Cardiology Flashcards
1
Q
Two AF characteristics on the ECG
A
RR intervals are irregularly irregular
No distinct p waves
2
Q
How can you classify AF?
A
Paroxysmal: at least one episode >30s, resolves within 7 days
Persistant: lasts more than 7 days or requires termination with medication or cardioversion
Permanent: does not resolve on cardioversion, sinus rhythm cannot be achieved and AF deemed the final rhythm
3
Q
Risk factors for AF
A
Cardiac: Cardiomyopathy IHD/heart failure Valvular disease HTN
Resp: COPD, pneumonia, PE, pleural effusion, lung cancer
Endocrine: diabetes, thyrotoxicosis
Infection
Electrolyte disturbances
Drugs: bronchodilators, thyroxine (+alcohol/caffeine)
4
Q
Signs and symptoms of AF
A
Symptoms: Dizziness/confusion Palpitations Chest pain Breathlessness Dyspnoea
Signs: Raised JVP Tachycardia Murmurs Irregular pulse Hypotension
5
Q
AF investigations
A
Bedside: blood pressure, ECG
Bloods: FBC, U&Es, TFTs, magnesium, calcium, cholesterol
Imaging: CXR, CT/MRI if emboli, transthoracic echo
6
Q
CHADSVASC score
A
Congestive heart failure Hypertension 140/90 Age >75 (2) Diabetes Stroke/TIA/thromboembolism (2) Vascular disease Age (65-74) Sex (female)
7
Q
CHADSVASC score interpretation
A
> 2 anti-coagulate
1 consider anti-coagulation
8
Q
HAS-BLED score
A
Hypertension Abnormal liver/renal function Stroke Bleeding Liable INRs Elderly (>65) Drugs/alcohol
9
Q
3 methods of AF treatment
A
Rate control (>65, IHD)
Rhythm control (<65, first presentation, symptomatic, CHF)
Anti-coagulation
Catheter and surgical ablation
10
Q
Rate control medication for AF
A
Beta blockers (metopralol, bisoprolol) CCBs (verapamil cardia selective) Digoxin (in sedentary patients)
11
Q
What is the complication of BB and CCBs being co-prescribed?
A
AV heart block
12
Q
Rhythm control in AF
A
First rate control with beta blockers
Electrical cardioversion
Drugs: amiodarone, sotalol, flecainide (pill in the pocket for paroxysmal AF)
This should be followed by 4 weeks of anticoagulation
13
Q
Cardioversion considerations in AF
A
Identifiable reversible cause
Heart failure
Onset <48 hours: immediate cardioversion due to bleeding risk
Onset >48 hours: 3 weeks of anticoagulation before cardioversion due to risk of thromboembolism
14
Q
When would you choose to rhythm control in an AF patient?
A
Rate control unsuccessful or symptoms persisting
Younger patient (to prevent permanent AF)
Recurrent symptomatic episodes
First onset AF (DC cardioversion if unstable)
Reversible cause
Co-existent HF
15
Q
Anticoagulation options in AF
A
Warfarin (vitamin K antagonist) - regular INR monitoring
NOACs - rivaroxaban/apixaban (dirext Xa inhibitor)
16
Q
Mechanism of low-molecular weight heparin?
A
Inhibition of antithrombin III leading to factor Xa inhibition
17
Q
Mechanism of aspirin?
A
COC inhibitor
18
Q
Causes of irregularly irregular heart beat
A
AF
Atrial/ventricular ectopics
Atrial flutter with variable block
19
Q
What cardiac change does Wolff-Parkinson-White cause?
A
Supraventricular tachycardia
20
Q
what causes a sawtooth ECG pattern, and what treatment is there?
A
Atrial flutter (ventricular rate is dependent on degree of AV block - atrial rhythm usually 300/min) Same treatment as AF, although more sensitive to cardioversion
21
Q
What investigations would you use to identify the cause of a TIA
A
Large vessel occlusions:
Carotid duplex ultrasound
MRA
CTA
Cardiac analysis:
Transthoracic Echo
ECG
Holter monitoring
22
Q
Treatment of permanent AF?
A
Rate control and anti-coagulation
23
Q
Adverse effects of amiodarone
A
Thyroid disease
Interstitial lung disease
Hepatotoxicity
24
Q
What is the mechanism of digoxin toxicity?
A
Triggered activity in which there are afterdepolarisation oscillations in membrane activity
25
What are the three mechanisms of arrhythmogenesis?
```
Automaticity
Re-entry (most common)
Triggered activity (digoxin toxicity)
```
26
What is the mechanism of Class I anti-arrhythmics?
Slow depolarisation (depress phase 0). Inhibits fast sodium channels and so reduce sodium entry.
27
Class I anti-arrhythmics examples
IB: phenytoin (also decreases length of action potential)
IC: flecainide (just depresses phase 0)
28
Class I anti-arrhythmics side-effects
```
Nause and vomiting
SLE-like syndrome (flecainide)
Negative inotropic (weaken muscle contractions)
Proarrhythmic
CNS toxicity
```
29
Class II anti-arrhythmics mechanism?
Catecholamine antagonist at the beta-adrenoreceptors
Negative inotrope and chronotrope (reduce HR and contraction strength)
Reduce conduction at AV node
Reduce rate of spontaneous depolarisaiton at SA node (reduces slope of phase 4)
30
Class II anti-arrhythmics examples and side effects?
Bisoprolol
Propanalol
```
Bradycardia
Postural hypotension
Insomnia
Bronchoconstriction
Erectile dysfunction
Hypoglycaemia
AV nodal heart block
```
31
Class III anti-arrhythmics mechanism?
Prolong action potential by blocking potassium channels (prolongs phase 2)
32
Class III anti-arrhythmics examples and side effects
Amiodarone
Nausa, thyroid dysfunction, peripheral neuropathy, photosensitivity, proarrhythmic, hepatitis, potentiates warfarin and digoxin
Sotalol (same as Class II)
33
What are the two different kinds of CCBs?
Dihydropyridines (anti-hypertensive e.g. amlodipine and nifedipine)
Non-dihydropyridines (anti-arrhythmics e.g. verapamil and diltiazem)
34
Class IV anti-arrhythmics mechanism
Block L-type calcium channels in autorhythmic cells (reduce rate of spontaneous depolarisation)
Negative inoptrope and chronotrope
35
Digoxin mechanism
Inhibits Na/K ATPase pump in cardiomyocytes
Increases intracellular calcium
More forceful contractions (positive inotrope)
36
What needs monitoring when a patient is on digoxin?
```
Kidney function
ECG changes (ST depression, T wave changes, PR prolongation)
```
37
Digoxin side effects
Nausea and vomiting
Visual disturbances (yellow rings, change to colour perception)
Proarrhythmic
Insomnia
38
Adenosine mechanism and what is it treatment for?
Slows heart rate
| Treats supraventricular tachycardia
39
Atropine mechanism and what is it treatment for?
Increases heart rate
| Treats sinus bradycardia and AV block
40
What is magnesium sulfate used to treat?
Polymorphic ventricular tachycardia (torsades des pointes)
| Digoxin toxicity
41
Tests and monitoring of amiodarone?
LFTs and TFTs
| Every 6 months on starting
42
Which patients should you not start flecainide on?
Coronary heart disease
43
Treatment for regular ventricular tachycardia?
Amiodarone (IV 300mg)
44
Which anti-arrhythmic can prolong QT interval?
Sotalol
| Must have regular ECG monitoring
45
Three stages of hypertension
1. 140/90 (135/85 ABPM) (plus end-organ damage, CVS, renal disease, diabetes, >20% CVS risk on Framingham calculator)
2. 160/100 (150/95 ABPM)
3. 180/110
46
Causes of secondary hypertension
Renal: renovascular disease, internal disease (CKD, AKI, glomerulonephritis)
Endocrine: Cushing's, Acromegaly, Conn's, phaeochromocytoma
Drugs: SSRIs, oral contraceptives, glucocorticoids, NSAIDs, EPO
Coarctation of the aorta
47
What symptoms and signs might you see with hypertension (either reflecting end-organ failure or secondary cause)
Symptoms: blurred vision, palpitations, chest pain, dyspnoea, headaches, new onset neuropathy
Signs: retinopathy, cardiomegaly, arrhythmias, proteinuria, uraemia
48
KWB retinopathy grades
1. generalised arteriolar narrowing (silver wiring)
2. focal narrowing and arteriovenous nipping
3. retinal haemorrhages and cotton wool spots (retinal nerve fibre layer micro-infarcts leading to exudation of axoplasmic materials)
4. papilloedema
49
Investigations for a patient with newly diagnosed hypertension?
Bedside: BP, urinalysis, fundoscopy, ECG
Bloods: FBC, U&Es, HbA1c/fasting glucose, cholesterol
Special tests: ambulatory BP, renal US, endocrine tests (aldosterone:renin ratio)
50
What are the BP targets in <80s and >80s?
<80s: 140/90
>80s: 150/90
(130/80 if renal disease and proteinuria or diabetes)
51
What is malignant hypertension?
180/110 with papilloedema and/or retinal haemorrhage
```
Signs:
Uncontrollable epistaxis
Haematuria
Epistaxis
Raised ICP - headaches and nausea
```
52
Treatment of malignant hypertension/hypertensive emergency?
```
IV nitroprusside (nitric oxide releasing) or labetalol
Phentolamine (alpha adrenergic antagonist)
```
Over 24-48 hours so as to avoid hypoperfusion
53
Causes of aortic regurgitation?
Aortic leaflets:
rheumatic heart disease (commonest in developing countries)
congenital (bicuspid/quadcuspid)
degenerative (calcification) - commonest in developed
infective endocarditis
Aortic root: aortitis, aortic dissection (Stanford A), connective tissue disorders (Marfan's)
Syphilis
54
Organisms causing infective endocarditis and rheumatic heart disease?
Infective endocarditis: strep viridans, staph aureus, enterococci
Rheumatic heart disease: post-strep Group A (pyogenes) auto-immune condition
55
What connective tissue disorders can cause aortic and mitral regurgitation?
Marfan's: defective FBN1 gene
Ehlers-Danlos: collagen defects
56
What other chronic inflammatory diseases is aortitis associated with
Rheumatic arthritis
Anylosing spondilitis
Takayasu arteritis
Complicates giant cell arteritis
57
What are the complications of acute aortic regurgitation?
Reduced coronary flow leading to angina or MI
Increased end-diastolic pressure leads to pulmonary oedema and dyspnoea and eventually cardiogenic shock
58
What cardiac changes might you see in a patient with chronic aortic regurgitation?
Increased preload, leading to left ventricular dilatation and hypertrophy
Greater contractility
Eventual heart failure
59
Acute aortic regurgitation clinical features
Bilateral basal crackles
Raised JVP
Dyspnoea
Chest pain (consider angina or MI)
60
Chronic aortic regurgitation clinical features
```
Palpitations
Angina
Dyspnoea
Water hammer pulse (collapsing)
Wide pulse pressure
```
Chest signs: displaced apex, early diastolic decrescendo murmur (left sternal edge, high pitched and blowing), soft s1 and s2
61
Eponymous signs associated with aortic regurgitation
de Musset's: head bobbing with each heart beat
Quincke's: pulsation of nail beds
Muller's: vibrating uvula
62
Investigations for aortic regurgitation
Bedside: BP, ECG (LVH)
Bloods: FBC, U&Es, clotting, cholesterol
Imaging: echo (origin of regurgitant jet, its size, aortic valve pathology and hypertrophy), CXR (cardiomegaly, aortic dilatation, calcification)
Special: cardiac MRI, cardiac catheterisation, ECG exercise stress testing
63
Aortic regurgitation management
Surgery if acute or severe (determined by LVH, pressure gradient and valve area)
Transcatheter aortic valve replacement (TAVR)
Mechanical valve: for younger patients, need anti-coagulation, longer lifespan
Bioprosthetic: older patients, don't need anti-coagulation, 10 year lifespan
64
What is the order of valves affected by rheumatic heart disease?
1. Mitral
2. Aortic
3. Tricuspid
4. Pulmonary
65
What are the classic stigmata of infective endocarditis?
FEVER AND NEW MURMUR
(FROM JANE)
Fever
Roth spots: retinal haemorrhages
Osler nodes: painful, red lesions on fingers
Murmur
Janeway lesions: painless plaques on palms or soles due to septic emboli
Anaemia
Nails (splinter haemorrhages)
Emboli
+ pallor, weight loss, glomerulonephritis
66
How is infective endocarditis diagnosed?
Modified Duke's criteria (requires blood cultures and echo)
MAJOR: 2 separate positive blood cultures, endocardial involvement
MINOR: (FIVE)
Fever >38
IV drug user or predisposing heart condition
Vascular phenomena (myocotic aneurysm or Janeway)
Echo findings
Immunological findings (Rheumatoid factor, Osler nodes, glomerulonephritis)
67
Innocent murmurs characteristics (7s)
```
Soft
Systolic
Short
Symptomless
Sounds (normal s1 and s2)
Standing/sitting (vary with position)
Special tests normal (echo/ECG)
```
68
What is the effect of inhibiting ACE?
```
Reduction of angiotensin II leading to:
Reduced ADH (lowering H2O)
Reduced aldosterone (lower Na, Ca, H2O; raised K)
Reduced vasoconstriction
Reduced sympathetic activity
```
69
What are some adverse effects of ACE-i?
Persistent dry cough (build-up of bradykinin in lungs)
Headache
Postural hypotension
Rashes
Angioedema
TERATOGENIC (inhibit foetal urine production leading to oligohydramnios)
70
Who should you not give ACE-i to?
Pregnant women
Renal failure
Severe illness (can result in AKI, especially if also on NSAIDs)
71
Action of dihydropyridine CCBs and examples?
Block voltage-gated L-type calcium channels
Reduces vasoconstriction
Amlodipine, nifedipine
72
Adverse effects of CCBs?
```
Headache
Flushing
Peripheral oedema
Reduced cardiac contractility
Dizziness
Constipation
```
73
Action of thiazide diurectics?
Block Na/Cl channels in distal convoluted tubules of kidney, preventing Na/Cl/H2O entering tubule cells
Long-term anti-hypertensive effects mainly due to vasodilation
74
Examples of thiazide diuretics and their adverse effects
Bendroflumethiazide
Indapamide
Electrolytes: LOW magnesium, sodium, potassium, HIGH calcium
Metabolites: HIGH glucose, uric acid (gout)
GI: disturbances
Severe: pancreatitis, cholestasis, agranulocytosis
Impotence
Frequency
TERATOGENIC
75
Alpha-1 blockers action and examples
Block alpha-1 adrenoreceptors in vascular smooth muscle
Reduced arteriolar tone
Venous dilation
Doxazosin
76
Adverse effects of alpha-1 blockers
```
Headaches
Postural hypotension
Dizziness
Nausea
Rhinitis
Frequency
```
77
Beta blockers mechanism of action
Reduced renin production
Negative inotropic and chronotropic effects
Vasodilation
78
Beta blockers adverse effects
```
Cold peripheries
Erectile dysfunction
Bronchoconstriction/asthma exacerbation
Postural hypotension
Headache
AV nodal heart block
Hypoglycaemia
Insomnia
```
79
Contraindications for beta blockers
Pheochromocytoma (unless given with alpha blocker - phenoxybenzamine)
Asthma
Severe peripheral arterial disease
Bradycardia (especially if with verapamil)
80
Starling equation
Net pressure = hydryostatic pressure - oncotic pressure (pull of proteins in blood)
81
Ohm's law
Flow = change in pressure/resistance
82
Poiseulle's law
Resistance (R) ∝ η x L / r4
(inversely proportional to radius^4)
OR
Flow (F) ∝ 𝚫p x r4 / η x L
83
Cardiac output =
stroke volume x heart rate (average of 5L)
84
What effect does the vagus nerve have on the heart?
Acts on SAN and AVN and contractile cells to reduce HR
SAN: Increases K+ permeability and action potential length
AVN: increases k+ permeability and AVN delay
contractile cells: reduces strength of contractions
85
What relationship does the Frank-Starling Law describe?
between preload (LVEDP) and stroke volume
86
Signs and symptoms of acute coronary syndrome?
Can be silent in MI if elderly or diabetic
Symptoms: chest pain >15 mins, SOB, sweating, nausea and vomiting
Signs: pale, clammy, hypotension, pulmonary oedema, tachycardia
87
ACS investigations
Bedside: obs, BP, glucose, ECG
Bloods: FBC, U&Es, TFTs, LFTs, cholesterol, Mg
Cardiac enzymes: troponin T/I, CK-MB, myoglobin
Imaging: CXR, transthoracic echo
Special: coronary angiogram
88
What changes would you see on an ECG following an MI (how do STEMI, NSTEMI and unstable angina differ)?
```
STEMI:
minutes-hours: hyperacute T waves
0-12 hours: STEMI
1-12 hours: Q wave development
Days: T wave inversion
Weeks: T wave normalisation and persistent Q waves
```
NSTEMI and UA: may have signs of MI, T wave inversion or no changes
89
When can you measure troponins after MI? And when else might you see them raised?
6-12 hours (usually 8 hours rise)
New tests can be done 3 hours after event
Prognostic value
CKD,PE
90
Immediate management of ACS
MONA
IV morphine (2.5-5mg) + anti-emetic (10mg metoclopramide)
Oxygen (if <94%) - 15l/min via high flow non-rebreather mask
GTN
Aspirin 300mg
(+ metoclopramide)
91
Hospital management of STEMI
Aspirin + second antiplatelet (clopidogrel, prasugrel or ticagrelor) --> PCI within 120 mins --> LMWH
Fibrinolysis (alteplase) --> PCI 6-24 hours
Lifelong aspirin, 12 months of second antiplatelet
IV glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) if 6-month mortality >3%
92
How should UA or NSTEMI be managed according to GRACE scoring?
High risk (>3%):
1. Angiography within 72 hours (fondaparinux if not possible);
2. dual antiplatelet (lifelong aspirin and 12 months clopidogrel)
3. if chest pain continues - glycoprotein inhibitor (IV eptifibatide, or tirofiban)
4. PCI if chest pain continues
Medium risk (1.5-3%): dual antiplatelet
Low risk (<1.5%): lifelong aspirin only
93
What are the 8 factors considered in GRACE scoring and what does it estimate?
```
Age
Heart rate
CHF
Renal function
Elevated biomarkers
ST segment deviation
Cardiac arrest
Systolic BP
```
6 month mortality risk in patients with NSTEMI or UA
94
Long-term management of ACS
Beta blocker and ACE-i (if not contraindicated) - bisoprolol and ramipril up to 10mg
Dual antiplatelet therapy (aspirin and clopidogrel 75mg OD)
Artorvastatin 80mg OD
95
Cardiac complications of MI
Pericarditis (autoimmune - Dressler's syndrome 2-10 weeks after)
Mitral regurgitation (secondary to ischaemia and rupture of papillary muscles) - systolic murmur
Complete heart block (AV node ischaemia from right coronary artery occlusion)
Ventricular tachycardia
HF
Recurrent MI
Thromboembolism
Ventricular aneurysm
96
What effect does COX enzyme have?
Production of prostaglandins and thromboxane A2 --> platelet aggregation
97
Acute pericarditis vs STEMI ECG changes?
Pericarditis:
widespread ST changes
PR depression
saddle-shaped ST elevation
STEMI
ST elevation greater in III than II
Convex or horizontal ST elevation
ST depression in leads other than aVR or V1
98
Most common cause of acute pericarditis? Treatment?
Viral secondary to coxsackie B infection
| NSAIDs and colchicine
99
Which artery are most inferior MIs supplied by, and what leads will be affected? What other artery may be occluded in other patients?
Right Coronary Artery
II, III, aVF
Circumflex will sometimes supply posterior descending artery
100
Three stages of atherosclerosis
1. Endothelial damage: LDL deposits under epothelium which are oxidised and cause more damage. Monocyte recruitment to tunica intima
2. Plaque formation: monocytes become macrophages (lipid-laden = foam cells), multiple foam cells - fatty streak. Muscle cells from tunica media migrate and cover to form lipid rich atheroma with plaque on top
3. Plaque rupture: leads to platelet aggregation and vessel occlusion
101
Artery occluded in posterior MI and ECG changes?
Left circumflex artery or RCA
ST DEPRESSION V1-V3
Tall R waves V1 and V2; upright T waves
102
Anterior MI artery
Left coronary artery
103
Anteroseptal MI artery and leads affected
LAD
| V1-V3
104
Lateral MI - which artery and leads are affected?
left circumflex
| Leads I, aVL and V4-V6
105
When does CK peak following MI, and what is it useful to assess?
24 hour peak
| Recognition of re-infarction
106
Contraindications of fibrinolysis
```
Absolute:
Active bleeding
Bleeding disorder
Previous haemorrhagic stroke
Ischaemic stroke last 6 months
Recent major surgery or head trauma
Suspected aortic dissection
CNS neoplasm
```
```
Relative:
anticoagulation
peptic ulcer
pregnancy or less than 1 week postpartum
TIA in preceding 6 months
Recent trauma/surgery last 2 months
infective endocarditis
```
107
Dressler's syndrome features and treatment
```
1-4 weeks post MI
Low grade fever
Sharp chest pain
Raised ESR
Pericardial rub and pericardial effusion
```
Tx: NSAIDs or steroids
108
Signs and symptoms of left ventricular heart failure
```
Symptoms:
Dyspnoea
Wheeze
Cough
Paroxysmal nocturnal dyspnoea
Orthopnoea
Nocturnal cough (pink froth)
Haemoptysis
Fatigue and lethargy
Exercise intolerance
```
```
Signs:
Tachypnoea and cardia
Cyanosis
Pulsus alternans
S3 (gallop rhythm)
Inspiratory basal crackles
Pleural effusion
Cardiomegaly
```
109
Signs and symptoms of right ventricular heart failure
```
Symptoms:
abdominal discomfort
fatigue
nausea
peripheral oedema
```
```
Signs:
tachycardia
hepatomegaly
ascites
cachaxia
cardiomegaly
raised JVP
pitting oedema
right ventricular heave
```
110
Signs and symptoms of aortic stenosis
SAD (syncope, angina, dyspnoea)
Epistaxis (acquired von Willebrand's)
```
Signs:
Ejection systolic murmur (low-pitched in second right intercostal space)
Sustained apex, thrill
Slow rising pulse
Narrow pulse pressure
Soft S2 if severe
S4 sign of LVH
Reversed splitting
```
111
Causes of aortic stenosis
Calcification - >65s, most common cause
Bicuspid valve - congenital, <65s, turbulent flow leads to stenosis and calcification
Rheumatic heart disease - post-Strep A autoimmune condition leading to inflammation
112
What compensatory changes do you see in the heart in aortic stenosis?
Increased left ventricular hypertrophy
Increased pressure gradient across the valve
Left ventricular heart failure (bibasal crackles and dyspnoea)
Exertional syncope
Angina due to increased O2 demands from the heart and reduced coronary flow
113
Investigations for suspected aortic stenosis
Bedside:
BP
ECG: LVH (deep S-waves in V1 and V2, tall R-waves V5 and V6)
Bloods: FBC, U&Es, cholesterol, clotting
Imaging:
CXR - typically small heart, but cardiomegaly if HF occurs; dilated ascending aorta - can be normal!avl
Transthoracic Echo - ejection fraction, valve area, ventricular hypertrophy
Special:
Cardiac catheterisation
Cardiac MRI
ECG exercise stress testing
114
How is the severity of aortic stenosis assessed?
Transaortic pressure
| Aortic valve area
115
Management of aortic stenosis
Surgery in severe or symptomatic cases
Valvotomy - percutaneous ballon or open (forces valve leaflets apart)
Valvular replacement:
Mechanical - for younger patients, long lifespan, lifelong anti-coagulation
Bioprosthetic - older, no anti-coagulation needed, 10 year lifespan
TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) if open surgery not indicated
116
Complications of aortic stenosis
Sudden death
Infective endocarditis
Arrhythmias
Cardiac failure
117
How might you distinguish aortic stenosis from sclerosis?
Sclerosis: normal pulse, normal heart sounds, quiet and soft murmur
118
Most common effected areas in infective endocarditis
Left sided native or prosthetic valves
Right sided native valves
Devices e.g. pacemaker or defibrillator
119
Angiotensin II receptor blockers - side effects
Hypotension
| Hyperkalaemia
120
What is first degree heart block?
PR interval >0.2s
| Commonly asymptomatic and no need for intervention
121
What is second degree heart block?
Mobitz i: progressive prolongation of PR interval until a dropped beat (no QRS) [Wenckebach]
Mobitz ii: normal PR interval, but P-wave often not followed by QRS complex
122
What is third degree heart block?
Complete heart block
| No association between P-wave and QRS complex
123
Characteristics of cardiac tamponade
Beck's triad: muffled heart sounds, hypotension, raised JVP
Dyspnoea
Tachycardia
Absent Y descent on JVP due to limited R ventricular filling
Pulsus paradoxus (abnormal BP drop on inspiration)
ECG: electrical alternans (alternating QRS heights)
124
Signs and symptoms of acute pericarditis
```
Chest pain, may be pleuritic - relieved on sitting forward
Dyspnoea
Tachypnoea
Tachycardia
Pericardial rub
Non-productive cough
```
125
Causes of acute pericarditis
```
Coxsackie (+ varicella, influenza, mumps)
Dressler's syndrome (post-MI)
Uraemia (fibrinous pericarditis)
TB
Hypothyroidism
Trauma
Malignancy
Connective tissue disease (RA, SLE)
```
126
70-year-old woman is found to have a pan-systolic murmur after presenting with dyspnoea. A soft S1 and split S2 is also noted
Mitral regurgitation
127
Risk factors for mitral regurgitation?
```
Female
Older
Collagen disorders (Marfan's, Ehler-Dalnos)
Low BMI
Renal dysfunction
MI
Mitral prolapse or stenosis
```
128
Causes of mitral regurgitation?
MI (damage/ischaemia to papillary muscle or chordae tendenae)
Infective endocarditis
Rheumatic heart disease
Mitral valve prolapse
Congenital
129
Signs and symptoms of mitral regurgitation
Fatigue, SOB, oedema
```
Soft S1 (incomplete closure of mitral valve)
Split S2 if severe
Pansystolic murmur (blowing) over apex and radiating to axilla
```
130
Mitral regurgitation investigations
BP
ECG: broad P-waves (atrial enlargement)
CXR: cardiomegaly
Transthoracic Echo - assessment of severity
131
Management of mitral regurgitation
Nitrates, diuretics, positive inotropes, intra-aortic balloon pump (increases cardiac output)
HF: ACE-i, beta blockers, spironolactone
§
Severe - surgery (either repair or valve replacement)
132
What is aortic dissection?
Tear in the tunic intima of the wall of the aorta
133
What is aortic dissection associated with?
```
Hypertension
Trauma
Syphilis
Collagen disorders (Marfen's, Ehlers-Danlos)
Bicuspid aortic valve
Pregnancy
Turner's and Noonan's
```
134
Features of aortic dissection
Tearing chest pain radiating to back
Aortic regurgitation
HTN
Absent subclavian pulse
Carotid dissection
Specific arteries (angina from coronary, paraplegia from spinal, limb ischaemia from distal aorta)
Rarely ECG changes (sometimes ST elevation)
135
Types of aortic dissection
Stanford A: ascending (2/3s)
| Stanford B: descending
136
Which drugs can lead to gout?
Loop diuretics
Thiazides
Pyrazinamide
137
What ECG changes would you see in a PE?
SINUS TACHYCARDIA
RBBB
Right axis deviation
Inverted T waves
138
How does the New York Health Association classify heart failure?
Class I-IV based on exercise ability (normal - unable without discomfort); and symptoms (none - at rest)
139
What is the difference between systolic and diastolic heart failure?
Systolic: reduced LV ejection fraction (pumping out reduced proportion of its blood), ventricular dilatation
Diastolic: HF with preserved ejection fraction, ventricular hypertrophy
140
Main causes of heart failure
Vascular: previous infarction; hypertension
Electrical: arrhythmias (leading to cardiac compensation)
Muscular: dilated cardiomyopathy, hypertrophic cardiomyopathy, congenital heart disease
Valvular: stenosis or regurgitation
High-output: anaemia, thyrotoxicosis, septicaemia, liver failure - leading to reduced peripheral resistance
141
What is the Frank-Starling law?
Increased preload (stretching of myocytes) leads to increased contractility (i.e. stroke volume)
This is up to a point. After preload increases to a certain threshold, stroke volume plateaus and then decreases
142
What are the main determinants of stroke volume?
Preload
Cardiac contractility
Afterload (pressure against which the ventricles must contract)
143
Signs and symptoms of heart failure
Symptoms:
Resp - SOB, orthopnoea, paroxysmal nocturnal dyspnoea, wheeze
General - fatigue, ankle swelling, abdominal pain, weight loss, cachexia
Signs:
Raised JVP, peripheral oedema, bibasal crackles, hepatomegaly, ascites, displaced apex, S3/S4, pulsus alternans
144
What urgent investigation would you do in suspected HF, and in which cases would you carry it out?
Echocardiogram <2 weeks
Patients with: previous MI, severe symptoms, BNP >400, evidence of valvular disease or renal dysfunction
145
General investigations in patients with suspected HF
Bedside: BP, ECG (LVH, infarct), urinalysis (renal dysfunction)
Bloods: FBC (exclude anaemia or infection), U&Es (exclude renal causes of odema), TFTs (exclude thyrotoxicosis), cholesterol and HbA1c (CV risk stratification), LFTs (exclude liver failure), BNP
Imaging: CXR, echo
Special: cardiac catheterisation, cardiac biopsy, 24 hour ECG, lung function tests
146
What might you see on a CXR in a patient with HF?
Alveolar oedema (perihilar shadowing)
Kerley B (fluid in septae of secondary lobules)
Cardiomegaly
Upper lobe Diversion
Pleural Effusion (blunting of costrophrenic angle)
147
Lifestyle modifications for a patient with HF
Patient education
Smoking, weight, diet, sexual and travel advice
One-off pneumococcal vaccine and annual flu vaccine
148
What condition is classically associated with S4?
hypertrophic obstructive cardiomyopathy
149
What heart condition does alcohol abuse commonly cause?
Dilated cardiomyopathy
150
Management of HF
ACE-i (ramipril 1.25mg OD - 5mg BD) - check renal function
Beta blockers (bisoprolol 1.25mg OD) - double dose every 4 weeks untel target reached; NOT IN BRADY, ASTHMA, COPD or PULMONARY OEDEMA
+/- spironolactone
If still symptomatic then consider:
Hydralazine + nitrate (esp if Afro)
ARB
If still symptomatic:
- digoxin
- cardiac resynchronisation therapy
151
Management of heart failure with preserved ejection fraction
Loop diuretics for symptom control
| Address co-morbidities and underlying causes
152
Management of acute pulmonary oedema
FOND
Furosemide 40mg
O2 high-flow
Nitrates
Diamorphine
153
What is considered a normal ejection fraction?
55-70%
154
What is cor pulmonale and what are its causes?
Abnormal enlargement and dysfunction of right side of the heart due to pulmonary hypertension
PE
COPD
Pulmonary fibrosis
155
Causes of LBBB
Cardiomyopathy
Aortic stenosis
IHD
HTN
156
Treatment of severe bradycardia with signs of shock?
IV atropine 500mcg boluses
| Transcutaneous pacing if necessary
157
Causes of S3
Normal if <30 (<50 for women)
Left ventricular failure
Constrictive pericarditis
Mitral regurgitation
158
Causes of S4
HOCM
Aortic stenosis
HTN
159
Management if patient on warfarin has INR 5-8 (no bleeding)
Withhold two doses warfarin
| Reduce subsequent maintenance dose
160
Causes of RBBB
```
Right ventricular hypertrophy
PE
Increased right ventricular pressure (cor pulmonale)
MI
Atrial septal defect
Myocarditis or cardiomyopathy
```
161
Management of a patient on warfarin due to undergo surgery
If can wait 6-8 hours give IV Vit K
| If emergency: four-factor prothrombin factor complex
162
Major and minor criteria of rheumatic heart disease (2 major/1 major and 2 minor)
```
Major:
Erythema marginatum (pink rings on torso or inner limb surfaces)
Sydenham's chorea (late)
Polyarthritis
Carditis and valvulitis
Subcutaneous nodules
```
```
Minor:
Raised ESR/CRP
Pyrexia
Arthralgia
Prolonged PR interval
```
163
Treatment of rheumatic heart disease
IM Benzylpenicillin
Admit and bed rest
10 day penicillin (long-term)
Aspirin as needed
164
Cause of mitral stenosis
RHEUMATIC HEART FEVER
165
Features of mitral stenosis
```
Mid-diastolic murmur (low-rumbling)
Tapping apex (non-displaced)
Malar flush
AF
Loud S1, opening snap
Low volume pulse
```
166
Mitral stenosis CXR and ECG features
CXR: left atrial enlargement
ECG: bifid p waves or absent p waves
167
Most common cause of death following MI? What management would you consider for such patients
Cardiogenic shock (but actually VF)
Inoptropic support
Coronary angiography
Echo
Surgical intervention
168
Common causes of cardiogenic shock following MI?
Damage to ventricular myocardium leading to reduced ejection fraction
Left ventricular free wall rupture
169
What initial tests would you perform in someone with suspected pericarditis?
ECG (may be normal in 10%)
Echo (pericardial effusion)
Troponin (exclude MI or show myocardial involvement)
170
Complications of acute pericarditis
```
Chronic pericarditis
Cardiac tamponade (due to pericardial effusion)
```
171
Management of VSD and shock post-MI
```
Inotropic support
Intra-aortic balloon pump
Analgesia
Consider angiogram
Positive pressure ventilation
Transfer to cardiothoracic unit
Swann-Ganz pulmonary artery catheter
```
172
Normal pressures and oxygen sats in heart chambers
RA: 0-4mmHg (70%)
RV: 20/0-4mmHg (70%)
LV: 105/0-5 (95-100%)
173
Antibiotic management of infective endocarditis (for each organism)
Empirical: benpen, gentamicin
Strep: benpen and amoxicillin
Staph: fluclox and gentamicin
Aspergillus: miconazole
174
Definition of supraventricular tachycardia?
Narrow complex tachycardia
175
Acute and long-term management of SVT
Acute:
Vagal manoeuvres (valsalva, carotid sinus massage)
IV adenosine - 6mg, 12mg, 12mg (verapamil if asthmatic)
Electrical cardioversion
Long-term:
Beta-blocker
Radio-frequency ablation
176
What manoeuvres can patients use to terminate SVT attacks?
Head in icy water
Pressing on eyeballs
Finger down throat
All stimulate vagus nerve, slowing AV node conduction
177
What kind of tachy is Wolf-Parkinson-White and what are the ECG findings?
Atrioventricular re-entry tachy
Wide QRS with Delta waves (slurred upstroke)
Left axis deviation in most cases
Short PR
178
Associations of WPW and treatment
```
HOCM
Thyrotoxicosis
Mitral valve prolapse
Ebstein anomaly
ASD
```
Tx:
Radio-frequency ablation (definitive)
Sotalol (not if AF), flecainide, amiodarone
179
Anterolateral MI leads and artery?
V2, V3, I and aVL
180
Investigations for suspected aortic dissection
Bloods
BP both arms (20mmHg difference)
ECG: any ischaemia, right heart strain or AF in PE
CXR: widened mediastinum
CT thoracic aorta: quantify damage and assess for possible repair
181
Immediate management of aortic dissection
Admit to intensive care
Antihypertensives (reduce BP and HR) - IV sodium nitroprusside, beta blocker
Oxygen and analgesia
Surgery
182
Definitive treatment of type A and B aortic dissections
A: median sternotomy and cardiopulmonary bypass for aortic root repair/replacement
CONTRAINDICATED - evolving CVA or renal failure
B: BP control (surgery if aortic expansion evidence)
183
ECG changes in LVH
V1 or V2 S wave >30mm
| V5 or V6 R wave >30mm
184
What might lead to a false LVH diagnosis?
Obesity
Emphysema
Pericardial effusion
Young people with thin chest walls
185
Marfan's syndrome features
```
Tall and long limbed
High arched palate
Pes planus
Pectus excavatum
Aortic dilation (aortic aneurysm, dissection, regurgitation, mitral prolapse)
Upwards lens dislocation, blue sclera, myopia
Arachnodactyly
Scoliosis
Pneumothoraces
```
186
Most common cause of death in HOCM and what is the hereditary pattern?
Arrhythmia
| Autosomal dominant
187
HOCM features
AUTOSOMAL DOMINANT
Exertional dyspnoea and angina
Syncope following exercise
Ejection systolic murmur
Arrhythmia
Sudden death (ventricular arrhythmia, arrhythmia, HF)
Jerky pulse, large a waves, bisferiens (double beat)
188
Echo and ECG features of HOCM
Echo (MR SAM ASH)
Mitral Regurgitation
Systolic Anterior Motion of the mitral valve leaflet
Asymmetric hypertrophy
ECG
ST and T wave changes, progressive T wave inversion
Deep Q waves
AF
189
Management of HOCM
```
Amiodarone
Beta blocker
Cardiac defibrilator
Dual chamber pacemaker
Endocarditis prophylaxis
```
190
Drugs to avoid in HOCM
ACE-i
Nitrates
Inotropes
191
How should suspected DVT be investigated if Wells' score is >/=2 points?
Arrange leg vein ultrasound within 4 hours
If negative, take D-dimer
If US not possible in 4 hours, carry out D-dimer and give LMWH while waiting for US within 24 hours
192
How should DVT/PE be managed?
Initial LMWH or fondaparinux - continued for 5 days or until INR is >2 for at least 24 hours (6 months if active cancer)
Warfarin (or other vitamin K antagonist) within 24 hours - continued for 3 months and then reassessed (extended if unprovoked DVT and no bleeding risk)
Thrombolysis if massive PE (hypotensive etc)
193
What investigations would you carry out for a patient with an unprovoked DVT?
Cancer Ix:
Full examination, CXR, bloods (FBC, calcium, LFTs) and consider abdo-pelvic CT/mammogram if >40
```
Antiphospholipid antibodies (Hughes/APS)
Hereditary thrombophilia screening
```
194
What is taken into consideration when deciding a dose for LMWH?
Weight of patient
| Renal function
195
How is heparin monitored?
Activated partial thromboplastin time (APTT)
196
Causes of sinus bradycardia
```
Athletics
Hypothyroidism
Hypothermia
Legionnaire's, typhoid
MI
```
197
Investigations for infective endocarditis
```
ECG
Echo
Blood cultures (3 sets) - from peripheral vein
MC&S
US abdomen (possible splenic infarcts)
```
198
Complications of infective endocarditis
```
TIA
Complete heart block
AKI
HF
Vertebral osteomyelitis
```
199
Risk factors for infective endocarditis
```
Miscarriage
IVDU
Prosthetic heart valve
Chronic cholecystitis
Pneumonia
Colonic malignancy
```
200
What are the two contraindications for statins
```
Pregnancy
Macrolide antibiotics (risk of rhabdomyolosis)
```
201
Causes of cardiac arrest
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypocalcaemia, hypoglycaemia, acidaemia
Hypothermia
Thrombosis
Tension pneumothorax
Tamponade
Toxins
202
Action of loop diuretics and examples?
Inhibit Na-K-Cl transporter in ascending loop of Henle
Furosemide, bumetanide
203
Treatment of stable angina?
BETA BLOCKER (or CCB unless HF)
+ Aspirin and simvastatin
204
Normal QRS range
80-100ms
205
Features of coarctation of the aorta
HF/HTN
Poor feeding
Lethargy, SOB
Hypoperfusion of lower extremities - weakened femoral pulses
Notching of inferior border of ribs
Systolic murmur loudest at left sternal border
Apical click
```
Associated with:
Turner's
Bicuspid aortic valve
Neurofibromatosis
Berry aneurysms
```
206
First-line investigation for PE, and when is it contraindicated>
CT pulmonary angiogram
contraindicated if renal impairment as contrast is nephrotoxic - carry out V/Q (ventilation-perfusion) scan instead
Pulmonary angiography gold standard but significant complications
207
What is the DRAGON score used for?
3-month outcome in ischaemic stroke patients receiving tissue plasminogen activator
208
Indications for urgent surgical valve replacement in infective endocarditis?
Severe congestive heart failure
Overwhelming sepsis despite Abx
Pregnancy
Recurrent embolic episodes despite abx
209
What ECG changes might you see in a patient with a pulmonary embolism?
SINUS TACHYCARDIA
```
Large S wave lead I
Large Q wave lead III
Inverted T wave lead III
S1Q3T3
RBBB
```
210
Causes of raised proBNP
```
Renal dysfunction
Age >70
LVH
Ischaemia
Hypoxaemia (PE)
Sepsis
COPD
Liver cirrhosis
Diabetes
```
211
What drugs can cause a prolonged QT interval?
```
TCAs
Sotalol
Amiodarone
Chloroquine
Erythromycin
```
212
What conditions can cause a prolonged QT interval?
Hypo - calcaemia, kalaemia, magnesaemia
MI
Myocarditis
SAH
Hypothermia
213
Management of ventricular tachycardia
If adverse signs (<90 systolic BP, chest pain, HF) - immediate cardioversion
Amiodarone (central line)
Lidocaine (not if severe LV impairment)
Electrical cardioversion if these fail
Implantable cardioverter-defibrillator
214
Management of coarctation of the aorta in newborn
IV prostaglandins to keep patent ductus arteriosus
Surgical correction
215
How is angina diagnosed?
1. Constrictive pain in chest, neck, shoulders, jaw or arms
2. Worsened by physical exertion
3. Relieved within 5 mins by GTN
```
3 = typical angina
2= atypical angina
1 = non-anginal pain
```
216
Investigations for typical/atypica angina
1st line: CT coronary angiography
2nd line: non-invasive functional imaging (e.g. stress echo, MRI)
3rd line: invasive coronary angiography
217
When would you refer a patient with acute chest pain?
Current or within last 12 hours - emergency admission
12-72 hours ago - same-day admission
>72 hours - ECG and full assessment with troponin before deciding
218
Adverse effects of statins
Myopathies: rhabdomyolysis, myalgia, myositis
Liver impairment (must check baseline, 3 and 12 month LFTs): only stop statin if transaminise rises and persists at 3 times normal
Avoid if hx of cerebral haemorrhage
219
What is pulsus paradoxus and in whom would you see it?
Drop of systolic BP by 10mmHg on inspiration
Seen with cardiac tamponade and asthma
220
Features of Takayasu's arteritis, and what is its management?
```
ASIAN FEMALES
Systemic arteritis features - headache, malaise
Unequal BP in both arms
Absent limb pulses
Renal artery stenosis associated
Carotid bruit
Aortic regurgitation
Claudication
```
Mx: steroids
221
Features of hypokalaemia on an ECG
Prolonged PR
U waves
Small or absent T wave
Long QT
222
Causes of hypokalaemia with and without HTN
HTN:
Cushings, Conn's, Liddle's syndrome
Without:
Diuretics, renal tubular acidosis, GI loss (diarrhoea/vomiting)
223
Features of hypokalaemia
Muscle weakness, hypotonia
| Predisposition to digoxin toxicity - take care if giving digoxin to a patient on diuretics
224
Hypercalcaemia features on ECG
Short QT
| J (osborne) waves
225
Adverse effects of loop diuretics
LOW sodium, calcium, potassium, magnesium, chloride (alkalosis)
Ototoxicity
Hypotension
Gout
Renal impairment (dehydration and direct toxic effect)
226
What valvular disease is associated with PCOS?
Mitral valve prolapse
227
How many days before a surgery should warfarin be stopped, and what should INR be less than?
5 days before
| <1.5 INR
228
Management of aortic stenosis patients?
Aortic valve replacement if symptomatic or >40mmHg aortic valve gradient
229
What are the Levine grades of murmur?
1: faint murmur
2: slight murmur
3: moderate murmur without palpable thrill
4: loud with palpable thrill
5: very loud with extremely palpable thrill and heard with stethoscope edge
6: can hear with stethoscope off the chest
230
Takotsubo cardiomyopathy features
Crushing central chest pain following severely stressful event
Echo: apical ballooning of myocardium (octopus pot)
231
What ECG changes are indications for immediate thrombolysis or PCI?
ST elevation of >1mm (one small square) in at least two consecutive inferior leads II, III, avF, avR
LBBB
ST elevation of >2mm in 2 or more consecutive anterior leads
232
Management of orthostatic hypotension
Lifestyle measures - adequate salt and hydration
Compression stockings
Fludrocortisone (increases sodium reabsorption and plasma volume) or midodrine
Counter-pressure manoeuvres and head-tilt sleeping
233
What is Eisenmenger's syndrome?
Reversal of a left to right shunt once the right ventricle is so large it overcomes the pressure in the left leading to cyanosis. Child comes in cyanosed with haemoptysis, RVF, having had pansystolic murmur at birth.
Associated with uncorrected ASD, VSD and patent ductus arteriosus
Managed by lung-heart transplant
234
What heart condition are alcoholics predisposed to?
Dilated cardiomyopathy (dilated left ventricle, <40% left ventricle ejection fraction)
235
ECG changes with hypothermia
```
Prolonged PR, QT and QRS
J waves
Brady <60bpm
Shivering artefacts
VT, VF, asystole <16 degrees
```
236
Bus or lorry driver post-MI going back to work
Must notify DVLA and stay off work for 6 weeks. DVLA will then determine safety to return
237
Target INR for a patient who has suffered more than one PE
3.5
238
Broad complex tachycardia following MI and drop in BP
Ventricular tachycardia
239
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.
Left ventricular free wall rupture
240
Orthostatic hypotension diagnosis
>20mmHg drop in systolic or >10mmHg drop in diastolic after 3 mins of standing
241
Young male smoker with painful hands and feet, cold and pale extremities (Raynaud's) and ulcers
Buerger's syndrome
242
Features of constrictive pericarditis
JVP with X + Y descent
positive Kussmaul's (rise in JVP on inspiration)
Dyspnoea, RHF signs (oedema, hepatomegaly, ascites)
Pericardial knock (loud S3)
CXR: pericardial calcification
243
What investigations must you do for a patient starting on a statin?
LFTs baseline, 3 and 12 months
244
DVLA advice post MI
cannot drive for 4 weeks
245
First line test for coronary artery disease?
CT angiogram
246
Immediate management of MI
Dual antiplatelet therapy - Aspirin + clopidogrel/ticagrelor
Morphine + metoclopramide (antiemetic)
Anticoagulation for 24-72 hours: heparin/fondaparinux
Angiography (within 24 hours for STEMI, 72 hours for NSTEMI)
247
How to treat bradycardia
Pacemaker
248
Commonest cause of leg pain following bypass surgery?
Reperfusion
249
What is required prior to giving a CT angiogram?
```
Beta blocker (lowers heart rate before scan)
U&Es - ensure renal function before giving CT contrast
```
250
Diagnosis of rheumatic heart disease?
ASO titre
251
How many small squares on an ECG is 1 second?
25mm
252
P waves in normal sinus?
Positive in I, II and avF
| Negative in avR
253
Sinus arrhythmia
Increased HR on inspiration, decreases on expiration
Regularly irregular
Still fulfils criteria for sinus rhythm
254
Characteristics of premature atrial complex on an ECG?
Positive p wave (lead II)
Narrow QRS
Different morphology of p wave
255
Premature junctional complex characteristics
Absent or inverted p wave (II)
| Narrow QRS
256
Premature ventricular complex characteristics
Wide qrs
No p wave
T wave opposite to r wave
257
Sinus brady characteristics ecg
narrow qrs
p wave present
HR <60
258
SVT characteristics ecg
HR >150
Indistinguishable p wave
Narrow qrs
Regular
259
Atrial flutter ecg characteristics
Sawtooth p waves >250
Narrow qrs
Often 2:1 ratio (can be confused with SVT)
260
Junctional arrhythmia ecg
40-60 HR
Absent/inverted p wave
Narrow qrs
261
When would you not treat AF with BB and CCB?
If patient has CHF - treat instead with digoxin and amiodarone
262
Which patients should you not start on ACE-i for blood pressure?
Non-diabetics over55
Afro-Carribean
Women expecting to get pregnant
263
Definitive management of WPW syndrome?
Radiofrequency ablation of the accessory pathway
Medical: sotalol, amiodarone, flecainide
264
Treatment of torsades de pointes
Magnesium sulphate
265
```
Cause of
J waves
U waves
Delta waves
Q wave
```
J wave: hypothermia and hypercalcaemia
U wave: hypokalaemia
Delat wave: WPW
Q wave: previous MI
266
Causes of ejection systolic murmur
```
Pulmonary stenosis
Aortic stenosis
HOCM
Tetralogy of Fallot
Atrial septal defect
```
267
When should you prescribe anticoagulation to a patient following a stroke?
2 weeks after the event (as long as haemorrhage excluded)
268
Most important causes of ventricular tachy
Hypokalaemia
| Hypomagnesaemia
269
Normal PR interval?
3-5 small squares
270
Normal QRS interval
3 small squares
271
Next investigation if BNP is high in patient with suspected heart failure?
Transthoracic echo
