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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
What is Stable Angina?
A condition characterised by the onset of Chest Discomfort provoked by effort/emotion and relieved by rest
26
What are some associated symptoms of Stable Angina?
Radiation of pain to throat/arm Exertional breathlessness Autonomic features inc Fear, Sweating and Nausea if severe
27
What are some common causes of angina?
``` Coronary Artery disease - Most common Aortic stenosis Hypertensive heart disease Hypertrophic cardiomyopathy Iatrogenic - No identifiable cause ```
28
What are some important things to ask with an angina history?
``` Provoking/relieving factors Stability of symptoms Risk factors Occupation Exercise Hx Diet Alcohol, smoking and drug Hx ```
29
What are important things to examine with suspected Angina?
``` Weight and Height BP Murmurs Evidence of Hyperlipidaemia Evidence of Peripheral Vascular disease ```
30
Which Investigations are appropriate with suspected stable angina?
FBC and Biochemistry Lipid profile 12 lead ECG
31
What is important to identify with suspected stable angina, and how is this identified?
Percentage likelihood of Coronary Artery disease, calculated using a table
32
Which investigation is recommended if a suspected Angina patient has a 61-90% chance of having Coronary Artery disease?
Coronary Angiography
33
Which investigation is recommended if a suspected Angina patient has a 30-60% chance of having Coronary Artery disease?
Cardiac MRI | Echo
34
Which investigation is recommended if a suspected Angina patient has a 10-29% chance of having Coronary Artery disease?
CT Calcium Scoring
35
What must have been calculated to allow diagnosis of stable angina with an exercise ECG?
Percentage likelihood of Coronary Artery disease
36
For males aged over 70, what is their percentage likelihood of coronary artery disease assumed to be?
90%
37
For women aged over 70, what is their percentage likelihood of coronary artery disease assumed to be?
61-90% unless high risk/typical symptoms then its 90%
38
What drug treatment is recommended for confirmed stable angina?
Aspirin 75mg OD, Clopidogrel if unable to take aspirin Sublingual GTN Beta Blockers for rate limitation Isosorbide Mononitrate - Long acting Nitrate Statin
39
How is Stage 1 Hypertension defined?
Clinic BP >140/90mmHg | Average Home/Ambulatory BP >135/85mmHg
40
How is Stage 2 Hypertension defined?
Clinic BP >160/100mmHg | Average Home/Ambulatory BP >150/95mmHg
41
How is Severe Hypertension defined?
Clinic Systolic >180mmHg | Clinic Diastolic >110mmHg
42
What are some risk factors for hypertension?
``` TIA/Stroke Diabetes Previous Renal Disease Smoking Cholesterol NSAID excess ```
43
Which conditions in a previous medical history increase the risk of hypertension?
``` Angina CCF Palpitations Syncope Valvular heart disease ```
44
What are some appropriate investigations for hypertension?
``` Urine Sample - ?Proteinuria Bloods inc Glucose, U+E, Cholesterol Fundoscopy - ?Retinopathy 12 lead ECG Consider ECHO if suspicious of structural defect ```
45
Which risk assessment score is available to assess cardiac risk with hypertension?
QRISK
46
When should patients with Stage 1 Hypertension be offered treatment?
``` <80 y/o Evidence of Target Organ damage Renal impairment Diabetes QRISK>20% ```
47
When should patients with Stage 2 Hypertension be offered treatment?
All should be treated, irrespective of patient factors
48
When should patients with Severe Hypertension be offered treatment?
Immediately. Do not wait for Average/Home BP readings
49
What are some non-pharmacological management options for Hypertension?
``` Weight reduction if BMI >25 Moderate/Reduce salt intake Minimise alcohol intake Aerobic exercise Smoking cessation ```
50
What is a Hypertensive Crisis?
An increase in blood pressure which if sustained over the next few hours will lead to irreversible end-organ damage
51
What is a Hypertensive Emergency?
High BP associated with a critical event - Encephalopathy, Pulmonary oedema, AKI, Myocardial ischaemia
52
What is a Hypertensive Urgency?
High BP without a critical illness. May include malignant hypertension
53
What is the aim of treatment of hypertensive emergencies?
To reduce Diastolic BP to 110mmHg in 3-12 hours
54
What is the aim of treatment of hypertensive urgencies?
To reduce Diastolic BP to 110mmHg in 24 hours
55
What pharmacological management is appropriate with a Hypertensive emergency?
Sodium Nitroprusside Labetalol GTN Esmolol
56
What is the Diastolic BP usually in Hypertensive Urgencies?
>130mmHg
57
What is the aim of treatment of Hypertensive Urgencies?
To reduce the Diastolic BP to <100mmHg over 48-72 hours
58
What pharmacological management is appropriate with a Hypertensive Urgency?
Nifedipine | Amlodipine
59
What trio of symptoms are common with a Pheochromocytoma?
Episodic headache Sweating Tachycardia
60
What is a common/defining symptom of a Phaechromocytoma?
Paroxysmal Hypertension
61
How is a Pheochromocytoma diagnosed?
24h urine collection | CT/MR to identify tumour
62
What pharmacological management is indicated with a confirmed Phaeochromocytoma prior to surgical resection?
Combined alpha and beta blocker - Phenoxybenzamine
63
What is Heart Failure?
The heart is unable to pump sufficiently to maintain the blood flow to meet the body's needs
64
What are some common causes of Heart Failure?
``` Ischaemic Heart Disease Hypertension Valvular Heart disease AF Chronic Lung Disease Cardiomyopathy Previous Chemotherapy HIV ```
65
What is HFREF?
Heart failure with reduced ejection fraction - Systolic dysfuncion
66
What is HFNEF?
Heart failure with normal ejection fraction
67
Which patients can present with HFNEF?
Elderly Overweight Hypertension AF
68
What are some common symptoms of Heart Failure?
``` Breathlessness Proxsymal Nocturnal Dyspnoea Fatigue Peripheral Oedema Persistent cough ```
69
Which investigations are appropriate with suspected HF?
U+Es - Check renal function prior to diuresis FBC - ?Anaemia LFTs - ?Hepatic Congestion TFTs - ?Thyroid Disease Ferritin and Transferin - ?Haemochromatosis
70
Is BNP an appropriate diagnostic marker in suspected HF?
No, can also be raised in AF and RV strain. Use if diagnosis uncertain
71
Which signs are commonly seen on a CXR with HF?
``` Cardiomegaly Pleural effusions Perihilar Shadowing/Consolidations Alveolar oedema Air Bronchograms ```
72
How is LV function assessed in suspected HF?
Echocardiography | Cardiac MRI
73
What are some lifestyle management options with confirmed HF?
Smoking cessation Reduced alcohol consumption Salt restriction Fluid restriction
74
What pharmacological management options are available with HF?
Diuretics - Furosemide, Bendroflumethiazide ACE Inhibitors ARBs Beta blockers
75
What defines Class I HF?
No symptomatic limitation of physical activity
76
What defines Class II HF?
Slight limitation of physical activity Ordinary physical activity results in symptoms No symptoms at rest
77
What defines Class III HF?
Marked limitation of physical activity Less than ordinary physical activity results in symptoms No symptoms at rest
78
What defines Class IV HF?
Inability to carry out any physical activity without symptoms May have symptoms at rest Discomfort increases with any degree of activity
79
When can a pacemaker be offered with HF?
If there is evidence of L BBB and medical therapy has failed
80
How can a pacemaker help improve symptoms with HF?
Reduce delay in ventricle depolarisation and increase cardiac output
81
What types of pacemaker can be offered to patients with HF?
Cardiac Resynchronisation Pacemaker (CRT) | Implantable Cardiac Defibrilator (ICD)
82
Which classical symptoms can Aortic Stenosis present with?
Angina HF Syncope
83
What is often the initial presenting symptom with Aortic Stenosis?
Decrease in exercise tolerance or dyspnoea on exertion
84
What are some causes of Aortic Stenosis?
Congenital Bicuspid valve CKD Previous Rheumatic Fever
85
Where is the murmur of Aortic Stenosis best appreciated?
R 2nd Intercostal Space, S1 murmur
86
How are valvular heart abnormalities assessed?
Echocardiography
87
How can Aortic Stenosis be graded?
Mild Moderate Severe
88
When is surgery indicated with Aortic Stenosis?
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
What is a TAVI?
Transcatheter Aortic Valve Implantation
90
Why do patients eventually become symptomatic with Aortic Regurgitation?
The increased LV load leads to progressive LV dilatation and HF
91
What is the most common presenting complaint with Aortic Regurgitation?
Exertional Dyspnoea or a reduced exercise tolerance
92
What are some common causes of Aortic Regurgitation?
``` Idiopathic Dilatation of Aorta Congenital Aortic valve Abnormalities Calcific degeneration Rheumatic disease Infective endocarditis Marfans ```
93
Where is the murmur of Aortic Regurgitation best appreciated?
L Sternal edge, S2 murmur
94
What clinical signs are associated with Aortic Regurgitation?
Collapsing Pulse | Head-Bobbing - De Musset's sign
95
What are valid indications for surgery with Chronic Aortic Regurgitation?
Symptomatic severe AR Asymptomatic severe AR with evidence of early LV systolic dysfunction Asymptomatic AR with aortic root dilatation
96
What are some classic symptoms of Mitral Stenosis?
``` SOBOE Orthopnoea PND Chest Pain Haemoptysis Peripheral Oedema ```
97
What are some common causes of Mitral Stenosis?
Rheumatic fever Calcification of Mitral Valve Leaflets Congenital Heart Disease Infective endocarditis
98
Where is the murmur of Mitral stenosis best appreciated?
Apex, S2 murmur
99
What are some causes of Mitral Regurgitation?
``` Mitral valve prolapse Rheumatic heart disease IHD Infective Endocarditis Collagen vascular diseases - Marfans ```
100
Where is the murmur of Mitral Regurgitation best appreciated?
5th ICS Mid-clavicular line R | S1 murmur
101
Which surgical interventions are available for Mitral Regurgitation?
Mitral Valve Repair | Mitral Valve Replacement
102
When is surgical intervention indicated in Mitral Regurgitation patients?
Symptomatic patients | Asymptomatic patients with Mild-Moderate LV dysfunction
103
What is infective endocarditis?
Infection of the heart valves or endocardium
104
Which conditions can pre-dispose to infective endocarditis?
Mitral valve prolapse Presence of Prosthetic Material Rheumatic heart disease Aortic valve disease
105
What are some common causative organisms of infective endocarditis?
Viridans Streptococci - 50% Staph. Aureus - 20% Enterococci - 10% Fungi - Candida/Aspergillus
106
Which patients should always be suspected of infective endocarditis?
Unexplained fever, bacteraemia or systemic illness +/- New/unexplained murmur
107
Which investigations are appropriate with suspected infective endocarditis?
``` FBC ESR, CRP U+E LFTs MSU CXR ECG Echocardiogram Cultures ```
108
How many cultures are appropriate to take with suspected infective endocarditis?
At least 3, 6 if possible from varying sites. Delay ABx if possible until cultures are taken
109
Which sonographic investigations are available for suspected infective endocarditis?
Echocardiogram - 65% of vegetations | Transoesophageal Echocardiogram - 95% of vegetations
110
How can the diagnostic criteria for infective endocarditis be classified?
Major | Minor
111
Which diagnostic criteria are required for infective endocarditis?
2 Major 1 Major, 3 Minor 5 Minor
112
What are viewed as major diagnostic criteria for infective endocarditis?
``` +ve Blood Cultures Endocardial involvement +ve Echo findings New Valvular regurgitation Dehiscence of prosthesis ```
113
What are viewed as minor diagnostic criteria for infective endocarditis?
Predisposing valvular/cardiac abnormality IVDU Temperature >38 Suggestive Echo/Culture
114
Which line is useful in the treatment of infective endocarditis?
CVC
115
How should the treatment of infective endocarditis be monitored?
1/Weekly Echo 2/Weekly ECG 2/Weekly Bloods
116
When is surgery indicated with confirmed infective endocarditis?
``` Moderate - Severe Cardiac Failure Valvular dehiscences Uncontrolled infection Relapse after optimal therapy Threatened/Actual systemic emboli ```
117
How does AF initially manifest?
Paroxysmal/episodic, before progressing to persistent/permanent AF
118
How do the majority of patients with AF present?
Asymptomatic
119
What are some associated complications of AF which make identification of AF easier?
Haemodynamic Instability due to Arrhythmia ACS Congestive Cardiac Failure Cardioembolic Stroke
120
Which conditions' risk increases with AF?
Cardioembolic Stroke | Cardiac instability
121
What are some common symptoms of AF?
``` Breathlessness Palpitations Syncope/Dizziness Chest Discomfort Stroke/TIA ```
122
What is the initial presenting clinical sign of AF?
Irregularly irregular pulse
123
Once AF is suspected, how soon should an ECG be performed?
ASAP, preferrably same day
124
With AF, when is Cardiac Monitoring indicated?
If suspected of being Paroxysmal/Intermittent
125
When is Echocardiography indicated with suspected AF?
Structural heart defect is suspected | Cardioversion is being considered
126
Should anticoagulation be held until after echocardiography with suspected AF?
No
127
What are the three management steps with confirmed AF?
Anticoagulation to prevent stroke Rate Control Rhythm control
128
Which score can predict the risk of a stroke/systemic embolus with known AF?
CHADS-VASC
129
What does a CHADS-VASC score of 2 or more indicate?
Significant risk of stroke | Anticoagulation should be offered
130
What does a CHADS-VASC score of 1 in men indicate?
Intermediate risk of stroke | Consider anticoagulation
131
What does a CHADS-VASC score of 0 indicate?
Truly low risk of stroke | Anticoagulation not required
132
What does a CHADS-VASC score of 1 in women indicate?
Low risk of stroke | Anticoagulation not required
133
How can the bleeding risk associated with anticoagulated AF patients be assessed?
HAS-BLED
134
What are some reversible risk factors associated with anticoagulation and AF?
Uncontrolled Hypertension Poor INR control Concurrent medication - Aspirin, NSAIDs Harmful alcohol consumption
135
What is the primary management of AF?
DOACs
136
What is a DOAC?
Daily Oral Anti-coagulant
137
How do Apixaban, Rivaroxaban, Edoxaban work?
Inhibit Factor Xa
138
How does Dabigatran work?
Inhibit Thrombin
139
Why are DOACs preferable to Warfarin with AF?
Do not require INR monitoring | No food/alcohol restrictions
140
How are DOACs excreted?
Renally, require yearly renal monitoring
141
How is the Rhythm controlled in known AF?
Controlled DC Shock | Pharmacological intervention
142
How is the Rate controlled in known AF?
Beta Blockers
143
What are the most common types of Supraventricular Tachycardia?
AV Nodal Re-entry Tachycardia (AVNRT) - 60% | Atrio-ventricular Re-entry Tachycardia (AVRT) - 30%
144
In haemodynamically stable patients, what is the first line treatment for SVTs?
Vagal manoeuvers: Breath-holding Valsalva Carotid Sinus massage
145
What are some important rules with Carotid Massage for SVT?
First auscultate for carotid bruits - stroke risk | Do not massage both together
146
What pharmacological intervention can be used with SVT?
Calcium Channel Blockers - Adenosine
147
What symptoms can Adenosine produce in SVT treatment?
Chest Discomfort Transient Hypotension Flushing
148
When should Adenosine not be used with SVT treatment?
If the patient has known reversible airway disease
149
What is a potential side-effect of Adenosine when treating SVT?
Arrhythmia - Keep Crash trolley close
150
When can Cardioversion be offered in SVT?
Hypotension Pulmonary Oedema CP with ischaemia
151
When is Cardioversion indicated in patients with sustained VT?
If they are haemodynamically stable
152
What pharmacological options can be used with VT?
Beta Blockers - Careful if Hypotension or reduced LV function Amiodarone/Lidocaine

Year 3 Medicine (8 decks)

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