Cardiology Flashcards
3 key features of typical angina?
Central chest pain
Precipitated by exertion
Relieved by rest or nitrates, usually within 5 minutes
What medication is used for an attack of angina and when should an ambulance be called?
Glyceryl trinitrate used as and when necessary, repeated if needed after 5 minutes, call ambulance if pain persists 5 minutes after second dose
Drugs for secondary prevention of CVD in angina?
Aspirin and statin
What dose of aspirin is used for prevention of CVD?
75mg daily
What are the first line anti-anginal drugs?
Beta blocker or rate-limiting CCB (verapamil)
Second line treatment for angina?
Beta blocker and CCB.
DO NOT prescribe a beta blocker + verapamil due to risk of heart block. Instead use non-rate limiting CCB e.g. nifedipine
Third line options for angina?
Ivabradine, nicorandil, ranolazine
Which type of cholesterol, HDL or LDL, guides the goals of lipid therapy?
LDL
What dose of atorvastatin is used for:
1) Primary prevention if QRISK >10%
2) Secondary prevention in pts with pre-existing CVD
1) 20mg (this is controversial in some centres)
2) 80mg
Name 3 criteria that would constitute metabolic syndrome
Any 3 out of the following 5:
- Hyperinsulinaemia
- Decreased HDL
- Central obesity
- Hypertriglycerdaemia
- Hypertension
Name 4 modifiable and 4 non-modifiable risk factors for ACS
Modifiable: DM, obesity, sedentary lifestyle, smoking, HTN, dyslipidaemia
Non-mod: age, male, South Asian, FH in a first degree relative (<55 in men, <65 in women), previous MI
Which patients may present atypically with ACS?
How may they present?
Those with autonomic dysfunction e.g. diabetes and the elderly. Silent MI (no pain), delirium, hypotension, epigastric pain
Name 3 investigations in a patient presenting with ACS.
ECG, bloods- troponin (also FBC, U&Es, LFTs), CXR
Name 3 other conditions that can cause a raised troponin
Acute heart failure, myocarditis, pericarditis, pulmonary embolism, renal failure, sepsis
What is the intial management for ACS?
Initiate dual anti-platelet therapy= aspirin 300mg + other antiplatelet (ticagrelor, clopidogrel)
IV morphine and IV metoclopramide
O2 therapy if <94%
GTN
What is the gold standard reperfusion strategy for STEMI?
PCI
What time frame from onset of symptoms is PCI indicated in?
Within 12 hours of symptom onset
What is the treatment method used if PCI isn’t available within 90-120 minutes of diagnosis of STEMI?
Thrombolysis
What is the diagnostic difference between NSTEMI and UA?
NSTEMI= troponin positive +/- ischaemic changes on ECG UA= negative troponin +/- ischaemic changes on ECG
What ischaemic changes may be seen on ECG in a NSTEMI?
ST depression, T wave inversion
Following ACS, how long should patients remain on aspirin and at what dose?
How long should they remain on the other antiplatelet agent e.g. ticagrelor?
75mg daily, LIFELONG
12 months
Aside from antiplatelet agents, what other drugs are used in the post-acute management of ACS?
Statins
Beta blockers
Nitrates- PRN and regular if required
ACE inhibitors
What is the mnemonic for complications of ACS?
Sudden Death on PRAED Street Sudden death Pericarditis/pump failure Rupture Aneurysm/arrhythmia Embolism Dressler syndrome
What marker is useful for detecting re-infarction following MI and why is troponin not used?
CK-MB
Troponin not used as levels take 14 days to normalise
Which two types of troponin may be measured to diagnose MI?
Troponin T or I
Displaced apex beat, S3 and pulmonary congestion are signs of right or left heart failure?
Left heart failure
Name 3 signs of right heart failure?
Elevated JVP, hepatomegaly, ascites, significant peripheral oedema
Key blood test when investigating suspected heart failure?
B-type natriuretic peptide
What are the classical Xray findings in heart failure?
Alveolar oedema Kerley B lines Cardiomegaly Dilated upper lobe vessels Effusion
What is the key investigation in suspected heart failure?
TTE
Other than bloods, BNP and echo, what investigation should all patients with heart failure have?
ECG
What is first line medication for heart failure?
Loop diuretics e.g. furosemide
Outline the stepwise drug management of heart failure.
1) Loop diuretics- furosemide
2) ACE inhibitor
3) Beta blockers (bisoprolol, carvedilol, nebivolol)
4) Aldosterone antagoists (spironolactone)
5) Ivabradine
6) Hydralazine plus nitrate
Give 4 causes of secondary hypertension
Renal- diabetic nephropathy, glomerulonephritis, PKD
Endocrine- Conn syndrome, phaeochromocytoma
Pre-eclampsia
Coarctation of the aorta
How is HTN diagnosed?
Clinic blood pressure >=140/90 mmHg and either ambulatory or home blood pressure monitoring average 135/85mmHg or higher
Other than BP, name 4 investigations to carry out in a patient newly diagnosed with HTN.
U&E, echo (if HF suspected), ECG, fasting blood glucose, lipid profile,
Name 4 conditions hypertension predisposes to
ACS, stroke, CKD, hypertensive retinopathy, aortic aneurysm, aortic dissection
What are the treatments targets for hypertension in:
- Under 80 year olds
- Over 80 year olds
- Diabetics
- <140/90mmHg
- <150/90mmHg
- <130/80mmHg
If a patient needs triple therapy to control their hypertension, what would this consist of?
ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic
Give an example of a thiazide diuretic.
Indapamide
What is first line therapy for hypertension in a diabetic? What if they are >55?
ACE inhibitor. Same regardless of age
Give 4 causes of pericarditis
Idiopathic Viral- coxsackie, EBV AI disease- SLE, sarcoidosis Acute MI Drugs- hydralaine, isoniazid, penicillin Uraemia
What is the most common presenting feature of pericarditis?
Sharp retrosternal chest pain, classicaly worse on leaning back and better sitting forward
Muffled heart sounds, hypotension and raised JVP are called what triad? What is this suggestive off?
Beck’s triad, suggestive of cardiac tamponade
What is the most specific ECG finding for pericarditis?
PR segment depression
What may a CXR reveal in pericarditis?
Cardiomegaly from pericardial effusion
What is the mainstay of treatment for pericarditis?
NSAIDs/aspirin and colchicine
What is the purpose of giving colchicine for pericarditis, and what is a common side effect patients should be warned about?
To prevent recurrence.
Common side effect= GI disturbance e.g. diarrhoea
What is given in pericarditis if NSAIDs + colchicine is ineffective?
When else may these be useful for pericarditis?
Corticosteroids
Given in connective tissue disease, uraemic or immune-mediated pericarditis.
The SA nodal artery is a branch of which artery in 90% of the population?
Right coronary artery
Give 4 causes of bradycardia.
Physiological- athletes, young, sleeping Medications- beta blockers, CCBs, anti-arrhythmics, digoxin Infection (myocarditis) Sick sinus sydrome Metabolic- hypothyroidism, hypothermia
What is the first line management for bradycardia if there are adverse clinical signs or risk of asystole?
IV atropine
When assessing risk of asystole, what factors should be taken into account?
Recent asystole, Mobitz II heart block, complete heart block with wide QRS, ventricular pause >3s.
What is the long term management for bradycardia and in which patients is it indicated?
Dual chamber pacemaker
Patients with symptomatic bradycardia due to sick sinus syndrome and/or AV conduction block
In which type of heart block is a permanent pacemaker indicated even if asymptomatic?
Mobitz type II and third degree/complete heart block
Why is the QRS complex widened in bundle branch blocks?
One ventricle depolarisation is delayed, then must be depolarised indirectly from the other bundle branch. Delayed ventricular depolarisation causes widening of QRS complex.
Which type of bundle branch block invariably indicates underlying pathology e.g. IHD, cardiomyopathy or hypertrophy?
LBBB
Name 2 associated conditions with RBBB/
RVH, right heart strain, pulmonary stenosis, pulmonary emboli
A new LBBB on ECG + chest pain is suspicious of what?
Acute MI
Which ECG leads do you look at for WiLiaM MaRroW?
V1 and V6
A narrow complex tachycardia typically originates where?
Supraventricular- atria, SAN, AVN
What are 4 causes of LBBB?
Aortic stenosis, IHD, HTN, dilated cardiomyopathy, anterior MI, hyperkalaemia, digoxin toxicity
NICE recommends performing manual plse palpaton to assess for presence of an irregularly irregular pulse that may indicate AF in pts presenting with any of 5 symptoms. What are these symptoms?
Breathless/dyspnoea Palpitations Syncope/dizziness Chest discomfort Stroke/TIA
First line Ix for AF?
ECG
How does AF predispose to stroke?
The disorganised atrial electrical activity means the atria fibrillate rather than contract, leading to pooling of blood and a predisposition to thrombus formation or emboli.
Give 3 non-cardiac causes of AF
Fever/infections, thyrotoxicosis, electrolyte disturbance (hypoK, hypoMg), drug/alcohol/caffeine use,
Name 4 blood tests to perform when investigating AF and why you would do them.
FBC- look for infection e.g. leucocytosis; anaemia
U&Es- hypokalaemia, hypoMg
TFTs- look for hyperthyroid
LFTs- evidence of alcohol use/liver damage
Other than ECG and bloods, what investigation might you do for AF?
TTE- if considering rhythm control, if suspicion of structural heart disease
What is the management of new onset AF with haemodynamic instability?
Immediate synchronised DC cardioversion
What score is used to assess stroke risk in AF?
Name the components
CHA2DS2-VASc CCF Hypertension Age: >=75 (2), 65-74 (1) Diabetes Stroke/VTE history (2) Vascular disease Sex category: female (1)
What are the two treatment modalities in approaching AF and which dose NICE recommend as a first line strategy?
Rate and rhythm control
Rate control is first line
When would rate control not be first line management for AF? Give 2 situations.
If there is a reversible cause, if it’s new onset AF (<48h), heart failure is present, rhythm control more suitable (clinical judgement)
What is first line therapy for rate control of AF?
Beta blocker or rate-limiting CCB monotherapy
What is second line therapy for rate control of AF if first line doesn’t control symptoms?
Combo therapy with any two of: beta blocker, diltiazem, digoxin
Give 2 examples of a rate limiting calcium channel blocker.
Diltiazem and verapamil
Give 3 drugs that may be used to cardiovert patients with AF.
What are 2 factors that might mean you aim for rhythm control rather than rate control?
Sotalol, amiodarone, flecainide
Younger (<65), first episode of AF, AF secondary to treatable cause, congestive heart failure, symptomatic.
What CHADS-VASc score should prompt anticoagulant therapy?
2+
1+ in men, consider anticoagulation
Characteristic ECG feature in atrial flutter?
Saw tooth waves (F waves)
What is the main difference between AF and atrial flutter?
Atrial flutter is regular atrial rate whereas atrial fib is irregular
What management may be offered in AF which doesn’t respond to medical therapy?
Radiofrequency ablation
True/false: patients with atrial flutter do not require anticoagulation because the atrial contractions are regular.
False- patients should be risk assessed to decide whether they should be anticoagulated as with AF
What is the management for patients presenting acutely with atrial flutter?
Synchronised DC cardioversion
Management of recurrent atrial flutter or when cardioversion is unsuccessful?
Radiofrequency ablation of the flutter circuit
What are the two general pathophysiological mechanisms that cause SVT?
Re-entry mechanisms or impulse initiation disorders.
What is the most common type of SVT?
Atrioventricular nodal re-entrant tachycardia
Name the investigations that should be carried out for SVT and in what order?
1) ECG
2) Electrolytes, TFTs and toxicology (e.g. digoxin)
Management of SVT in a haemodynamically unstable patient?
Sedation and urgent DC cardioversion
Stepwise managment of SVT in haemodynamically stable patient?
1) Vagal maneouvres
2) IV adenosine
3) If unsuccessful, consider digoxin, beta blocker or amiodarone
4) Synchornised DC cardioversion
Describe the administration of IV adenosine and what side effects do you need to warn the patient of beforehand.
Given rapidly via large-bore cannula in ACF, followed by saline flush
SEs= chest tightness, impending sense of doom, breathlessness and discomfort.
What drug is used as an alternative to adenosine for SVT if it’s CI? In particular what patient group is adenosine CI in?
IV verapamil
CI in asthmatics
Give 3 adverse features of bradycardia that suggest treatment is necessary.
Shock, heart failure, myocardial ischaemia, syncope
Give 3 cardiac causes of clubbing.
Atrial myxoma, bacterial endocarditis, cyanotic congenital heart disease.
(Remember ABC)
MI in which region is frequently associated with bradycardia?
Inferior MI
