cardiology Flashcards
1
Q
- autosomal dominant - exertional dyspnoea - angina - syncope - following exercise - sudden death (due to ventricular arrhythmias) - jerky pulse - ejection systolic murmur diagnosis
A
hypertrophic obstructive cardiomyopathy
2
Q
Hypertrophic obstructive cardiomyopathy + ………… –> sudden death in young athletes
A
ventricular arrhythmia
3
Q
infancy: heart failure adult: hypertension radio-femoral delay mid systolic murmur - max over back apical click from aortic valve associated with bicuspid aortic valve
A
Coarctation of the aorta - a congenital narrowing of the descending aorta.
4
Q
ECG changes in hypotrophic obstructive cardiomyopathy
A
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep narrow (dagger-like) Q waves
atrial fibrillation may occasionally be seen
5
Q
70yrs
HTN 170/106
no symptoms
what does the ECG show
A
RBBB + left axis deviation = bifascicular block
6
Q
what does the ECG show
A
bifascicular block (RBBB + left axis deviation) + first degree heart block (PR interval >5 small sqrs)
7
Q
34yrs
unwell
fever
no PMH
IV drug user
alcoholic
smoker
pansystolic murmer in left lower sternal edge and enlarged cervical lymph nodes
most helpful investigation to make a diagnosis?
diagnosis?
A
infective endocarditis (fever + murmur + IV drug user)
blood cultures - 3 sets
8
Q
most common bacteria cause of infective endocarditis
A
- staphylococcus aureus
other:
streptococcus viridans
coagulase-negative staph (staph. epidermidis) - after prosthetic valve surgery
9
Q
non-infective causes of endocarditis
A
systemic lupus erythematosus
malignancy: marantic endocarditis
10
Q
culture negative causes of endocarditis
A
prior abx therapy
coxiella burnetii
bartonella
brucella
HACEK: haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
11
Q
35yrs
bouts of palpitations
SOB on exertion
ejection systolic murmur
asymmetric hypertrophy in septal region on echo
cardiovascular MR - systolic anterior movement of anterior leaflet of mitral valve
diagnosis?
A
hypertrophic obstructive cardiomyopathy
12
Q
45yrs
palpitations - for 40mins - no obvious trigger
no chest pain or dyspnoea
ECG: regular tachycarida (180bpm) with QRS 0.10s
BP: 106/70
O2 sats: 98%
valsava manoeuvre: no effect
next appropriate course of action (treatment)?
diagnosis?
A
diagnosis: supraventricular tachycardia
acute management:
- valsava manoeuvre
- IV adenosine (contraindicated in asthmatics - verapamil instead)
- electrical cardioversion
13
Q
treatments to prevent episodes of supraventricular tachycardia
A
beta-blockers
radio-frequency ablation
14
Q
65yrs
type 2 diabetes - started on insulin
PMH: heart attack- on beta-blocker, calcium channel blocker, ace-inhibitor, statin, GTN
which medication can lead to reduced awareness of symptoms of hypoglycemic event following his insulin use?
A
beta blocker
eg. atenolol
15
Q
side effects of beta blockers
A
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
16
Q
contraindications of beta blockers
A
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
17
Q
61yrs
central crushing chest pain
ECG: ST elevation in leads II, III and aVF
PMH: HTN : ramapril, aspirin, simvastatin
what is the optimum manamgement?
A
primary percutaneous coronary intervention - gold standard for ST-elevation MI
aspirin
P2Y12-receptor antagnoist - clopidogrel/ ticagrelor
unfractionated heparin / LMWH (for PCI)
where PCI is not available, use thrombolysis + alteplase + ECG after 90mins - if no resolution then PCI
18
Q
management for hyperglycaemia in acute coronary syndromes
A
dose-adjusted insulin with regular monitoring of blood glucose levels to glucose <11
19
Q
82yrs
lives in care home
off feet for last week - now unresponsive
temp 28 degrees
what changes would you expect to see on ECG?
A
hypothermia:
- J-waves - small hump at the end of the QRS complex
- bradycardia
- first degree heart block
- long QT interval
- atrial and ventricular arrhythmias
20
Q
what are Q waves on ECG associated with?
A
previous MI
21
Q
what are delta waves on ECG associated with?
A
Wolff-Parkinson-white syndrome
22
Q
what are saddle ST elevation on ECG associated with?
A
pericarditis
23
Q
what ECG changes are considered as normal variants in an athlete
A
- sinus bradycardia
- junctional rhythm
- first degree heart block
- wenckebach phenomenon
24
Q
causes of peaked T waves on ECG
A
hyperkalaemia
myocardial ischaemia
25
what are the causes of inverted T waves on ECG
myocardial ischaemia
digoxin toxicity
subarachnoid haemorrhage
arrhythmogenic right ventricular cardiomyopathy
pulmonary embolism (S1Q3**T3**)
brugada syndrome
26
what is increased P wave amplitude on ECG a sign of
cor pulmonale
27
causes of ST depression on ECG
- secondary to abnormal QRS (LVH, LBBB, RBBB)
- ischaemia
- digoxin
- hypokalaemia
- syndrome X
28
causes of prolonged PR interval on ECG
idiopathic
ischaemic heart disease
digoxin toxicitiy
hypokalaemia
rheumatic fever
aortic root pathology (eg abscess 2ndry to endocarditis)
lyme disease
sarcoidosis
myotonic dystrophy
29
what condition is a short PR interval seen in
wolf parkinson white syndrome
30
causes of left axis deviation
/\
= left
\/
let anterior hemiblock
LBBB
inferior MI
**wolff-parkinson-white syndrome** - right sided accessory pathway
hyperkalamia
congenital: ostium primum ASD, tricuspid atresia
minor LAD in obese people
31
causes of right axis deviation
\/
= right
/\
right ventricular hypertrophy
left posterior hemiblock
lateral myocardial infarction
chronic lung disease --\> cor pulmonale
pulmonary embolism
ostium secundum ASD
**wolff-parkinson-white syndrome** - left sided accessory pathway
normal in infant \<1yrs
minor RAD in tall people
32
how to remember the difference between RBBB and LBBB
WiLLiaM MaRRoW
in LBBB there is a W in V1 and an M in V6
in RBBB there is a M in V1 and a W in V6
33
what is this ECG showing
right bundle branch block (RBBB)
diagnostic criteria:
- broad QRS \>120ms
- M shaped QRS in V1-3
wide, slurred S wave in lateral leads
34
35
causes of RBBB
- normal variant - more common with increasing age
- right ventricular hypertrophy
- chronically increased right ventricular pressure - eg cor pulmonale
- pulmonary embolism
- myocardial infarction
- atrial septal defect (ostium secundum)
- cardiomyopathy or myocarditis
36
causes of ST elevation on ECG
MI
pericarditis/ myocarditis
normal variant
left ventricular aneurysm
Prinzmetal's angina (coronary artery spasm)
takotsubo cardiomyopathy
rare: subarachnoid haemorrhage
37
what does this ECG show
hyperkalaemia:
- peaked T waves
- prolonged PR segment
- loss of P waves
- broad bizarre QRS complexes
- sine wave (severe hyperkalaemia)
suspect hyperkalamia in patients with new bradyarrhythmia or AV block or newly on haemodyalysis or taking any combo of:
ACEi, potassium-sparing diuretics or potassium supplements
38
what does this ECG show
LBBB
W in V1 and M in V6
39
causes of LBBB
- ischaemic heart disease
- HTN
- aortic stenosis
- cardiomyopathy
- hyperkalaemia
40
PE investigations
if PE is suspected:
1. wells score:
PE likely: \>4 points
PE unlikely: 4 points or less
if PE likely: immediate CTPA (if delayed, give DOAC e.g. apixaban, rivaroxaban)
if -ve no further investigations
if PE unlikely: D-dimer
if +ve: immediate CTPA
if -ve: consider alternative diagnosis
if allergy to contrast media or renal impairment do V/Q scan instead of CTPA
41
what does this ECG show
pulmonary embolism
S1Q3T3:
- large s wave in lead 1
- large Q wave in lead III
- inverted T wave in lead III
sinus tachycardia - most common abnormality seen
42
what does this ECG show?
features of the condition on ECG
wolff parkinson white syndrome
- short PR interval
- wide QRS complexes with slurred upstroke (delta wave)
- left axis deviation if right sided accessory pathway (majority)
type A: left sided accessory pathway:
- right axis deviation
- dominant R wave in V1
type B: right sided accessory pathway: (majority of cases)
- left axis deviation
no dominant R wave in V1
43
associations of WPW syndrome
HOCM (hypertrophic obstructive cardiomyopathy)
mitral valve prolapse
Ebsteins anomaly
thyrotoxicosis
secundum ASD
44
management for Wolff Parkinson White syndrome
definitive treatment:
**radiofrequency ablation** of the accessory pathway
medical therapy:
sotalol (not when atrial fibrillation- can lead to ventricular fibrillation),
amiodarone,
flecainide
45
what does this ECG show?
features
digoxin toxicity:
- down-sloping ST depression ('reverse tick' 'scooped out')
- flattened/ inverted T waves
- short QT interval
- arrythmias e.g. AV block, bradycardia
46
what does this ECG show
features
hypokalaemia:
- U waves
- small/absent T waves (usually inversion)
- prolonged PR interval
- ST depression
- long QT
rhyme:
in Hypokalaemia, U have no Pot and no T, but you have a long PR and a long QT
47
a new LBBB points towards what diagnosis
ACS
48
coronary artery territories on ECG
I, V5-6: left circumflex (lateral)
II, III, aVF: right coronary artery (inferior)
V1-V4: left anterior descending (anterior)
I, aVL, V4-6: left anterior descending or left circumflex
Tall R waves V1-2: usually left circumflex, also right coronary
49
ECG changes of an acute MI - chronologically
- **hyperacute T waves** - first sign (only persist a few **mins**)
- **ST elevation** develops
- **T waves** become **inverted** within first 24hrs (can last days/months)
- pathological **Q waves** - develop after several hrs to days. persist indefinitely
50
heart appears morphologically and histologically normal
autosomal dominant
most common in middle aged men
FHx sudden cardiac death (\<45yrs)
nocturnal agonal respiration (gasping breaths) during sleep
events usually occur at rest or during sleep
ECG attached
diagnosis?
Brugada syndrome
pseudo-RBBB and persistent ST elevations in V1-V2
type 1:
ST elevations
downsloping ST segment
inverted T wave
type 2:
ST elevation
saddle back ST-T wave
upright or biphasic T wave
51
what can brugada syndrome ECG changes be accentuated by
fever
drugs (e.g. beta blockers, TCA)
toxins (e.g. alcohol, cocaine)
52
modifiable risk factors for ACS
smoking
diabetes mellitus
hypertension
hypercholesterolaemia
obesity
53
chest pain - central/ left sided
may radiate to jaw or left arm
heavy - 'elephant on chest'
dyspnoea
sweating
nausea and vomiting
pale and clammy
diagnosis?
ACS
54
investigations for ACS
ECG
cardiac markers - troponin
55
what does this ECG show
ST- elevation MI (STEMI)
- ST elevation in leads II, III, AVF = right coronary artery blockage
56
what does this ECG show
STEMI
in leads:
II, III, aVF
aVR
V1, V3-6
right coronary artery
left anterior descending
left circumflex?
57
management of ACS (angina + NSTEMI)
MONA:
M: morphine + metoclopramide
O: O2 if sats \<94%
N: nitrates: GTN
A: aspirin + ticagrelor
+
heparin/ LMWH
58
management for ACS (STEMI)
PCI
MONA BASH:
M: morphine + metoclopramide
O: O2 if sats \<94%
N: nitrates: GTN (acutely and indefinitely)
A: aspirin + clopidogrel (acutely and indefinitely) 300mg then 75mg each
B: beta-blocker - indefinitely
A: ACEi - if contraindicated use angiotensin-II receptor antagonist
S: statin 80mg
H: heparin/ LMWH
59
what does this ECG show
Torsades de pointes
polymorphic ventricular tachycardia associated with a long QT interval
it may deteriorate into ventricular fibrillation and lead to sudden death
clue: psychiatric patient - as can be caused by antipsychotics, tricyclic antidepressants
60
causes of long QT interval
congenital: Jervell-Lange-Nielsen syndrome, Romano-Ward syndrome
antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
tricyclic antidepressants
antipsychotics
chloroquine
terfenadine
erythromycin
electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage
61
management of Torsades de pointes
IV magnesium sulphate
62
side effects of nitrates (GTN)
have vasodilating effects - angina and heart failure management
hypotension
tachycardia
headache
flushing
63
staging of HTN
stage 1:
clinic BP \>= 140/90
ABPM/HBPM\>= 135/85
stage 2:
clinic BP\>= 160/100
ABPM/HBPM\>= 150/95
severe HTN
clinic systolic BP\>= 180
or clinic diastolic BP\>= 110
64
lifstyle advice for HTN
low salt diet
caffeine intake reduced
stop smoking
drink less alcohol
eat a balanced diet
exercise more
lose weight
65
what stage of HTN do you treat regardless of age
stage 2 (clinic BP \>= 160/100, ABPM\>= 150/95)
66
ABPM\>= 135/85 (stage 1) when to treat
treat if \<80yrs AND any of the following:
target organ damage
established cardiovascular disease
renal disease
diabetes
10 year Qrisk \>10%
67
treatment for HTN
Step 1 treatment
patients \< 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotension receptor blocker (ACE-i or ARB): (A)
angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough)
patients \>= 55-years-old or of Afro-Caribbean origin: Calcium channel blocker (C)
ACE inhibitors have reduced efficacy in patients of Afro-Caribbean origin are therefore not used first-line
Step 2 treatment
if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic
if already taking a Calcium channel blocker add an ACE-i or ARB
for patients of Afro-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor
(A + C) or (A + D)
Step 3 treatment
add a third drug to make, i.e.:
if already taking an (A + C) then add a D
if already (A + D) then add a C
(A + C + D)
Step 4 treatment
NICE define step 4 as resistant hypertension and suggest either adding a 4th drug (as below) or seeking specialist advice
first, check for:
confirm elevated clinic BP with ABPM or HBPM
assess for postural hypotension.
discuss adherence
if potassium \< 4.5 mmol/l add low-dose spironolactone
if potassium \> 4.5 mmol/l add an alpha- or beta-blocker
68
a patient of Afro-Caribbean origin is taking a calcium channel blocker for hypertension, if they require a second agent what should this be?
ARB (losartan, candesartan) in preference to ACEi
69
if a patient of any age with HTN also has diabetes, which medication should they be started on
ACEi (ramipril) or ARB
70
step 4 HTN management with reference to K+
K+ \<4.5 = spironolactone
K+ \> 4.5 = apha (doxazosin) or beta blocker (atenolol)
71
what is a target INR for patients suffering from recurrent pulmonary embolisms and recurrent deep-vein thrombosis receiving anticoagulation
INR 3.5
72
what is the target INR for treatment of DVT or PE, AF, cardioversion, mitral stenosis, bioprosthetic heart valves, MI
INR 2.5
73
is long term warfarin required in bioprosthetic valves in the absence of AF
no
74
which anticoagulant should be used first line for PE and for how long
DOAC (apixaban, rivaroxaban) once diagnosis is suspected - continued if diagnosis confirmed
(including in active cancer)
if contraindicated use LMWH followed by dabigatran/ edoxaban or LMWH followed by vitamin K antagonist (warfarin)
if renal impairment severe: LMWH
if antiphospholipid syndrome: LMWH then warfarin
all patients have anticoagulation for at least 3 months
after that:
provoked - stopped after 3 months
unprovoked - further 3 months (6 in total)
75
treatment for PE with haemodynamic instability
**thrombolysis** - first line for massive PE with circulatory failure (eg hypotension)
76
what does a high INR mean
the higher the INR the longer time your blood takes to clot
77
what is the management for a patient on warfarin with recurrent PEs that is below their target INR
target INR = 3.5
increase dose of warfarin
may be considered for IVC filters - stop clots from the legs moving into the pulmonary arteries
78
what happens to the ST segment of the ECG in a posterior STEMI
in leads V1-V3:
ST depression
tall, broad R-waves
upright T waves
79
NSTEMI ECG signs
no ST elevation
T wave inversion
80
side effects of loop diuretics
eg furosemide
ototoxicity - hearing loss, tinnitus
hypotension
hyponatraemia, hypokalaemia, hypomagnesaemia, hypocalcaemia
81
anteroseptal: ECG leads and coronary artery?
V1-V4
left anterior descending
82
inferior leads and coronary artery?
II, III, AVF
right coronary
83
anterolateral leads and coronary artery?
V4-6, I, aVL
left anterior descending or left circumflex
84
lateral leads and coronary artery?
I, aVL +/- V5-6
left circumflex
85
posterior leads and coronary artery?
tall R waves V1-2
usually left circumflex, also right coronary
86
what diagnosis does a NEW LBBB point towards
ACS
87
what cardiac conditions are hypertrophic obstructive cardiomyopathy associated with
wolff parkinson white syndrome
Friedrich's ataxia
88
short PR interval
wide QRS
upsloping delta wave
condition?
wolff parkinson white syndrome
89
ECG changes in hypertrophic obstructive cardiomyopathy
left ventricular hypertrophy (increased amplitude of QRS)
non specific ST and T wave abnormalities
progressive T wave inversion
deep Q waves
AF
90
saw tooth pattern on ECG
atrial flutter
91
first degree heart block
increased PR interval \>200ms
92
increasingly prolonged PR interval until there is a dropped beat before restarting the pattern
second degree type 1 heart block - Wenckebach's
93
no association between the atria and ventricles on ECG
long term management
third degree heart block
pacemaker
94
features of Hypertrophic obstructive cardiomyopathy
often asymptomatic
exertional dysponoea
angina
syncope - typically following exercise
sudden death
jerky pulse, double apex beat
ejection systolic murmur - increases with valsalva manoeuvre and decreases on squatting
95
ECHO findings of Hypertrophic obstructive cardiomyopathy
mneumonic - MR SAM ASH:
MR mitral regurg
SAM systolic anterior motion (of the anterior mitral valve leaflet)
ASH asymmetic hypertrophy
96
presentation of stable angina
chest pain on exertion \<20mins
radiates to left arm/jaw
sweating
relieved by GTN
ECG: normal/ST depression
Troponin: normal
97
management of stable angina
GTN
Aspirin 75mg OD
Bisoprolol
ACEi
statin
98
difference in presentation (signs and symptoms and investigations) between unstable angina and NSTEMI
unstable angina:
exertional chest pain relieved by GTN
Troponin: no elevation
NSTEMI:
chest pain \> 20mins
not relieved by GTN
troponin: raised
both have ST depression +/- T wave inversion
99
STEMI presentation
chest pain \> 20mins
sweating
not relieved by GTN
ECG: ST elevation, new LBBB
troponin: raised
100
immediate management for STEMI
PCI (if available within 2hrs - if not thrombolysis)
morphine + metoclopramide
O2 if \<90%, SOB or pulmonary oedema
nitrates: GTN if not effective --\> iV nitrate
Aspirin 300mg + clopidogrel 300mg
101
long term management for STEMI
aspirin 75mg (lifelong) + clopidogrel 75mg (12months)
**B**eta blocker - bisoprolol (if no CI - asthma, COPD)
**A**CEi - within 24hrs
**S**tatin - atorvastatin 80mg
**H**eparin - LMWH SC or fondaparinux SC
102
60yr male
3day hx
sharp, tearing pain in center of chest
radiating straight through to back between shoulder blades
most likely diagnosis?
aortic dissection
103
56yr man
2hr hx central chest pain radiating to left arm
sweaty
ECG: ST elevation in leads II, III and aVF
troponin significantly raised
which is the most likely coronary vessel to be occluded
right coronary artery
104
what are the coronary territories
II, III AVF: inferior (right coronary artery)
prominant R in V1 V2: posterior MI (posterior descending artery)
V1-V4: anterior/septal (left anterior descending)
I, aVL, V5, V6: lateral (left circumflex)
105
44yr M
sudden onset chest pain radiating to jaw
sweating and nausea
ECG: ST elevation in V1-V6, I, aVL
what is the single most likely occluded coronary artery
left main coronary artery
V1-V4: left anterior descening
V5-V6, I, aVL: left circumflex
as both are affected the left main coronary artery is most likely to be affected
106
65yr M
central chest pain radiating to left arm 2hrs
increasingly regular chest pain over last 2 weeks
type 2 diabetes- metformin
ECG
single most likely occluded coronary artery (look at ECG)
right coronary artery
107
76yr W
SOB on minimal exertion 5 days
walking upstairs - central chest tightness
pain free since being diagnosed with CAD 10yrs ago
troponin (36hrs after onset of pain): 1.45 (0-0.4)
ECG: T wave inversion in inferolateral leads
single most appropriate immediate step in management
previous IHD hx + ischaemic ECG + raised troponin --\> treat as per protocol for ACS (NSTEMI)
aspirin 300mg PO + clopidrogrel 300mg PO
108
52 yr M
sudden central chest pain whilst watching TV
suffocating sensation rose up to neck and made it difficult to breath
arrived at ED within 2hrs of onset of pain
ECG: ST depression, T wave inversion
troponin: 0.09 (normal \<0.10) taken after 1hr of onset of pain
following morning looks pale, clammy
single most appropriate course of action
repeat troponin level
first troponin taken 1hr after onset- may not have risen yet - needs to be repeated - 12hrs after onset of pain
also needs cardiac monitoring
109
causes of low cardiac output (leading to heart failure)
pump failure:
- systolic failure: impaired contraction --\> **MI**, dilated cardiomyopathy, HTN, myocarditis
- diastolic failure --\> impaired filling --\> pericardial effusion/ tamponade (fluid in pericardium --\> constriction)/ constriction
- arrhythmias: **AF**, bradycardia, hyeart block, tachycardia --\> antiarrhythmics (beta-blockers, CCB)
excessive preload:
aortic, mitral regurgitation
fluid overload
excessive afterload:
- aortic stenosis
- HTN
hypertrophic obstructive cardiac myopathy
110
causes of high cardiac output (leading to heart failure)
increased needs --\> RVF initially --\> left ventricular failure
**A**naemia
**T**hyrotoxicosis
**P**regnancy, **P**agets
111
cor pulmonale
abnormal enlargement of right side of heart due to lung disease or disease of pulmonary lblood vessels
112
right sided heart failure symptoms and signs
fluid retention in legs
ascites
anorexia and nausea
signs:
increased JVP + jugular venous distension
hepatomegaly
cant go through right side of heart so backlog of fluid. therefore excess fluid in jugular --\> raised JVP
113
causes of right sided heart failure
LVF
cor pulmonale
tricuspid and pulmonary valve disease
114
left sided heart failure symptoms and signs
body not getting oxygenated blood properly from left side of heart, backlog of fluid into lungs
symptoms:
exertional dispnoea, fatigue
orthopnoea, PND
nocturnal cough (+- pink frothy sputum)
wheeze
improves 15-30mins after getting up
signs:
tachypnoea
S3 gallop on heart sounds (after S2)
tachycardia
cardiomegaly with displaced apex
bi-basal inspiratory pulmonary crepitations (sign of fluid)
cold peripheries +- cyanosis
115
causes of left sided heart failure
IHD
idiopathic dilated cardiomyopathy
systemic HTN
mitral and aortic valve stenosis
116
what is congestive cardiac failure
long term LVF leading to RVF or disorders affecting entire myocardium
117
what criteria is used to determine the diagnosis of congestive heart failure
explain it
**Framingham** criteria for CCF
diagnosis: presence of at least **2 major criteria**
or **1 major criteria and 2 minor**
major:
- PND
- raised JVP
- basal crepitations
- cardiomegaly
- acute pulmonary oedema
increased venous pressure (\>16)
weight loss \>4.5kg in 5d
minor:
bilateral ankle oedema
nocturnal cough
dyspnoea on ordinary exertion
hepatomaly
pleural effusion
30% in vital capacity
tachycardia
118
investigations for chronic heart failure
bloods:
- FBC, U&Es, **BNP**, TFTs, glucose, lipids
**CXR: ABCDEF**
**A**lveolar shadowing
Kerley **B** lines
**C**ardiomegaly (cardiothoracic ratio \>50%)
**D**ilated prominent upper lobe vessels
**E**ffusions
**F**luid in fissures
**ECG - LVH, Q-waves**
**_Echocardiogram_** - key investigation
119
120
what does left ventricular hypertrophy look like on ECG - what criteria can you use
tall QRS complexes
Sokolow Lyon criteria: add height of R wave in V5 or V6 and S wave in V1
if its over 35mm you have left ventricular hypertrophy
121
classification to determine severity of Chronic CCF
**NYHA** criteria
I: no limitation of activity (\>2 flights of stairs with ease)
II: comfortable at rest, dysnpnoea on ordinary activity (2 flights of stairs with difficulty)
III: marked limitation on ordinary activity (can climb \< 1 flight of stairs)
IV: dyspnoea at rest, all activity --\> discomfort
122
management for chronic CCF
1st line:
ACEi/ARB + BB + loop diuretic (furosemide) (ABD)
monitor K+ levels
2nd line:
potassium sparing diuretics (spironolactone)
vasodilators: hydralazine + isosorbide dinitrate
sacubitril valsartan
3rd line:
digoxin or
ivabradine
invasive therapies:
cardiac resynchronisation +- implantable cardioverter defib (ICD)
coronary revascularisation
partial left ventriculectomy
heart transplantation
123
side effect of loop diuretic
decreases K+
124
side effect of ARB
increases K+
125
acute presentation of HF
new onset or decompensation of chronic HF
peripheral/pulmonary oedema
+- peripheral hypoperfusion (cold extremities)
symptoms:
dyspnoea
orthopnea, PND
pink frothy sputum
signs:
distresses, pale, sweaty
tachycardia, tachypnoea
pulsus alternans (alternating strong and weak pulse - indicative of left ventricular systolic impairment - poor prognosis)
126
management of acute HF/ pulmonary oedema
sit patient upright
O2 - 15L/ min via reservoir mask - target SpO2: 94-98%
IV access: bloods: FBC, U&Es, Troponin, BNP, ABG
diamorphine 1.25-5mg IV - pain
furosemide 40-80mg IV slowly
GTN 2 puffs
give positive inotropes (e.g dobutamine IV) (strengthen force of heart beat)
increase renal perfusion by low-dose dopamine
127
36yr F
lethargic
increasingly dizzy over last 2 months
usually well but reports long and very heavy periods, especially in last 6 months
T:36.6.
HR: 110bpm
BP: 95/65
JVP raised
bilateral ankle oedema pitting to mid calf
bibasal find end inspiratory crepitations
single most appropriate next step
symptomatic anaemia (Hb usually \<50g/L) causing heart failure
management: packed red cells 2U IV slowly + diuretic e.g furosemide IV (alternate between units)
128
78yr F
admitted with HF
underlying cause determined to be aortic stenosis
which sign is most likely to be present
bibasal crepitations
left sided heart failure --\> respiratory symptoms
129
stages of HTN
stage 1: 140/90
stage 2: 160/100
severe: 180/110
malignant: 180/110 + organ damage
130
causes of HTN
renal: renal artery stenosis, glumerulonephritis, polycycstic kideny disease
endocrine: increased **T4 (hyperthyroidism), cushings**, pheochromocytoma, acromegaly, Conns
drugs: **steroids, NSAIDs**, cocaine, COCP
**pre-eclampsia**
**coarctation of aorta** - consider if young
131
HTN end organ damage
CANCER
Cardiac:
- IHD, LVH --\> CCF
- AR, MR
Aortic:
- aneurysm
- dissection
Neuro:
- **CVA** (cerebrovascular accident): ischaemic, haemorrhagic
- encephalopathy (malignant HTN)
Eyes: **hypertensive retinopathy**
Renal:
- proteinuria
- CRF
132
investigations of HTN
bedside: **urinalysis**: haematuria, Alb:Cr ratio
bloods: **FBC, U&Es, glucose**, fasting lipids
imaging: **12 lead ECG**: LVH, old infarct
calculate 10yr CV risk: **QRISK2**
133
diagnosis of HTN
clinic BP \> 140/90:
offer ABPM
calculate CV risk & look for organ damage
ABPM \<135/85: normotensive --\> no treatment
ABPM \>135/85: stage HTN --\> treat if QRISK \> 20%/10yrs or end organ damage
ABPM \>150/95: stage 2 HTN --\> treat
Clinic BP \>180/110 --\> consider treatment immediately, consider referral
134
\<55. \>55/afrocaribbean
A C
A+ C (or D)
A+ C + D
resistant HTN:
A+C+D+ consider further diuretic (spironolactone) or alpha blocker/ beta blocker
seek expert opinion
A: ACEi or ARB (ARB with CCB if afrocaribbean for second line)
C: CCB: nifedipine, amlodipine
D: thiazide like diuretic: furosemide, indapamide
135
causes of aortic stenosis
calcification
congenital
136
symptoms and signs of aortic stenosis
symptoms:
**angina**
**syncope**
**HF**: SOB, orthopnoea, PND
signs:
early systolic click (if young valve)
**ejection systolic murmur (right 2nd ICS - sit forward to enhance)**
- parvus tardus: slow rising pulse
- narrow pulse pressure
aortic thrill
137
causes of aortic regurgitation
infective endocarditis
ascending aortic dissection
rheumatic fever
connective tissue
138
symptoms and signs of aortic regurgitation
aortic regurg **mimics LVF**:
symptoms:
**exertional dyspnoea**
**PND**
**orthopnoea**
signs:
**collapsing pulse**
**early diastolic/ mid diastolic murmur - heard at Erb's point (left 3rd ICS)**
wide pulse pressure
Quincke's (capillary pulsations with light pressure on finger nail bed)
Corrigan's (abrupt distension and collapse of carotid arteries)
De Musset's (head bobbing in synchronisation with heart beat)
139
140
causes of mitral stenosis
rheumatic fever
congenital
mitral calcification
141
symptoms and signs of mitral stenosis
symptoms:
**dyspnoea**
**fatigue**
**haemoptysis**
signs:
**mid-diastolic murmur** (with a snap) (Bell) - at **apex**
**malar flush**
low-volume pulse
increased JVP later on
AF
tapping apex beat
142
causes of mitral regurgitation
mitral valve prolapse
LV dilatation
post-MI
rheumatic fever
connective tissue
143
symptoms and signs of mitral regurgitation
symptoms:
**dyspnoea**
**fatigue**
**pulmonary congestion**
signs:
**pansystolic murmur - radiates to axilla** (S3)
AF
**left parasternal haeve**
displaced apex beat
144
57yr F
worsening SOB
decreased exercise tolerance
rhuematic fever in adolescence
essential HTN
mitral stenosis
which of the following is not a sign of mitral stenosis?
A.Malar flush
B.Atrial fibrillation
C.Pan-systolic murmur which radiates to axilla
D.Tapping, undisplaced apex beat
E.Right ventricular heave
pan-systolic murmur which radiates to axilla
145
76yr M
collapsing at home
recovered within minutes - fully alert and orientated
first episode of this
increasing SOB - last 6 months
episodes of central chest pain
BP: 115/88
crackles at both bases
ECG: borderline LVH
which murmur and where would you expect to find on auscultation
crescendo systolic murmur best heard at right sternal edge (ejection systolic murmur)
aortic stenosis:
- syncope
- angina
- HF
146
49yr F
increasing SOB - last 3 months
no chest pain or cough
no ankle swelling
BP: 158/61
pulse collapsing
pulse:88bpm
crackles at both lung bases
decrescendo diastolic murmur at left sternal edge
most likely diagnosis?
aortic regurgitation
147
Hyperlipidaemia presentation
CVD
xanthomata
pancreatitis (increased triglycerides)
148
investigations for hyperlipidaemia
non-fasting lipids
non-HDL cholesterol
149
management for hyperlipidaemia
lifestyle advice:
- lose weight
- increase fibre, fresh fruit, veg
- increase exercise
treat those with known CVD and DM and with QRISK \> 20%
1st line:
- **statins** - e.g **atorvastatin** (10mg OD)
2nd line:
- fibrates - bezafibrate
- cholesterol absorption inhibitors - ezetimibe
niacin/ nicotinic acid
PCSK9 inhibitors: high risk & homozygous FH patients
150
presentation of arrhythmias
palpitation
chest pain
syncope
hypotension
asymptomatic
151
classifications of bradycardias
sinus bradycardia
1st degree heart block
2nd degree heart block:
- wenkebach/ Mobitz type I
- Mobitz type II
complete heart block:
- junctional
- ventricular
152
causes of heart block
DIVISIONS
most important: **drugs, ischaemia, vagal hypertonia, hypothyroidism, hypokalaemia**
Drugs
Ischaemia/ infarction
Vagal hypertonia
Infection
Sick sinus syndrome
Infiltration: restrictive/ dilated cardiomyopathies
O:
hypOthyroidism
hypOkalaemia
hypOthermia
Neuro: increased ICP
Septal defect: ASD
Surgery or catheterisation
153
what does this ECG show
first degree heart block
prolongation of PR interval to \>0.2s (\>5 small squares)
(normal PR 3-5ss)
154
what does the ECG show
2nd degree heart block - Mobitz type 1 (Wenckebach)
progressive PR prolongation and then drops beat
155
what is the ECG?
this ECG shows 3:1 Mobitz II block
intermittent non-conducted P waves without progressive PR interval prolongation
usually fixed amount on non conducted P waves for every successfully conducted QRS complex
e.g. Mobitz II where there are two P waves for every one QRS = 2:1 Mobitz II
three P waves for every one QRS 3:1 Mobitz II block
156
what does this ECG show?
3rd degree heart block (complete heart block)
all atrial activity fails to conduct to ventricles
no relation between atria and ventricles contracting so P waves and QRS complexes are unrelated (no pattern between them)
157
treatment for bradycardias (including heart blocks)
if asymptomatic + rate \>40bpm - no treatment needed
if symptomatic or rate \<40bpm --\> urgent
- rx underlying cause: MI, drugs, thyroid, electrolytes
- IV atropine 0.6-1.2g
- temporary pacing wire
elective --\> permanent pacing
- Mobitz II
complete heart block
sick sinus
AF
158
how to differentiate between narrow and broad complex tachycardias?
both have rate \>100bpm
narrow complex: supraventricular tachycardia
tachy originating from above/within AV node
QRS \<3ss
broad complex: ventricular tachycardia
QRS \>3ss
tachy originating within ventricles
159
what are the causes of narrow complex (supraventricular) tachycardias that have a regular rhythm/ irregular rhythm
narrow QRS + regular rhythm:
sinus tachycardia
atrial flutter
SVT
narrow QRS + irregular rhythm
AF (no P waves)
MAT (multifocal atrial tachycardia)
160
what are the causes of broad complex (ventricular) tachycardias with regular rhythm/ irregular rhythm
broad QRS + regular rhythm:
ventricular tachycardia
sinus tachycardia
AF with BBB/WPW
broad QRS + irregular rhythm:
VF
AF with BBB
AF with pre-excitation
161
what does sinus tachycardia look like and how would you control it
normal P wave followed by normal QRS
\>100bpm
162
what does the ECG show
AF
absent P waves
irregualr QRS complexes (rhythm)
163
what does this ECG show
atrial flutter
**sawtooth** appearance
atrial rate ~260-340bpm
due to re-entrant circuit usually in RA
ventricular rate often 150bpm (2:1 block)
164
types of junctional tachycardias
AV nodal re-entry tachycardia
Wolf parkinson White syndrome
165
what is the ECG?
AV nodal re-entry tachycardia
P waves absent or immediately before/after QRS
normal QRS
typical: no P wave or P wave inverted after QRS complex
atypical: P wave inverted before QRS
166
what does the ECG show
**Wolf-Parkinson-White syndrome**
**short PR** interval
slurred upstroke of QRS - **delta** wave
167
narrow complex tachycardia management
1. **carotid sinus massage** (1 side only) or blow the plunger out a syringe
2. **IV adenosine 6mg** rapid bolus - if no response 12mg, if no response another 12mg after 1-2 mins
(amiodarone if adenosine CI or not successful)
3. if pt compromised --\> **DC cardioversion**
- hypotension: BP \<90
- heart failure
impaired consciousness
HR \>200bpm
4. maintenance therapy: beta blockers or verapamil
168
20yr F
palpitations 6hrs
similar episodes before - never lasted this long
ECG - regular rhythm 160bpm with inverted P waves in leads II, III and aVF and narrow complexes.
vagal manoeuvres do not work
after adenosine 6mg IV - normal sinus rhythm 90bpm restored
single most likely origin of her tachycardia
AV node
av nodal re-entry tachycardia
169
21yrs M
sudden onset rapid palpitations
uncomfortable but not SOB, no chest pain
SVT rate 170bpm
carotid sinus transient reversion to sinus rhythm
tachycardia resumed
next step in management?
IV adenosine
DC cardioversion if bpm \>200
170
signs symptoms and causes of AF
irregular QRS rhythm, no p waves
symptoms: **palpitations, SOB**, faintness, angina, fatigue
signs: **irregularly irregular pulse**, signs of LVF
causes:
anything leading to: raised atrial pressure, increased atrial muscle mass, atrial fibrosis
common:
IHD
rheumatic heart disease
thyroxicosis
hypertension
171
investigations for AF
ECG - **absent p waves** + **irregular** QRS
bloods: **troponin, U&Es, TFTs, Mg2+, Ca2+**, FBC
echo:
LV function
valve lesions
to exclude intracardiac thrombus prior to conversion
172
causes of slow AF
hypothermia
digoxin toxicity
medications
sinus node dysfunction
173
management of AF
rate control:
1st line: **BB** (bisoprolol) or **CCB** (verapamil)
2nd line: **digoxin/ amiodarone**
rhythm control:
**cardioversion if \<48hrs** -electrical/pharmacological
1st line: **IV flecainide**
2nd: **amiodarone** - antiarrhythmic
anticoagulants:
**LMWH** until full risk of emboli assessed
if risk of emboli high **(\>2) DOAC**
check with **CHADSVASC** score
174
what is paroxysmal AF
management?
self-limiting \<7days, recurs
prevention: **BB, amiodarone, sotalol**
Rx "pill in pocket": **flecainide**
anticoagulate: use CHA2DS2 VASc score
175
what is the CHA2DS2 VASc score
Coronary heart disease
HTN
age \>75 - 2 points
Diabetes
Stroke, TIA - 2 points
Vascular disease
Age 65-74
Sexual category (female)
if \> or = 2 - change warfarin to DOAC
176
62yr M
palpitations
AF on ECG
ventricular rate 130/min
mild chest discomfort but not acutely distressed
noticed 3hrs before coming to hospital
first episode
best first-line therapy
attempt DC cardioversion
177
hyperkalaemia causes and signs (including ECG signs)
hyperkalaemia: serum K+ \>5.5
causes:
- inability of kidney to excrete K+
- impaired absorption of K+ by cells
clinical signs:
often non specific
generalised muscle weakness
chest pain, palpitations
ECG signs:
peaked T waves
flattened P wave
increased PR interval
widened QRS
178
what does this ECG show
hyperkalaemia
* Peaked T waves
* Flattened P wave
* ↑ PR interval
* Widened QRS
179
diagnosis
pericarditis
saddle shape
180
psych patient
recent cardiac arrest
diagnosis?
long QT syndrome
181
three types of supraventricular tachycardia
AV nodal re-entrant tachycardia: re-entrant point is back through AV node
AV re-entrant tachycardia: re-entry point is an accessory pathway (wolff-Parkinson-White syndrome)
atrial tachycardia: orginates in atria but not at SAN (abnormally generated activity in atria)
182
SVT on ECG
narrow complex tachycardia (QRS \<0.12)
183
acute mangement of SVT in stable patient
continuous ECG monitoring
first line: valsalva manoeuvre: blow hard against resistance
2. carotid sinus massage
3. adenosine - rapid bolus antecubital fossa 6, 12, 12 (brief asystole or brady on administration)
- alternative is verapamil (CCB)
4. direct current cardioversion if others fail
184
contraindications for adenosine
asthma
COPD
cardiac failure
heart block
severe hypotension
185
long term management for paroxysmal (recurring) SVT
drugs: beta blocker, CBB, or amiodarone
radiofrequency ablation
186
treatment for wolf parkinson white syndrome
definitive treatment is **radiofrequency ablation of accessory pathway**
187
what does the ECG show
what ECG signs
wolf parkinson white syndrome
short PR interval (\<0.12 / \< 5 small squares)
wide QRS (\>0.12)
delta wave - slurred upstroke on QRS
188
when are antiarrythmic medications contraindicated in the management of WPW syndrome
when they develop atrial fibrillation or atrial flutter at the same time as WPW
can lead to promotion of the accessory pathway
189
which conditions can radiofrequency ablation be used on
atrial fibrillation
atrial flutter
supraventricular tachycardias
WPW syndrome
190
diagnosis of ECG
acute mangement
**Torsades de pointes**
- ventricular tachycardia
- **height** of **QRS progressively get smaller, then larger**, then smaller etc
- occurs in **patients with prolonged QT interval**
acute management:
- **correct cause**
**- magnesium IV**
defib if VT occurs
191
causes of prolonged QT
long QT syndrome (inherited)
meds: antipsychotics, citalopram, flecainide, sotalol, amiodarone, macrolide abx
electrolyte disturbance (hypokalaemia, hypomagnesaemia, hypocalcaemia)
192
long term management of prolonged QT syndrome
**avoid meds** that prolong QT interval
**correct electrolyte** disturbances
**beta blockers** (not sotalol)
**pacemaker** or implantable **defib**
193
random brief palpitations
diagnosis + management
ventricular ectopic
- random abnrmal broad QRS on background of normal ECG
Management:
- check bloods for aneamia, electrolyte disturbance, TFTs
no treatment in healthy
specialist in patients with background of heard conditions or other concerning features
194
treatment for unstable or risk of asystole bradycardias/ AV node blocks (mobitz type 2, complete heart block or previous asystole)
first line: **atropine 500mcg IV**
no improvement: **atropine 500mcg repeated** (up to 6 doses for total to 3mg)
other inotropes (noradrenaline)
**transcutaneous cardiac pacing** (defib)
195
treatment for high risk asystole (mobitz type 2, complete heart blcok or previous asystole)
**temporary transvenous cardiac pacing** (electrode in wire into vein to stimulate heart directly)
permanent **implantable pacemaker**
196
tachycardia treatment summary
narrow complex:
atrial fibrillation
atrial flutter
SVT
broad complex:
ventricular tachycardia
if known SVT with bundle branch block
atrial fibrillation: rate control with beta blocker or diltiazem (CCB)
Atrial flutter: rate control with beta blocker
SVT: vagal manouvres and adenosine
VT: amiodarone + 3 synchronised shocks
SVT with bundle branch block: treat as normal SVT
197
diagnosis + management
irregular complexes + no p waves = atrial fibrillation
Mx:
- first line: **rate control: BB or CCB**
emergency cardioversion if haemodynamically unstable
- 2nd line: **rhythm control: amiodarone or flecainide** or electrical cardioversion (if **\<48hrs** since onset)
if patient needs rhythm control but been \>48hrs delay electrical cardioversion for 3 weeks
- anticoagulants: **CHADVASC score** (risk of clot) : **heparin**
198
management for paroxysmal atrial fibrillation
paroxysmal AF terminates spontaneously within 7 days, usually within 48hrs
pill in pocket strategy: taking antiarrhythmic drugs only when an episode of atrial fibrillation starts
199
diagnosis?
management
**atrial flutter**
**- saw tooth appearance**
**- 150bpm**
Mx:
**rate/ rhythm** control: BB or cardioversion
treat underlying cause
**radiofrequency ablation**
anticoagulation: CHADVASC score: **heparin**
200
conditions associated with atrial flutter
HTN
ischaemic heart disease
cardiomyopathy
thyrotoxicosis
201
what are the two shockable rhythms
ventricular tachycardia
ventricular fibrillation
202
diagnosis + management
ventricular fibrillation
203
management for ventricular fibrillation/ pulsless ventricular tachycardia
asystole/ pulseless electical activity (all electrical activity except ventricular tachycardia)
Mx:
- ventricular fib/ pulseless tachy: **CPR** 2 mins + **defib** (cycle)
asystole/ PEA: CPR
during CPR:
- **adrenaline** 1/10,000 **every 3-5mins**
- sustained stable ventricular tachy/fib: **amiodarone IV** after 3 shocks
- refer to specialist: **implantable cardioverter defibrillator**
if IV access not obtained use intraosseus route (bone marrow)
204
indications for pacemaker
symptomatic bradycardias
mobitz type 2 AV block
third defree (complete) heart block
severe heart failure
(biventricular pacemakers)
hypertrophic obstructive cardiomyopathies
205
types of pacemakers
single chamber: sit in right atria (problem with SAN)
dual chanber: right atria and right ventricle (to synchronise atria and ventricular contractions)
biventricular (triple chamber): right atria, right ventricle, left ventricle
- patients with heart failure
also called cardiac resynchronisation therapy (CRT) pacemakers
implantable cardioverter defibrillators (ICDs):
- continually monitor the heart and apply defib shock to cardiovert patient back to sinus rhythm if it identifies a shockable arrythmia
206
diagnosis?
dual chamber pacing
- spike before p wave (atrial pacing)
- spike before QRS (ventricular pacing)
207
investigations and management for carotid artery stenosis
can cause stroke or TIA
- investigations of stroke/ TIA can pick it up
Ix: USS duplex
if narrowing showed on USS then:
CTA (using dye) or MRA
(CT angiography, MR angiography)
management:
- first line: **carotid endarterectomy** - if **stroke/TIA + moderate/severe stenosis** (\>50% narrowed) (carried out **within 2wks of stroke/TIA**)
or: stenting - less invasive
208
what is pericardiocentesis used to treat
removal of fluid from pericardium by needle aspiration
used to treat pericardial effusion & cardiac tamponade
209
indications for CABG and how to investigate
Ix: coronary angiography
indications:
1. left main coronary artery stenosis:
- stenosis \>50%
2. left main equivalent:
\> 70% stenosis in proximal LAD and proximal circumflex artery
3. three vessel disease
especially in diabetes
4. one or two vessel disease with extensive myocardium at risk and not suitable for PCI (eg balloons, stenting)
5. coronary occulsive complications during PCI
6. surgery for life-threatening complications
e. g. after MI,
210
techniques for CABG
on pump: arrested heart using cardiopulmonary bypass
off pump: with beating heart - no cardiopulmonary bypass
211
vessels used for CABG
1. **left internal thoracic artery: gold standard** for LAD
should always be used unless emergency with haemodynamic decompensation, or injury/stensois to artery
2. reversed saphenous vein grafts - when many grafts needed (triple, quadruple bypass)
3. right internal thoracic
4. radial artery - prone to severe vasopasm
212
palpable expansile pulsation in abdomen
Ix and management
AAA
Ix:
- **aortic USS** to determine size
**CT angiography for elective repair** or **suspected rupture** being evaluated for repair
Mx:
monitoring size
treating peripheral artery disease
surgically:
- **symptomatic**
- asymptomatic \>4cm and grown by \>1cm in 1 yr
- **asymptomatic \>5.5cm**
- **open surgical repair**: first choice of surgical intervention
- endovascular stenting
- laparoscopic repair
213
pulsatile mass in abdo
severe abdo pain
hypotension
tachycardia
diagnosis + Ix + Mx
ruptured AAA
Ix: CT abdo in patients that are haemodynamically stable
if haemodynamically unstable: straight to surgery for repair - no imaging
214
difference between a ruptured AAA and aortic dissection
aortic dissection: layers of the wall of the aorta separate allowing blood to flow between the layers causing further separation - increased risk of burst
ruptured AAA: the weakness in the wall due to the aneurysm lead to rupture
215
screening for AAA
men \>66: screening for AAA
especially with risk factors:
- COPD
- HTN
- FHx
- coronary, cerebrovascular or peripheral artery disease
- hyperlipidaemia
- smoker/ ex-smoker
aortic USS women \> 70 with the following risk factors and not already excluded AAA:
- same risk factors as above
216
referral for AAA
aortic USS for diagnosis
AAA \> 5.5cm = vascular referral within 2wks
AAA 3-5cm = vascular referral within 12 wks
217
sudden onset pain
very severe
tearing or sharp pain
maximal at time of onset
diagnosis + Ix
aortic dissection
- mainly in greater curvature of aorta or descending thoracic aorta
Ix: contrast CT angiography - not in haemodynamically unstable patients
echo can be used quickly at bed side
218
initial management of thoracic aortic dissections and aneurysms
initial management:
- **fluid resus**
- **BP control** to reduce force of LV contraction: **BB**
target HR: 60-80
target systolic BP: 100-120
219
management of type A aortic dissection
type A: ascending
Mx
- intial management - fluid resus
- urgent surgical management- replace ascending aorta with prosthetic graft
220
management of acute type B aortic dissection
type B: descending
intial management: fluid resus
**uncomplicated**: no visceral or limb ischaemia, rupture uncontrollable HTN
- medical management: **BB first line** or CCB (for COPD)
**complicated**:
- **open surgery or endovascular repair** using stent graft (alternative)
221
management of chronic type B dissection
conservative management
most develop complications which require surgical intervention
222
management for thoracic aneurysms
ascending aorta: surgery for prosthetic graft on aorta
descending aorta: endovascular stent-graft placement
223
what is Dressler's syndrome
pericarditis that develops 2-10 wks after MI or heart surgery (acute post-MI pericarditis)
inflammatory response
224
recent MI
low grade fever
chest pain
pericardial frictional rub
diagnosis
mangement
Dressler's syndrome
(acute post MI pericarditis)
Mx:
NSAIDs eg aspirin
in severe symptoms or repeated drainage of effusion: steroids
225
sharp chest pain
relieved on leaning forward
pain radiating to left shoulder or down arm
diagnosis
Ix
acute pericarditis
Ix:
- ECG: saddle shape (ST elevation without reciprocal st depression)
- CXR: globular cardiac enlargement
echo: presence of effusion
226
management of acute pericarditis
treating any underlying cause
analagesia - NSAIDs
large pericardial effusions complicated by hypotension: aspiration
may need aspiration for diagnostic purposes
227
most common cause of pericardial effusion
coxsackie virus
other causes:
MI
pneumonia, septicaemia
renal failure
tuberculosis
hypothyroidism
trauma
cancer of breast or bronchus
228
what can pericardial effusion cause
right and left heart failure
cardiac tamponade may occur
229
diagnostic test for pericardial effusion
management
echo - diagnostic
Mx: diagnostic pericardiocentesis: cytology may show malignant cells etc
(pericardiocentesis: drainage)
+ treat underlying cause
230
hypotension + shock
pulsus paradoxus
inaudible or distant (muffled) heart sounds
distension of neck veins
Kussmaul's sign
confusion
diagnosis
**cardiac tamponade**
Beck's triad of: **hypotension, raised JVP, muffled heart sounds**
pulsus paradoxus: large decrease in stroke volume, systolic BP and pulse during inspiration
Kussmaul's sign: paradoxical rise in JVP on inspiration
231
investigations and management for cardiac tamponade
Ix: echo - diagnostic
Mx: pericardiocentesis - can be diagnostic with cytology - send pericardial fluid for micro and cytology
232
constrictive pericarditis
symptoms & signs
Ix
Mx
fatigue
SOB - on exertion
swelling of abdo (ascites) and ankes
pulsus paradoxus
kussmauls sign
pericardial knock (loud-high pitched S3)
Ix: **echo - thickened pericardium** with normally contracting ventricle
Mx: surgical: **excision of pericardium**
233
investigation for new suspected heart failure
BNP (B-type natriuretic peptide) - used to rule out heart failure in values:
BNP \<100
if BNP \>100:
transthoracic doppler echo - cardiac abnormalities
234
initial management for acute decompensation of heart failure
IV diuretic - higher dose to what they were admitted on
monitor U&Es, weight and urine output
NIV if low O2
treatment after stabilisation:
- continue BB
- stable for 48hrs before discharge
- ACEi during hospital admission
- spironolactone during hospital admission
- surgical aortic valve replacement if due to severe aortic stenosis (or transcatheter aortic valve implantation for those unable to have surgery)
- follow up with heart failure team within 2wks of discharge
235
diagnosis of chronic heart failure
N-terminal pro-B-type natriuretic peptide (NT-proBNP) in people with suspected heart failure
NT-proBNP \> 2,000 = urgent specialist assessment + transthoracic echo within 2 wks
NT-proBNP 400-2000 = specialist assessment + transthoracic echo within 6 wks
NT-proBNP \<400 = heart failure less likely
ECG
236
management for chronic heart failure
237
what is defined as hypertensive crisis
sudden increase in BP + acute end-organ damage (e.g. heart failure)
systolic BP \>180
diastolic BP \>120
238
causes of hypertensive crisis
- cerebral infarction
- acute pulmonary oedema
- hypertensive encephalopathy
- acute aortic dissection
- ACS
- eclampsia
- acute renal failure
- phaeochromocytoma
239
treatment for hypertensive crisis
gradual but prompt reduction in BP
within 1st hr: reduce BP no more than 25%
target BP within next 2-6hrs : 160/100
within next 24/48hrs: normal BP
phaeochromocytoma crisis and severe pre/eclampsia: systolic BP 140 within 1st hr
aortic dissection: 120 within 1st hr
BP control IV:
GTN
sodium nitroprusside
labetalol
specific cause treatments:
pulmonary oedema: GTN, sodium nitroprusside
ACS: GTN
aortic dissection: IV labetolol
eclampsia: labetalol + magnesium (seizure prevention)
phaeochromocytoma: IV phentolamine (a blocker)
240
risk factors for infective endocarditis
dental procedures
surgery
infections
nonsterile injections
241
most common bacteria to cause **acute** infective endocarditis
most common bacteria to cause **subacute** infective endocarditis
acute: staph aureus
subacute: viridens strep - usually affects people with pre-existing damage to heart valves
242
fatigue
fever/ chills
malaise
new or changed heart murmur
comes on over hrs to days
may have damage to other organs eg glumerulonephritis
diagnosis
acute infective endocarditis
243
what criteria is used to diagnose acute infective endocarditis
Dukes criteria
- positive blood culutres
- evidence of endocardial involvement in echo
244
management of Infective endocarditis
empiric IV abx - then adapted to blood culture results - 4-6wks
**native** valves:
- empiric abx: **vancomycin**
after blood cultures: **penicillin G 4 wks**
or gentamicin + penicillin G 2wks
**prosthetic** valves: same treatment **6 wks**
**IVDU**:
empiric abx: vancomycin
after blood cultures:
IV nafcillin 2wks
PO cloxacillin 2wks
indications for surgery:
- congestive heart failure
- uncontrolled infection
- systemic embolisation
- prosthetic valve
- fungal endocarditis
245
246
congenital heart disease in adults presentation
arrythmias
cyanosis
SOB- on exersion
high heart rate
peripheral oedema
247
most common congenital heart disease in adults
tetralogy of fallot - most common cyanotic defect
then atrial septal defect - SOB, fatigue, palpitations - volume loaded right heart
ventricular sepatal defect: most common defect in children - loaded left side of heart
coarctation of aorta: presents with systolic HTN, murmur, absent or diminished femoral pulses (higher BP in arms than legs)
transposition of great arteries
248
most important diagnostic tool for cardiomyopathies
echo
249
what is dilated cardiomyopathy
most common type of cardiomyopathy
decreased ventricular contractility of the dilated left ventricle (LV) --\> failure of the left and eventually right heart (decreased ventricular output)
Mx: manage congestive heart failure and treat underling cause
250
what is restrictive cardiomyopathy
proliferation of connective tissue --\> **atrial enlargement (dilated)**
causes right and left heart failure
**diastolic filling reduced**
ejection fraction normal
251
most common cause of sudden heart failure in athletes and teenagers
hypertrophic cardiomyopathy
signs of left heart failure
sudden death
decreased LV cavity size
wall thickness significantly increased
252
most common viral infections causing myocarditis
symptoms
parovirus B19
coxsackie virus
rheumatic fever - group A strep
non specific symptoms: (flu-like symptoms + new ECG changes) fever, fatigue, weakness, arrythmias, heart failure
253
Ix and Mx of myocarditis
CXR: cardiac enlargement
elevated cardiac enzymes (CK, troponin)
further investigation: myocardial biopsy
Mx:
- treat underling cause - e.g. abx
- arrythmias - amiodarone
congestive heart failure - BB, ACEi, diuretics
254
saddle ST elevation on ECG
diagnosis?
pericarditis
255
diagnosis
hyperkalaemia
- **tall tented T waves**
- broad bizarre QRS complexes
256
diagnosis
**hypokalaemia**
**inverted T wave**
**prominant U wave** (after T wave)
257
diagnosis?
hypothermia
- J waves (osborne waves)
- most prominant in precordial/ chest leads (V1-V6)
- height of peak equates to extent of hypothermia
258
diagnosis
**bifid** (notched) **p wave**
sign of **left atrial enlargement** - most commonly due to:
**mitral stenosis**
259
what drug is BB contraindicated with
BB contraindicated with rate limiting CCB (verapamil, diltiazem)
risk of heart block
can be used with normal CCB (amiodarone)
260
diagnosis?
hypokalaemia
U waves
prolonged PR
absent/small T waves
long QT
in hypokalaemia U have no Pot and no T, but a long PR and a long QT
261
hypotension
raised JVP (absent Y descent)
muffled heart sounds
diagnosis
cardiac tamponade
Becks triad
absent Y descent in cardiac tamponade
(TAMponade = TAMpaX)
262
maangement of cardiac tamponade
urgent pericardiocentesis
263
first three months following prosthetic valve surgery
which bacteria
staphylococcus epidermidis
264
sudden onset endocarditis
IVDU
or
prosthetic valve replacement.
endocarditis after 3months
bacteria?
staph aureus
265
endocarditis associated with colorectal cancer
strep bovis
266
endocarditis associated with poor dental hygiene or dental procedure
bacteria?
strep viridans
267
side effects of thiazide diuretics
hyponatraemia
hypokalaemia
hypercalcaemia
gout
dehydration
postural hypotension
268
massive PE + hypotension
Mx
thrombolysis
269
first line investigation for stable chest pain of ACS
first line: CT coronary angiography
2nd line: non-invasive functional imaging
3rd line: invasive coronary angiogrpahy
270
new LBBB + ischaemia symptoms
MI
if someone has LBBB compare with old one to see if its new
271
how should adenosine be administered for SVT
infused via large-calibre vein (e.g. right antecubital vein) or central route
large bore (16G) cannula used
272
who should adenosine be avoided in
asthmatics
can cause bronchospasm
273
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic (indapamide). K+ \> 4.5mmol/l
next step
add alpha or beta blocker
274
stages of HTN
275
diagnosis
posterior MI
shows reciprocal changes therefore ST depression
ST depression and tall R waves in V1-3
276
rheumatic fever from which infection
strep. pyogenes infection
277
diagnosis of rheumatic fever major and minor criteria
diagnosis:
recent strep pyogenes infection plus:
- 2 major criteria
- 1 major with 2 minor criteria
major criteria:
- erythema marginatum (pic)
- sydenhams chorea (jerky, irregular movements)
- polyarthritis
- carditis and valvulitis
- subcutaneous nodules
minor criteria:
- raised ESR or CRP
- pyrexia
- arthralgia
- prolonged PR interval
278
for a person \<80 with stage 1 HTN who do you treat
treat if:
diabetes
renal disease
QRISK \>10 %
established coronary vascular disease
end organ damage
279
what test is used to test reinfarction in window of 4-10 days after initial insult
creatinine kinase (lowers after 3-4 days)
troponin can be used 10 days after initial infarct (remains high for 10 days)
280
what are the non-shockable rhythms
mx
pulseless electrical activity
asystole
give 1mg adrenaline IV + CPR
further adrenaline every 3-5 mins
281
how many shocks can you give for VF/ pulseless VT
**give 1 shock followed by 2 mins CPR** rather than 3 shocks
282
how many shocks can you give in a witnessed cardiac arrest in monitored patient
283
VF/ VT cardiac arrest Mx
shock
CPR
adrenaline 1mg IV then every 3-5 mins on rotation with CPR
284
type A vs type B aortic dissection
type B - distal to left subclavian origin
type A - ascending aorta - control BP (IV labetalol) + surgery
type B - descending aorta - control BP (IV labetalol)
285
what can hypokalaemia lead to on ECG where it commonly presents in young people as cardiac syncope, tachyarrhythmias, palpitations or cardiac arrest
long QT syndrome
286
MI leading to mitral regurg
cause?
rupture of papillary muscles
287
major bleed whilst on warfarin?
stop warfarin
give IV vit K 5mg
prothrombin complex concentrate (or FFP if other unavailable)
288
non pulsatile raised JVP
SVC obstruction
289
blood pressure target \> 80yrs
clinic reading
ABPM
clinic reading: 150/90
ABPM: 145/85
290
blood pressure target \<80yrs
clinic reading
ABPM
clinic: 140/90
ABPM: 135/85
291
diagnosis
digoxin toxicity
downsloping ST depression
Inverted T wave
short QT interval
reverse tick, scooped out
292
AF + acute stroke (non-haemorrhagic)
when should anticoag be started
two weeks after the event
due to risk of haemorrhagic transformation
293
what is buergers disease associated with
smoking
294
features of buergers disease
also called thromboangiitis obliterans
small and medium vessel vasculitis
associated with smoking
features:
- extremity ischaemia:
intermittent claudication
ischaemic ulcers
- superficial thrombophlebitis
- raynauds phenomenon
295
hypertension + notching of inferior border of ribs
coarctation of aorta
notching present in 70% of adults with coarctation
infants: hear failure
adults: HTN
radio-femoral delay
296
monitoring of ACEi
monitor renal function and electrolytes before starting and if increasing
rise in creatinine and K+ may be expected after starting ACEi
acceptable changes:
- creatinine up to 30% rise from baseline
- increased K+ up to 5.5
significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis
297
cardiac output low
pulmonary artery occulsion pressure low
what type of shock
hypovolaemic shock
cardiac output low in hypovolaemia due to decreased preload
298
cardiac output low
pulmonary artery occulsion pressure high
what type of shock
cardiogenic shock
pulmonary pressure high in cardiogenic shock
299
decreased systemic vascular resistance
high cardiac output
which type of shock
septic shock
decresed systemic vascular resistance - major feature
hyperdynamic circulation (increased circulatory volume)
300
new onset AF presenting within 48hrs of presentation
mx
\<48hrs: electrical cardioversion + anticoagulation (heparin, start prior)
if \> 48hrs: start anticoag then electrical cardioversion after 3 weeks
or can perform transoesophageal echo to exclude thrombus to thrombolyse straight away wth anticoag
anticoag continued for at least 4 weeks after cardioversion
301
contraindications to thrombolysis
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 HTN
302
heart failure mx
first line: ACEi + BB
2nd line: aldosterone antagonist (mineralocorticoid receptor antagonists) - spironolactone, eplerenone
3rd line: started by specialist. options:
- ivabradine
sacubitril - valsartan
digoxin
hydralazine in combo with nitrate
cardiac resynchronisation therapy
annual influenza vaccine
one off pneumococcal vaccine
303
which abx can cause torsades de pointes
macrolides - clarithromycin, erythromycin
304
mx for torsades de pointes
IV magnesium sulphate
305
breathing problems with clear chest
low sats
tachypnoeic and tachycardia
think PE
COPD - wheeze and crackles
asthma - wheeze
pneumothorax - absent breath sounds on one side
panick attack - wouldnt have low sats
306
AF + acute stroke management
altready had aspirin and alterplase
aspirin daily (for stroke mx)
start anticoag in 2 wks (for AF)
307
widespread ST elevation + PR depression
acute pericarditis
308
pericarditis mx
NSAIDs + colchicine = first line
309
mx of haemodynamically unstable AF
immediate electrical (DC) cardioversion followed by thromboprophylaxis
the cardioversion shouldnt be delayed for thromboprophylaxis
anticoag continued for 4 weeks
310
311
symptomatic bradycardia
(periarrest bradycardia
/haemodynamic instability)
mx
atropine 500mcg IV
features of bradycardia:
shock
myocardial ischaemia
heart failure
syncope
312
which abx causes long QT syndrome
erythromycin
313
suspected PE with a wells PE score of 4 or less
Ix
D-dimer
if 5 or above then do CTPA
314
most common cause of mitral stenosis
rheumatic fever
315
bacteria causing rheumatic fever
group A streptococcus (GAS)
indiginous population in central australia at risk
316
features of mitral stenosis
mid-late diastolic murmur
loud S1 opening snap
malar flush
317
pharmacological cardioversion for AF
if no evidence of structural or ischaemic heart disease:
flecainide or amiodarone
if evidence of structural heart disease:
amiodarone
318
wolff parkinson white symptoms
palpitations
dizziness
high heart rate
asscociated with hypertrophic obstructive cardiomyopathy
319
exertional dyspnoea
syncope following exercise
left ventricular hypertrophy
progressive T wave inversion
hypertropic obstructive cardiomyopathy
320
AF with decompensation mx
synchronised DC cardioversion
can try pharmacological cardioversion (flecainide or amiodarone) if unsuccessful
321
first line mx angina
BB or rate limiting CCB (verapamil) (cant be on both due to risk of heart block)
2nd line: BB + CCB
3rd line: PCI or CABG
isosorbide mononitrate given - 10-14hr gap inbetween doses to stop tolerance
322
what valve problem is associated with Marfans syndrome
aortic regurg (wide pulse pressure + collapsing pulse)
323
seondary prevention for MI
dual antiplatelet therapy (aspirin + ticagrelor)
ACE inhibitor
beta-blocker
statin
324
bifascicular Vs trifascicular block
bifascicular block:
- combination of RBBB + left antior or posterior hemiblock
e. g. RBBB with left axis deviation
trifascicular block
- features of bifascicular block + 1st degree heart block
325
radio-femoral delay
co-arctation of aorta
326
what congenital heart defect is turners syndrome associated with
coarctation of aorta
327
COPD + pan systolic murmur
tricuspid regurgitation
caused by pulmonary HTN
328
collapsing pulse
aortic regurgitation
329
indications for transcutaneous pacing
complete heart block with broad complex QRS
Mobitz type II
recent asystole
ventricular pause \>3s
330
SVT on ECG
mx
narrow complex tachycardia
absent p waves
Mx:
acute:
- vagal manoeuvres: valsalva, carotid sinus massage
- IV adenosine 6, 12, 12 (contraindicated in asthmatics, verapamil is prefered)
- electrical cardioversion
prevention of episodes:
- BB
- radio-frequency ablation
331
most common cause of aortic stenosis by age
younger patients \<65yrs: bicuspid aortic valve
older patients \>65: calcification
332
feel short of breath and adopt this position
tetralogy of fallot
overriding aorta, right ventricular hypertrophy, pulmonary stenosis, VSD
shows a tet spell - patient puts knees to chest
333
caution of amiodarone
patient should keep out of direct sunlight
334
drug contraindicated in renal artery stenosis
ACEi
335
most common cause of mitral stenosis
rheumatic fever
previous fever
annular (ring-like) erythematous rash, commonly known as erythema marginatum
