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Year 3 Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Which conditions fall under the monicker of Acute Coronary Syndromes?

A

STEMI
NSTEMI
Unstable Angina

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2
Q

How do patients with acute coronary syndromes present?

A

Cardiac Chest Pain

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3
Q

How is a STEMI defined on an ECG?

A

Persistent ST segment elevation or new LBBB on their ECG

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4
Q

What is a usual troponin I level with a STEMI?

A

> 100ng/L

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5
Q

In addition to Troponin i, what other biochemical value is appropriate to measure in a suspected STEMI, and what is a positive value for this marker?

A

Creatine Kinase, >400

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6
Q

How does an NSTEMI present?

A

ECG may show ST depression, T wave inversion or may even be normal

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7
Q

What is a usual troponin i level with an NSTEMI?

A

> 100ng/L

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8
Q

How does Unstable Angina present on an ECG?

A

ECG may show ST depression, T wave inversion or may even be normal

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9
Q

How is troponin i affected with unstable angina?

A

It isn’t, troponin i will usually be normal

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10
Q

How long after myocardial damage does troponin i increase, and how long will it be raised for?

A

3-4h after initial injury

Can stay elevated for 2 weeks

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11
Q

What is the upper limit of normal for troponin i in Males?

A

34ng/L

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12
Q

What is the upper limit of normal for troponin i in Females?

A

16ng/L

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13
Q

How much of a rise in serum troponin i may suggest ACS?

A

By more than 5ng/L

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14
Q

When should troponin i be measured with suspected ACS?

A

At admission then 1 hour later

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15
Q

When should troponin i be measured with suspected ACS if symptoms began more than 3 hours ago?

A

Only once.

Another sample can however be taken 2 hours later if there is diagnostic uncertainty

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16
Q

Which other non-ACS conditions can cause a rise in troponin i?

A 
Cardiac Failure
Myocarditis
Aortic Dissection
Aortic Stenosis
Hypertrophic Cardiomyopathy
Takotsubo Cardiomyopathy
Malignancy
Stroke
Sepsis
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17
Q

Which ECG changes are diagnostic for a STEMI?

A

ST elevation in 2/more leads from the same cardiac zone

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18
Q

Which additional ECG views should be performed with a suspected STEMI?

A

Posterior leads

RV leads

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19
Q

Which conditions can mimic a STEMI on an ECG?

A

Early repolarisation causes up-sloping ST elevation. Common in younger, more athletic patients.

Pericarditis
Brugada syndrome
Takotsubo Cardiomyopathy

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20
Q

What management is appropriate for a confirmed STEMI?

A 
IV Access
Pain relief 
Oxygenation
PPCI
Full Biochemistry inc Lipids and HbA1c
Diabetes control
Hypertension Control
Smoking Cessation
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21
Q

Which pharmacological management is indicated with a confirmed STEMI?

A

Aspirin - 300mg loading, 75mg OD for life
Bisoprolol for rate control
ACE/AT1 blocker for hypertension
Statin for risk factors

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22
Q

Which criteria must be met for a STEMI patient to be prescribed Prasrugel?

A

Eligible for PPCI
<75 years old
>60kg
No previous TIA/Stroke

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23
Q

If a patient is unsuitable for Prasrugel following a STEMI, what alternative medications are available?

A

Clopidogrel

Ticagrelor

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24
Q

What management is appropriate for a confirmed NSTEMI/Unstable Angina?

A

Pain relief
Aspirin 300mg loading, 75mg OD
48h Enoxaparin
Repeat ECG
Risk assessment if troponin is raised - GRACE score
Ticagrelor if MI risk >3%
Nitrates, Calcium channel blockers while wating for Angio

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25
Q

What is Stable Angina?

A

A condition characterised by the onset of Chest Discomfort provoked by effort/emotion and relieved by rest

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26
Q

What are some associated symptoms of Stable Angina?

A

Radiation of pain to throat/arm
Exertional breathlessness
Autonomic features inc Fear, Sweating and Nausea if severe

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27
Q

What are some common causes of angina?

A 
Coronary Artery disease - Most common
Aortic stenosis
Hypertensive heart disease
Hypertrophic cardiomyopathy
Iatrogenic - No identifiable cause
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28
Q

What are some important things to ask with an angina history?

A 
Provoking/relieving factors
Stability of symptoms
Risk factors
Occupation 
Exercise Hx
Diet
Alcohol, smoking and drug Hx
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29
Q

What are important things to examine with suspected Angina?

A 
Weight and Height
BP
Murmurs
Evidence of Hyperlipidaemia
Evidence of Peripheral Vascular disease
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30
Q

Which Investigations are appropriate with suspected stable angina?

A

FBC and Biochemistry
Lipid profile
12 lead ECG

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31
Q

What is important to identify with suspected stable angina, and how is this identified?

A

Percentage likelihood of Coronary Artery disease, calculated using a table

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32
Q

Which investigation is recommended if a suspected Angina patient has a 61-90% chance of having Coronary Artery disease?

A

Coronary Angiography

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33
Q

Which investigation is recommended if a suspected Angina patient has a 30-60% chance of having Coronary Artery disease?

A

Cardiac MRI

Echo

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34
Q

Which investigation is recommended if a suspected Angina patient has a 10-29% chance of having Coronary Artery disease?

A

CT Calcium Scoring

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35
Q

What must have been calculated to allow diagnosis of stable angina with an exercise ECG?

A

Percentage likelihood of Coronary Artery disease

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36
Q

For males aged over 70, what is their percentage likelihood of coronary artery disease assumed to be?

A

90%

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37
Q

For women aged over 70, what is their percentage likelihood of coronary artery disease assumed to be?

A

61-90% unless high risk/typical symptoms then its 90%

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38
Q

What drug treatment is recommended for confirmed stable angina?

A

Aspirin 75mg OD, Clopidogrel if unable to take aspirin
Sublingual GTN
Beta Blockers for rate limitation
Isosorbide Mononitrate - Long acting Nitrate
Statin

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39
Q

How is Stage 1 Hypertension defined?

A

Clinic BP >140/90mmHg

Average Home/Ambulatory BP >135/85mmHg

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40
Q

How is Stage 2 Hypertension defined?

A

Clinic BP >160/100mmHg

Average Home/Ambulatory BP >150/95mmHg

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41
Q

How is Severe Hypertension defined?

A

Clinic Systolic >180mmHg

Clinic Diastolic >110mmHg

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42
Q

What are some risk factors for hypertension?

A 
TIA/Stroke
Diabetes
Previous Renal Disease
Smoking
Cholesterol
NSAID excess
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43
Q

Which conditions in a previous medical history increase the risk of hypertension?

A 
Angina
CCF
Palpitations
Syncope
Valvular heart disease
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44
Q

What are some appropriate investigations for hypertension?

A 
Urine Sample - ?Proteinuria
Bloods inc Glucose, U+E, Cholesterol
Fundoscopy - ?Retinopathy
12 lead ECG
Consider ECHO if suspicious of structural defect
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45
Q

Which risk assessment score is available to assess cardiac risk with hypertension?

A

QRISK

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46
Q

When should patients with Stage 1 Hypertension be offered treatment?

A 
<80 y/o
Evidence of Target Organ damage
Renal impairment
Diabetes
QRISK>20%
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47
Q

When should patients with Stage 2 Hypertension be offered treatment?

A

All should be treated, irrespective of patient factors

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48
Q

When should patients with Severe Hypertension be offered treatment?

A

Immediately. Do not wait for Average/Home BP readings

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49
Q

What are some non-pharmacological management options for Hypertension?

A 
Weight reduction if BMI >25
Moderate/Reduce salt intake
Minimise alcohol intake
Aerobic exercise
Smoking cessation
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50
Q

What is a Hypertensive Crisis?

A

An increase in blood pressure which if sustained over the next few hours will lead to irreversible end-organ damage

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51
Q

What is a Hypertensive Emergency?

A

High BP associated with a critical event - Encephalopathy, Pulmonary oedema, AKI, Myocardial ischaemia

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52
Q

What is a Hypertensive Urgency?

A

High BP without a critical illness. May include malignant hypertension

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53
Q

What is the aim of treatment of hypertensive emergencies?

A

To reduce Diastolic BP to 110mmHg in 3-12 hours

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54
Q

What is the aim of treatment of hypertensive urgencies?

A

To reduce Diastolic BP to 110mmHg in 24 hours

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55
Q

What pharmacological management is appropriate with a Hypertensive emergency?

A

Sodium Nitroprusside
Labetalol
GTN
Esmolol

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56
Q

What is the Diastolic BP usually in Hypertensive Urgencies?

A

> 130mmHg

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57
Q

What is the aim of treatment of Hypertensive Urgencies?

A

To reduce the Diastolic BP to <100mmHg over 48-72 hours

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58
Q

What pharmacological management is appropriate with a Hypertensive Urgency?

A

Nifedipine

Amlodipine

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59
Q

What trio of symptoms are common with a Pheochromocytoma?

A

Episodic headache
Sweating
Tachycardia

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60
Q

What is a common/defining symptom of a Phaechromocytoma?

A

Paroxysmal Hypertension

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61
Q

How is a Pheochromocytoma diagnosed?

A

24h urine collection

CT/MR to identify tumour

62
Q

What pharmacological management is indicated with a confirmed Phaeochromocytoma prior to surgical resection?

A

Combined alpha and beta blocker - Phenoxybenzamine

63
Q

What is Heart Failure?

A

The heart is unable to pump sufficiently to maintain the blood flow to meet the body’s needs

64
Q

What are some common causes of Heart Failure?

A 
Ischaemic Heart Disease
Hypertension
Valvular Heart disease
AF
Chronic Lung Disease
Cardiomyopathy
Previous Chemotherapy
HIV
65
Q

What is HFREF?

A

Heart failure with reduced ejection fraction - Systolic dysfuncion

66
Q

What is HFNEF?

A

Heart failure with normal ejection fraction

67
Q

Which patients can present with HFNEF?

A

Elderly
Overweight
Hypertension
AF

68
Q

What are some common symptoms of Heart Failure?

A 
Breathlessness
Proxsymal Nocturnal Dyspnoea
Fatigue
Peripheral Oedema
Persistent cough
69
Q

Which investigations are appropriate with suspected HF?

A

U+Es - Check renal function prior to diuresis
FBC - ?Anaemia
LFTs - ?Hepatic Congestion
TFTs - ?Thyroid Disease
Ferritin and Transferin - ?Haemochromatosis

70
Q

Is BNP an appropriate diagnostic marker in suspected HF?

A

No, can also be raised in AF and RV strain. Use if diagnosis uncertain

71
Q

Which signs are commonly seen on a CXR with HF?

A 
Cardiomegaly
Pleural effusions
Perihilar Shadowing/Consolidations
Alveolar oedema
Air Bronchograms
72
Q

How is LV function assessed in suspected HF?

A

Echocardiography

Cardiac MRI

73
Q

What are some lifestyle management options with confirmed HF?

A

Smoking cessation
Reduced alcohol consumption
Salt restriction
Fluid restriction

74
Q

What pharmacological management options are available with HF?

A

Diuretics - Furosemide, Bendroflumethiazide
ACE Inhibitors
ARBs
Beta blockers

75
Q

What defines Class I HF?

A

No symptomatic limitation of physical activity

76
Q

What defines Class II HF?

A

Slight limitation of physical activity
Ordinary physical activity results in symptoms
No symptoms at rest

77
Q

What defines Class III HF?

A

Marked limitation of physical activity
Less than ordinary physical activity results in symptoms
No symptoms at rest

78
Q

What defines Class IV HF?

A

Inability to carry out any physical activity without symptoms
May have symptoms at rest
Discomfort increases with any degree of activity

79
Q

When can a pacemaker be offered with HF?

A

If there is evidence of L BBB and medical therapy has failed

80
Q

How can a pacemaker help improve symptoms with HF?

A

Reduce delay in ventricle depolarisation and increase cardiac output

81
Q

What types of pacemaker can be offered to patients with HF?

A

Cardiac Resynchronisation Pacemaker (CRT)

Implantable Cardiac Defibrilator (ICD)

82
Q

Which classical symptoms can Aortic Stenosis present with?

A

Angina
HF
Syncope

83
Q

What is often the initial presenting symptom with Aortic Stenosis?

A

Decrease in exercise tolerance or dyspnoea on exertion

84
Q

What are some causes of Aortic Stenosis?

A

Congenital Bicuspid valve
CKD
Previous Rheumatic Fever

85
Q

Where is the murmur of Aortic Stenosis best appreciated?

A

R 2nd Intercostal Space, S1 murmur

86
Q

How are valvular heart abnormalities assessed?

A

Echocardiography

87
Q

How can Aortic Stenosis be graded?

A

Mild
Moderate
Severe

88
Q

When is surgery indicated with Aortic Stenosis?

A

Symptomatic due to AS
Asymptomatic severe AS with LV systolic dysfunction
Asymptomatic severe AS with abnormal exercise test
Asymptomatic severe AS at time of other cardiac surgery

89
Q

What is a TAVI?

A

Transcatheter Aortic Valve Implantation

90
Q

Why do patients eventually become symptomatic with Aortic Regurgitation?

A

The increased LV load leads to progressive LV dilatation and HF

91
Q

What is the most common presenting complaint with Aortic Regurgitation?

A

Exertional Dyspnoea or a reduced exercise tolerance

92
Q

What are some common causes of Aortic Regurgitation?

A 
Idiopathic Dilatation of Aorta
Congenital Aortic valve Abnormalities
Calcific degeneration
Rheumatic disease
Infective endocarditis
Marfans
93
Q

Where is the murmur of Aortic Regurgitation best appreciated?

A

L Sternal edge, S2 murmur

94
Q

What clinical signs are associated with Aortic Regurgitation?

A

Collapsing Pulse

Head-Bobbing - De Musset’s sign

95
Q

What are valid indications for surgery with Chronic Aortic Regurgitation?

A

Symptomatic severe AR
Asymptomatic severe AR with evidence of early LV systolic dysfunction
Asymptomatic AR with aortic root dilatation

96
Q

What are some classic symptoms of Mitral Stenosis?

A 
SOBOE
Orthopnoea
PND
Chest Pain
Haemoptysis
Peripheral Oedema
97
Q

What are some common causes of Mitral Stenosis?

A

Rheumatic fever
Calcification of Mitral Valve Leaflets
Congenital Heart Disease
Infective endocarditis

98
Q

Where is the murmur of Mitral stenosis best appreciated?

A

Apex, S2 murmur

99
Q

What are some causes of Mitral Regurgitation?

A 
Mitral valve prolapse
Rheumatic heart disease
IHD
Infective Endocarditis
Collagen vascular diseases - Marfans
100
Q

Where is the murmur of Mitral Regurgitation best appreciated?

A

5th ICS Mid-clavicular line R

S1 murmur

101
Q

Which surgical interventions are available for Mitral Regurgitation?

A

Mitral Valve Repair

Mitral Valve Replacement

102
Q

When is surgical intervention indicated in Mitral Regurgitation patients?

A

Symptomatic patients

Asymptomatic patients with Mild-Moderate LV dysfunction

103
Q

What is infective endocarditis?

A

Infection of the heart valves or endocardium

104
Q

Which conditions can pre-dispose to infective endocarditis?

A

Mitral valve prolapse
Presence of Prosthetic Material
Rheumatic heart disease
Aortic valve disease

105
Q

What are some common causative organisms of infective endocarditis?

A

Viridans Streptococci - 50%
Staph. Aureus - 20%
Enterococci - 10%
Fungi - Candida/Aspergillus

106
Q

Which patients should always be suspected of infective endocarditis?

A

Unexplained fever, bacteraemia or systemic illness

+/-

New/unexplained murmur

107
Q

Which investigations are appropriate with suspected infective endocarditis?

A 
FBC
ESR, CRP
U+E
LFTs
MSU
CXR
ECG
Echocardiogram
Cultures
108
Q

How many cultures are appropriate to take with suspected infective endocarditis?

A

At least 3, 6 if possible from varying sites. Delay ABx if possible until cultures are taken

109
Q

Which sonographic investigations are available for suspected infective endocarditis?

A

Echocardiogram - 65% of vegetations

Transoesophageal Echocardiogram - 95% of vegetations

110
Q

How can the diagnostic criteria for infective endocarditis be classified?

A

Major

Minor

111
Q

Which diagnostic criteria are required for infective endocarditis?

A

2 Major
1 Major, 3 Minor
5 Minor

112
Q

What are viewed as major diagnostic criteria for infective endocarditis?

A 
\+ve Blood Cultures
Endocardial involvement
\+ve Echo findings
New Valvular regurgitation
Dehiscence of prosthesis
113
Q

What are viewed as minor diagnostic criteria for infective endocarditis?

A

Predisposing valvular/cardiac abnormality
IVDU
Temperature >38
Suggestive Echo/Culture

114
Q

Which line is useful in the treatment of infective endocarditis?

A

CVC

115
Q

How should the treatment of infective endocarditis be monitored?

A

1/Weekly Echo
2/Weekly ECG
2/Weekly Bloods

116
Q

When is surgery indicated with confirmed infective endocarditis?

A 
Moderate - Severe Cardiac Failure
Valvular dehiscences
Uncontrolled infection
Relapse after optimal therapy 
Threatened/Actual systemic emboli
117
Q

How does AF initially manifest?

A

Paroxysmal/episodic, before progressing to persistent/permanent AF

118
Q

How do the majority of patients with AF present?

A

Asymptomatic

119
Q

What are some associated complications of AF which make identification of AF easier?

A

Haemodynamic Instability due to Arrhythmia
ACS
Congestive Cardiac Failure
Cardioembolic Stroke

120
Q

Which conditions’ risk increases with AF?

A

Cardioembolic Stroke

Cardiac instability

121
Q

What are some common symptoms of AF?

A 
Breathlessness
Palpitations
Syncope/Dizziness
Chest Discomfort
Stroke/TIA
122
Q

What is the initial presenting clinical sign of AF?

A

Irregularly irregular pulse

123
Q

Once AF is suspected, how soon should an ECG be performed?

A

ASAP, preferrably same day

124
Q

With AF, when is Cardiac Monitoring indicated?

A

If suspected of being Paroxysmal/Intermittent

125
Q

When is Echocardiography indicated with suspected AF?

A

Structural heart defect is suspected

Cardioversion is being considered

126
Q

Should anticoagulation be held until after echocardiography with suspected AF?

A

No

127
Q

What are the three management steps with confirmed AF?

A

Anticoagulation to prevent stroke
Rate Control
Rhythm control

128
Q

Which score can predict the risk of a stroke/systemic embolus with known AF?

A

CHADS-VASC

129
Q

What does a CHADS-VASC score of 2 or more indicate?

A

Significant risk of stroke

Anticoagulation should be offered

130
Q

What does a CHADS-VASC score of 1 in men indicate?

A

Intermediate risk of stroke

Consider anticoagulation

131
Q

What does a CHADS-VASC score of 0 indicate?

A

Truly low risk of stroke

Anticoagulation not required

132
Q

What does a CHADS-VASC score of 1 in women indicate?

A

Low risk of stroke

Anticoagulation not required

133
Q

How can the bleeding risk associated with anticoagulated AF patients be assessed?

A

HAS-BLED

134
Q

What are some reversible risk factors associated with anticoagulation and AF?

A

Uncontrolled Hypertension
Poor INR control
Concurrent medication - Aspirin, NSAIDs
Harmful alcohol consumption

135
Q

What is the primary management of AF?

A

DOACs

136
Q

What is a DOAC?

A

Daily Oral Anti-coagulant

137
Q

How do Apixaban, Rivaroxaban, Edoxaban work?

A

Inhibit Factor Xa

138
Q

How does Dabigatran work?

A

Inhibit Thrombin

139
Q

Why are DOACs preferable to Warfarin with AF?

A

Do not require INR monitoring

No food/alcohol restrictions

140
Q

How are DOACs excreted?

A

Renally, require yearly renal monitoring

141
Q

How is the Rhythm controlled in known AF?

A

Controlled DC Shock

Pharmacological intervention

142
Q

How is the Rate controlled in known AF?

A

Beta Blockers

143
Q

What are the most common types of Supraventricular Tachycardia?

A

AV Nodal Re-entry Tachycardia (AVNRT) - 60%

Atrio-ventricular Re-entry Tachycardia (AVRT) - 30%

144
Q

In haemodynamically stable patients, what is the first line treatment for SVTs?

A

Vagal manoeuvers:
Breath-holding
Valsalva
Carotid Sinus massage

145
Q

What are some important rules with Carotid Massage for SVT?

A

First auscultate for carotid bruits - stroke risk

Do not massage both together

146
Q

What pharmacological intervention can be used with SVT?

A

Calcium Channel Blockers - Adenosine

147
Q

What symptoms can Adenosine produce in SVT treatment?

A

Chest Discomfort
Transient Hypotension
Flushing

148
Q

When should Adenosine not be used with SVT treatment?

A

If the patient has known reversible airway disease

149
Q

What is a potential side-effect of Adenosine when treating SVT?

A

Arrhythmia - Keep Crash trolley close

150
Q

When can Cardioversion be offered in SVT?

A

Hypotension
Pulmonary Oedema
CP with ischaemia

151
Q

When is Cardioversion indicated in patients with sustained VT?

A

If they are haemodynamically stable

152
Q

What pharmacological options can be used with VT?

A

Beta Blockers - Careful if Hypotension or reduced LV function
Amiodarone/Lidocaine

Year 3 Medicine (8 decks)

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