
NSTEMI first line tx?
aspirin 300 to prevent progression to stemi
which drug sometimes used as anti htn will worsen glucose control in t2dm?
indapamide
A 75-year-old lady presented to the emergency department after suffering a fall 2 hours ago. Before the fall, she was nauseous and experienced sweating, pallor and discomfort in the stomach. She believed that she briefly lost her consciousness but then recovered quickly. She did not have any confusion or weakness after the fall. There were no tongue bites. Neurological examination was normal. Her hearing has always been bad since she was young.
What is the diagnosis?
neurally mediated syncope
how should adenosine be given?
large bore cannula (16G) or centrally
adenosine sfx:
chest pain
bronchospasm
transient flushing
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
what type of organism (gram and shape) are the bugs that cause bacterial endocarditis?
gram positive cocci
which htn drugs cause cold peripheries?
BBs
can also cause reduced awareness of hypos
pulsus paradoxus - describe?
In cardiac tamponade, there will be an abnormally large drop in BP during inspiration, known as pulsus paradoxus
fondaparinux is sometimes used in nstemi tx - what is it’s moda?
activates antithrombin III
LMWH also does this
Abciximab, eptifibatide, tirofiban - moda?
Glycoprotein IIb/IIIa receptor antagonists
how to calculate the cardiac axis?
find most isoelectric line (pos=neg) out of first 6 (1,2,3,avl,avr,avf). direction of conduction is 90 degrees from that lead on the axis man
what condition is associated with an inverted P wave in lead I, right axis deviation, and loss of R wave progression??
dextrocardia
heart apex on the right, flipped heart
which drugs actually improve prognosis of heart failure?
ACEIs, BB, spironalactone
not furosemide
hypokalaemia ecg?
t wave flattening and u waves present
The most common valvular abnormality in infective endocarditis is ???
tricuspid regurgitation
tricuspid regurg murmur?
pan-systolic louder during inspiration (aka holo-systolic)
what is Beck’s triad of cardiac tamponade? (do ECHO)
hypotension
soft heart sounds
raised JVP
cardiac tamponade ECG?
electrical aleternans
the CT shows a large saddle embolus where the pulmonary trunk splits - dx?
PE
what else other than HF can raise a BNP?
CKD/renal failure
Orthostatic hypotension (A fall in SBP of >20mmHg on 3 mins standing) accompanied by an exaggerated increase in HR is indicative of which 2 conditions?
anaemia
hypovolaemia
Orthostatic hypotension (A fall in SBP of >20mmHg on 3 mins standing) accompanied by no change in HR is indicative of which condition?
DM
well’s score >4 which ix first line?
CTPA
if 4 or below do d-dimer to r/o
PE + hypotension tx?
alteplase (thrombolysis)
when to stop warfarin before surgery?
5 days before
surgery can go ahead after <1.5
where do loop diuretics act?
ascending loop of henle
how long do trop and CKMB stay elevated for post-MI?
trop 10 days
CK-MB 3-4 days
which drug is CI in ventricular tachycardia?
verapamil
can cause haemodynamic collapse
which drug is used in pulseless arrest / asystole?
adrenaline stat then 3-5minutely
not atropine anymore
which factors should determine if an intravenous glycoprotein Iib/IIIa receptor antagonist is to be given in nstemi?
GRACE score and whether the pt is having PCI
- give alongside
PCI criteria stemi?
presents in <12hrs and PCI can be delivered in <120 mins
PE + renal failure -> ix?
VQ scan
what cause of chest pain is commoner in Marfan’s syndrome?
pneumothorax
42-year-old overweight man presents with a two day history of anterior chest pain that is worse on deep inspiration and lying down
relieved by sitting forwards: dx
pericarditis
aortic dissection management:
type A - ascending aorta - control BP(IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
electrolyte causes of torsades de pointes?
hypokalaemia
hypomagnesia
hypocalcaemia
what examination sign is classic for HCM?
s4 sound
What is the most common cause of death in patients following a myocardial infarction?
ventricular fibrilation
if d-dimer negative and wells score of 4: mx?
consider alternative dx and reassure patient PE ruled out
If patients have persistent myocardial ischaemia following fibrinolysis what is next mx step?
consider PCI
when is fondaparinux used in nstemi mx?
those who are NOT having angiography immediately
child with inhaled foreign body - where is the blockage likely to occur and which lobe?
right side - right inferior bronchus
STEMI and patient suitable for PCI -> which drugs do they get?
aspirin and prasugrel
Witnessed cardiac arrest while on a monitor - tx?
3xshocks then CPR
if not witnessed on monitor -> do 1 shock then 2 mins CRP
hypothermia ecg changes:
bradycardia 'J' wave - small hump at the end of the QRS complex first degree heart block long QT interval atrial and ventricular arrhythmias also torsades de pointes
which rule out criteria used in 18yo with <15% chance PE?
PERC
what is a late neuro manifestation (and complication) of rheumatic fever?
sydenham’s chorea
loss of control of facial and arm muscles
organism responsible for rheumatic fever?
strep pyogenes
which drugs can precipitate gout attacks?
thiazide diuretics - bendroflumethiazide
reduces uric acid secretion from kidneys
which patients, regardless of age, should be started on statin for primary prevention :
T1DMs if: 1 of: over 40 had DM for >10yrs nephropathy other RFs - HTN, obesity qrisk >10%
how do statins work? (MODA)
inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.
statin CI:
macrorlides
pregnancy
doses of atorvastatin for different preventions:
20mg for primary
80 for secondary
patient is two days following a large abdominal procedure. increased SOB. sinus tachy. reduced AE at both bases. ddimer normal - dx?
basal atelectasis
The history of ischaemic heart disease combined with the presence of fusion and capture beats strongly suggests a diagnosis?
Ventricular tachycardia
Deep ‘arrowhead’ T wave inversion in the anterior leads is a sign of ?
wellens syndrome
cardiac ischaemia in the setting of unstable angina and is a high-risk trace
hyperkalaemia ecg?
peaked T waves
which drug should never be taken with verapamil and why?
BBs
can cause heart block and fatal arrest
which cardiomyopathy is WPW associated with?
HOCM
Friedrich’s ataxia as well
type of inheritance of HOCM?
autosomal dominant
ECHO findings HOCM? MR SAM ASH
Mitral regurg
Systolic anterior motion
Asymmetrical hypertrophy
suspected ruptured abdominal aorta aneurysm - which blood procducts?
crossmatch 6 units of blood
Major bleeding on warfarin. INR 8.5. mx?
stop warfarin + vit K 5mg IV + prothrombin complex concentrate (only give PCC if MAJOR bleed)
restart warfarin when INR<5
STEMI presents 6hrs after onset, would take >120mins to transfer to PCI centre - mx?
thrombolysis and repeat ECG 90 mins
(cannot wait for more than 120 mins to PCI if thrombolysis could be given)
also give unfractioned heparin
bendrofluemthiazide MODA?
inhibits Na reabsorption by blocking the Na+-Cl− symporter at the proximal part of the distal convoluted tubule
54M obese. ED. sudden onset severe frontal headache and neck pain unbearable. PMH: HTN, aortic regurgitation (bicuspid valve), hyperlipidaemia. 94% air, RR 16/min, hr 117/min, BP 101/68mmHg left arm and 122/82mmHg right arm, temperature 36.8ºC. ECG sinus tachycardia. dx?
aortic dissection
if presents like R-sided stemi and AR murmur -> ascending
which comes first in nstemi mx - grace score or DAPT?
grace score
NSTEMI first 2 drugs given if not major bleeding risk:
aspirin and fondaparinux if PCI NOT planned for immediately
60M is admitted with severe central chest pain to the resus department. The admission ECG shows ST elevation in leads V1-V4 with reciprocal changes in the inferior leads. What % occlusion of which artery likely?
100% occlusion LADA
45-F ED chest pain worse on deep inspiration and SOB. denies coryzal symptoms or cough. rr25/min, 96% air, HR 114/min, BP 114/81mmHg, 36.8°C. She is concerned that this may be due to her total mastectomy one week ago for breast cancer despite the wound site appearing to be healing well.
What is the next, most appropriate management step?
CTPA
Wells > 4
ECG shows both right bundle branch block and left axis deviation indicating???
bifascicular block
features of bifascicular block as above + 1st-degree heart block is called?
trifascicular block
MI+ bradycardia -> where?
inferior MI
STEMI > 12h since onset - ongoing ECG ischemia - mx?
PCI
what is a poor prognostic indicator in ACS??
cardiogenic shock - crackles on auscultation
age>65
initially raised creatinine
Young man with AF, no TIA or risk factors, mx?
no treatment now preferred over aspirin
44M central, severe chest pain started around one hour ago. No radiation of the pain or associated shortness-of-breath. He has had some similar fleeting pains over the past two weeks but these settled spontaneously after a few seconds. hr 84 / min, blood pressure 134 / 82 mmHg and respiratory rate 18 / min. dx?
MI
25M intermittent central chest pains 4/52. PMH: pilonidal abscess operation 9 months ago. The pain is described as ‘heavy’ and often associated with tingling in his lips and fingers. The episodes usually happen at rest and last several minutes. dx?
anxiety
31F 4/52 retrosternal ‘burning’ pain. The pain is often worse following eating. PMH depression and she uses Microgynon. Clinical examination is unremarkable. dx?
gord
In the context of a tachyarrhythmia, a systolic BP < 90 mmHg →
DC cardioversion
77F to ED with 3/7 hx lethargy and shortness-of-breath. She is confused and unable to give much useful history. On examination she is noted to be pale, hr 160/min bp 80/56 mmHg. sats 96% air. anaemic. ECG shows irregularly irregular narrow complex tachycardia. mx?
dc cardioversion
due to unstable BP
polycystic kidney disease: which murmur?
mitral valve prolapse (and MR)
2M ->GP parents are concerned that he is struggling to gain weight and is excessively short of breath on exertion. PMH congenital pulmonary stenosis which was managed conservatively however the parents are now questioning whether surgical intervention may be required.
What murmur is likely to be heard on examination?
ejection systolic louder on inspiration
late systolic murmur inidcates:
mitral valve prolapse and coarctation of the aorta
associated with bicuspid aortic valve
mid-systolic click :
prolapse of the mitral valve
tetralogy of fallot murmur:
ejection systolic
ventricular septal defect murmur:
pansystolic
nicorandil is useful in mx of?
angina - K channel activator - dilates coronary vessels
sfx - ulcer anywhere on GI tract
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination - dx?
VSD
67-M ->ED sudden onset chest pain. central chest, and started an hour ago. maximal at onset, and is not exacerbated with deep breaths. most intense pain he's ever experienced. nil previous. PMH HTN (ramipril and bendroflumethiazide). He has a 15-pack-year. Drowsy. He has left-sided ptosis and miosis of his left pupil. dx?
aortic dissection
can present with neuro sx
‘Provoked’ pulmonary embolisms are typically treated for?
3 months
unprovoked is 6 months
41-M ->GP due to erectile dysfunction and dizziness. He has a complex PMH and is on multiple medications. On examination his heart rate does not slow on deep breathing and his lying/standing blood pressure drops significantly. dx?
autonomic dysfunction effects of T2DM
Investigating suspected PE: if the CTPA is negative then consider??
proximal leg vein USS if DVT suspected
23-F -> ED with palpitations. No chest pain. No signs of shock, heart failure or syncope. ECG: regular narrow complex tachycardia, rate of 168 bpm. There are no obvious P waves visible. Vagal manoeuvres fail to terminate the arrhythmia.
What should be the next step in management?
SVT dx
Adenosine is next 6mg->12mg->12mg
67M COPD and paroxysmal atrial fibrillation who you are currenly looking after. Around 30 minutes ago he developed retrosternal chest pain which has not settled with Gaviscon. HR 90/min, sats 95% air, bp 134/82 mmHg, The ECG: STE in AVR and STD v2-6: mx:
acs mx - trasnfer to CCU
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be?
warfarin or DOAC
68-M -> ED with sudden onset pleuritic chest pain. CTPA shows PE. Nil previous, and is normally fit and well, and not on any medications. He is normotensive but tachycardic. What is the most appropriate initial management for this man?
DOAC
what is Ivabradine and what are its commonest sfx?
angina tx if HR>70
visual disturbances including phosphenes and green luminescence, brady, HB
alteplase (thrombolysis) MODA:
activates plasminogen -> plasmin
which ACS drug to be cautious with if pt normotensive/hypotensive?
nitrates - can cause collapse
which bloods indicate stop statin?
serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range.
Complete heart block following an inferior MI: mx?
reassure and observe
this is not an indication for pacing, unlike with anterior MI
what will make aortic stenosis murmur quieter?
LV dysfunction - reduced flow over the aortic valve - quieter murmur
50M cardiac ward following a stroke. 4/12 hx weight loss and fever. diastolic murmur. ECHO:
‘A pedunculated heterogeneous mass attached to the interatrial septum of the left atrium. Mitral valve obstruction also noted’. dx?
atrial myxoma
New onset AF presented within <48h - mx?
anticoagulate and dc cardioversion
must be sx for <48h!!!
Aortic stenosis management:
AVR if symptomatic otherwise cut-off gradient is 40mmHg
Downsloping ST depression (‘reverse tick’ sign) indicates ?
digoxin toxicity
A 50-year-old man complains of central, pleuritic chest pain 24 hours after being admitted with an anterior myocardial infarction. The pain is eased when he sits upright.dx?
pericarditis
After being admitted to the coronary care unit a middle aged man develops a regular, broad complex tachycardia. His blood pressure drops to 88/50 mmHg. He was admitted 6 hours previously following an anterolateral myocardial infarction.
dx?
ventricular tachycardia
A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air. dx?
left ventricular free wall rupture
sudden HF, raised JVP, pulsus paradoxus, recent MI
which cardiac drugs can cause erectile dysfunction and insomnia?
BB
Carotid sinus hypersensitivity may be cardioinhibitory or vasopressive - quantify?
vantricular pause >3seconds
SPB drop >50
which valve for infective endocarditis in IVDU?
tricuspid
what are pharmacological options for treatment of orthostatic hypotension?
fludrocortisone and midodrine
angina and not controlled on BB, next in line is?
CCB
If new BP >= 180/120 mmHg + no worrying signs then the first step is ?
ix for end-organ damage
if signs - admit for specialist assessment
rate control AF but asthmatic - first line?
CCB - diltiazem
second episode AF. During admission he was warfarinised and discharged with planned follow-up in the cardiology clinic. However, on review today he is found to be in sinus rhythm. What should happen regarding anticoagulation?
lifelong warfarin (as 2nd episode)
Long Q-T syndrome mx?
stop drugs worsening
BB
ICD if high risk
what is the first line investigation for stable chest pain of suspected coronary artery disease aetiology?
Contrast CT coronary angiogram
on-invasive functional imaging 2nd line
invasive coronary angiography 3rd line
previously asx 30-F -> ED severe dyspnoea while jogging. twice in past month but this time it was more serious which prompted her to seek help. She is adopted and is aware that her biological mother suffered from rheumatic fever as a child and biological father had ‘some sort of heart problem’. All vital signs were within normal range. An ECG was done and showed left ventricular hypertrophy. diagnosis?
HOCM
if had catheter ablation for AF - what changes regarding anticoag needed?
stay on anticoag per chadsvasc for life
what ECG finding is NOT normal variant for young athlete?
LBBB
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started when in timeline?
after 2 weeks
pericarditis ix?
echo - tte
pt on anti-epileptic meds. goes on warfarin. gets skin changes but INR in normal range - what side effect is this?
skin necrosis
In Raynaud’s phenomenon with extremity ischaemia think??
buerger’s disease
thromboangiitis obliterans
(young male smoker)
De Musset’s sign (head bobbing) is a clinical sign of ?
aortic regurgitation
One day following a thrombolysed inferior myocardial infarction a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur. dx?
papillary muscle rupture
-> acute mitral regurgitation
could also be new VSD
Four weeks after an anterior myocardial infarction a 69-year-old presents with pulmonary oedema. The ECG shows persistent ST elevation in the anterior leads. dx?
left ventricular aneurysm
no chest pain
angina step wise mx:
- BB
- CCB
- long-acting nitrate, ivabradine, nicorandil or ranolazine
how do ISMN takers minimise the development of nitrate tolerance?
assymetric dosing regime to maintain a daily nitrate-free time of 10-14 hours
no mortality benefit - sx only
For adults with type 1 diabetes, if there is no albuminuria the target BP should be < ??
135/85
adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case BP target should be?
130/80
Bleeding on dabigatran? (eg haemorrhagic stroke) - which reversal agent??
idarucizumab
drug monitoring for statin?
LFTs at baseline, 3months, 12 months
when to take statins?
last thing in evening - works overnight
Takotsubo cardiomyopathy is associated with which echo change?
apical ballooning of myocardium (resembling an octopus pot)
middle-aged lorry driver presents with central chest pain and ST elevation on electrocardiogram. He is treated for myocardial infarction with (PCI) and a stent is deployed to his left circumflex artery to good effect. Now asymptomatic and has been started on secondary prevention medications. He is keen to get back to work. What guidance should he be given on discharge?
contact DVLA and not drive for 6/52
if not lorry driver, should wait 4/52 before driving but no need to tell dvla
Acute heart failure not responding to treatment - next step?
CPAP
warfarin and pregnancy?
NO - teratogenic
but can be used in breast-feeding mothers
dental procedure on background of endocarditis - which abx prophylaxis?
none - not routinely recommended
ventricular tachycardia: tx if adverse sign and examples of adverse signs?
synchronised cardioversion
shock (systolic BP of <90), syncope, myocardial ischemia and heart failure.
if ventricular tachy without adverse sign (stable) - mx?
amiodarone IV
sfx causes thrombophlebitis
which drugs cause orthostatic hypotension?
diuretics, vasodilators (including CCB), alcohol
how to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause?
rhythm control
ace-i in pregnancy?
NO
foetal abnormalities and renal failure
useful investigation in clinically unstable patients with a suspected aortic dissection??
TOE (transoesophageal echo)
normally ct angiography is ix of choice if clinically stable = false lumen (of CAP)
CCB and heart failure:?
CI - negative inotropic effect; they reduce heart rate and cardiac output
(except for amlodipine)
In cases of hypothermia causing cardiac arrest, defibrillation…………..?
do 3 shocks but then if unsuccessful continue chest compressions and only shock again once pt temp >30degrees
ECG shows electrical alternans, which is considered pathognomic for?
tamponade
alteration of QRS amplitutes between beats
choking - mild mx?
ask are they choking - if yes encourage cough
severe choking - mx?
give up to 5 back-blows
if unsuccessful give up to 5 abdominal thrusts
if unsuccessful continue the above cycle
A 24-year-old Asian female presents to her GP with lethargy and dizzy spells. On examination she is noted to have an absent left radial pulse. Blood tests are as follows:
ESR high - dx?
takayasu’s arteritis
associated with renal artery stenosis and different BP in each arm
3 of these = typical chest pain
2= atypical
what are the three criteria?
pain is described as sharp (rather than constricting)
pain may be precipitated by physical exertion
pain is relieved by GTN spray within 5 minutes
chest pain relieved by sitting forwards?
pericarditis
A 52-year-old male presents with central chest pain and vomiting. He has drunk a bottle of vodka. On examination there is some mild crepitus in the epigastric region. dx?
boerhave syndrome
Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.
boerhave syndrome: mackler triad?
vomiting, thoracic pain, subcutaneous emphysema. It commonly presents in middle aged men with a background of alcohol abuse.
statin + clari ->
an important and common interaction
massively raised CK
commonest cause of mitral stenosis?
rheumatic fever
55-F -> GP 3/12 hx breathlessness on exertion, fatigue and ankle swelling. She reports that she requires 2 pillows to sleep at night. PMH: feverish illness 4-months previously. Mid-diastolic murmur present and a loud S1 opening snap consistent with mitral stenosis. Annular erythematous rash on her chest. ECG: right ventricular hypertrophy and P-mitrale. dx?
rheumatic fever
erythema marginatum
45-F->ED sudden onset weakness on the right side of her body. 30m ago. Her vision is unaffected but her speech is confused and slurred. Nil PMH. DH: COCP. 40 pack-years and drinks two bottles of wine/wk.
Clinically stable. 2/5 power down her right side. Peripheral cyanosis and clubbing with an ejection systolic murmur at the left upper sternal edge radiating through to the back and fixed splitting s2. There is also erythematous tender enlargement of the right calf.
what caused this?
atrial septal defect
embolism from peripheral veins may bypass pulmonary circulation
62-M 2 episodes of syncope. hr 90 bp 110/86 mmHg, his lungs are clear and there is a systolic murmur which radiates to the carotid area. Which ix first?
ECHO
syncope a late sign in aortic stenosis
ACE-I and worsening BP control but doesn’t tolerate CCB - which drug to add?
thiazide
which AD drug associated with dose dependent QT prolongation?
citalopram
used to reduce dyspnoea and anxiety in acute exacerbation of heart failure?
morphine
what is CI in aortic stenosis (drug):
nitrates - cause hypotension
58-F PE 1/52 ago. Warfarinised. She was covered with low molecular weight heparin until the INR was > 2 for 24 hours. For the past week she has been taking 4mg of warfarin and her INR four days ago was 2.2. Her INR has been checked today and is 1.3. mx?
up warfarin to 6mg/day and LMWH bridge
A 12-F from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. dx?
rheumatic fever
severe hypertension and bilateral retinal hemorrhages and exudates - ? (or epistaxis)
malignant hypertension
If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI - mx?
CABG
which anti-hypertensives cause hyperkalaemia?
ace-is
coarctation mx:
immediate prostaglandins
until corrective surgery can occur
ix endocarditis?
3 separate blood cultures taken
ECHO
absence of a carotid pulse in the presence of sinus tachycardia indicates that this is?
non-shockable rhythm
20-F. On feeling the woman’s radial pulse, the doctor can feel 2 separate systolic beats, as if there was a double pulse. dx and name of this phenomenon?
HOCM
bisferiens pulse
slight discomfort with ordinary activity. No symptoms on resting - NYHA ??
II
recurrent DVTs, warfarinised - target INR?
3.5 (3-4)
sfx GTN?
hypotension
tachycardia
headache
flushing
VF/pulseless VT should be treated with ?
1 shock as soon as identified then CPR
adrenaline after the 3rd shock
only ever 3 successive shocks when whole event witnessed on monitor eg post MI
ECG HOCM:
left ventricular hypertrophy (deep S in v1, tallest R in V5,6)
progressive t-wave inversion
deep Q waves
A sigmoid colon perforation of unknown cause, given his age;
Translucent looking skin and hypermobility of the small joints;
A presentation compatible with aortic dissection.
cause and ix of aortic dissection?
ehlers-danlos
TOE
NSTEMI management: unstable patients should have immediate?
coronary angiography
drug causes both hyponatraemia and hypokalaemia.?
bendroflumathiazide
also hypercalcaemia + hypocalciuria
A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation. What is the most likely underlying diagnosis?
ostium secundum atrial septal defect
drugs to avoid in HOCM?
ace-inhibitors
reduce afterload
falsely low BNP?
on ramipril for BP
angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.
commonest association for aortic dissection>
htn
NICE HF guidelines - if already on Ace, BB, on step 2:
aldosterone antagonist
ARB
Hydralazine+ nitrate (especially if black)
NICE HF guidelines step 3: cardiac resynchronisation therapy or?
digoxin
A 52-year-old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis?
subclavian steal syndrome
thrombolyisis CI:
active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension
breathing problems with a clear chest - think?
PE
There are regular p waves at a rate of around 90 / min but they do not conduct. The ventricular escape rhythm has a rate of about 36 / min and has a right bundle branch block (RBBB) like morphology. The bizarre, wide, inverted T-waves can be seen in?
stokes-adams attacks
Global’ T wave inversion (not fitting a coronary artery territory) - think?
non-cardiac cause
effect of phenobarbitone on warfarin?
decreases INR
first line investigation for stable chest pain of suspected coronary artery disease aetiology (angina):
contrast enhanced CT angiography
59F -ED 3/7 hx of new-onset palpitations. She has no structural or ischaemic heart disease. HR 120bpm, and she shows no signs haemodynamic compromise. Her ECG shows an irregularly irregular rhythm with the absence of p waves. The consultant recommends elective cardioversion for this patient. Which mx plan is most appropriate?
bisoprolol and oral anticoagulation for 3 weeks then electrical cardioversion
patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke
After starting an ACE inhibitor, significant renal impairment may occur if the patient has undiagnosed?
bilateral renal artery stenosis
cause of a loud S2 (due to a loud P2)??
pulmonary HTN
A 43-year-old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal long term treatment?
aortic root replacement
angiodema is sfx of which drug?
ace-i ramipril
Tachycardia with a rate of 150/min ?
atrial flutter
primary PCI via which artery?
radial
Complete heart block following a MI? - where is lesion?
Right coronary artery
A newborn child is assessed. They are found to be in the 25th centile for their weight along with a systolic murmur heard best over the back. When feeling the femoral pulses the doctor notices that there is a radio-femoral delay. Which condition causing these examination findings?
coarctation
Tuner’s syndrome
A 43-year-old lady presents with central chest pain, worse on deep inspiration, and shortness of breath. After her history and examining her, you suspect a pulmonary embolus (PE). Her Wells’ score is 9. You plan to do a CTPA, but the radiologists request you order one further investigation prior to a CTPA. What investigation is this likely to be?
CXR - do before CTPA acc to nice
Patients on warfarin undergoing emergency surgery -?
give four-factor prothrombin complex concentrate
amiodarone sfx?
grey skin appearance
ABG in a PE?
respiratory alkalosis
which HTN med can increase creat by 30% from baseline but should be continued?
ramipril
notching of the rib =
coarctation of aorta
ix before starting amiodarone?
CXR - pneumonitis
UE - hypokalaemia
LFT
TFT
Infective endocarditis causing congestive cardiac failure is an indication for?
emergency valve replacement
what is ebstein’s anomoly?
tricuspid regurgitation → pansystolic murmur, worse on inspiration
HOCM caused by?
mutation in the gene encoding β-myosin heavy chain protein or myosin binding protein C
clubbing, fever, AF, mid-diastolic murmur seen in?
atrial myxoma (more commonly LA)
furosemide/bumetanide MOA:
inhibits the Na-K Cl cotransporter in the thick ascending loop of henle
what are the name of the nodules found in rheumatic heart fever?
Aschoff bodies are granulomatous nodules
65M palpitations. ECG: VR 150/min with an underlying atrial rate of 300/min. Atrial flutter is suspected. What is the treatment of choice to permanently restore sinus rhythm?
radiofrequency ablation of tricuspid valve isthmus
