Cardiology Flashcards
What are the ECG criteria for a STEMI?
Elevation in at least two contiguous leads of 2mm in the precordial leads, and 1mm in the limb leads
Give 3 indications to attempt rhythm control rather than rate control for AF
New onset (within 48 hours)
Reversible cause
The atrial fibrillation is causing heart failure
Young age/ few comorbidities
Rate control is difficult to achieve/ symptomatic even after rate control
Link to ESC flowchart on rhythm control:
https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/eurheartj/PAP/10.1093_eurheartj_ehaa612/3/ehaa612f15.png?Expires=1609322446&Signature=0KcCkSeRXpk4JtA25clSB-xp2gbqukTr4D~pGAPUiHbLWyrsFDmgqx93FV-4jj43yDuw4L4lDK7Q3iqL4wV6s2ElMPH0OsroWkflzo7BGOv~5N74EDdsUykwTbFcb60Tr-j-H8pKmmmUfyOnCvigsRZzZW~fAynC~PTB-CypDPOeDnpEu0Mg4aheokjlPuon78GPSVCo1WE5jGdzKukXOTDJQWD6jY820KzidvUsXgGGfdqGViywuWkWIAvtiYgt3KZ0r2jO5LndCO4HOYrh~GkvAF0Ua~6EL0Fg5XhN2gW1QMlYsv-xWzie6l-gnJGHSt5~lkCqLBvwkUEVin3PSA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA
The F2 on call is bleeped to review a 67 year old woman who has developed breathlessness. She was admitted 2 days ago with a STEMI and is now SOB, coughing up frothy sputum, and saturating at 92% on room air. The nurse sits her up and gives 15L 100% oxygen through a non-rebreathable mask. On examination her peripheries are warm, and auscultation reveals bilateral fine crackles and expiratory wheeze. Her BP is 123/85, HR is 93. Her ECG features t wave inversion and pathological q waves.
How should this patient be managed?
A. Put out a 2222 call B. Give I.V. inotropes and vasopressors C. Contact the critical care outreach team with a view to haemofiltration and cardiac support D. Defibrillation E. Give I.V. furosemide and nitrates
E. Give I.V. furosemide and nitrates
This is a history of acute heart failure which can be classified by whether it is ‘wet’ or ‘dry’ (congestive vs. non-congestive) and whether it is ‘warm’ or ‘cold’ (is peripheral perfusion intact?): this will determine the management. 95% of cases are ‘wet’ and feature congestive features such as pulmonary oedema and peripheral oedema. Diuretics and vasodilators (e.g. nitrates) are commonly used for acute heart failure, but should be avoided if there is poor peripheral perfusion as they will worsen it. Vasopressors and inotropes may well be needed but will be given in an ICU setting, so although contacting critical care outreach is a good idea, the first priority in this woman (who is warm and well-perfused) is to give nitrates and furosemide.
NB: though furosemide’s properties as a diuretic are helpful here, its purpose in acute heart failure is actually venodilation to reduce preload on the heart
NB: the NICE guidelines aren’t hugely helpful for this topic, you are better off looking at the European guidelines and understanding the principles behind treatment
ESC flowchart for heart failure:
https://academic.oup.com/eurheartj/article/37/27/2129/1748921#109987142
ESC guidelines on heart failure:
https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/eurheartj/37/27/10.1093_eurheartj_ehw128/4/ehw12805.jpeg?Expires=1617535354&Signature=lu6fF~DmdyGgFz8cN1VVA~wj2a6ycvaZGkoh1Krr1WTs6oevA8loxNEI9kDToeqivvBwJXju08nCQx8H4xO64kArH1z5fdZZ9hD1oH-KAymJTAw1s28NAVhD1QZWajGu8Wq5CO7pW6HT-~XBdlRwREXRpNvCCmOwusXk3y8RM39To6uXd9ZGjvxdkAR3T3naHLx3cCUS1ou2Vo0t1LajVWb~023CVw3J71aorMyyqKpzk142N32CuiEq7Zm2XRYnf8wsBCg9Qo4NHuyJtVU9S-9WEekvLXzFIATjTjVG9XwP2FyuoTjcrutdQEHu3Ogt~4ACxHYJ5Tpv00RqBZhQgw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA
What is the management of chronic heart failure with reduced ejection fraction?
The aim is to get the ejection fraction above 35%
Furosemide is used for symptomatic relief
1st Start ACEi and beta blockers
If EF still <35%, add mineralocorticoid antagonist
If EF still <35%, consider an angiotensin receptor/neprilysin inhibitor combination (ARNI) e.g. sacubitril/valsartan, CRT, or Ivabradine
If EF still <35%, consider digoxin, LVAD, transplant
NB: CRT involves pacemaker leads in the right atrium, right ventricle, and a cardiac vein off the coronary sinus (over left ventricle). The patient is then blocked with beta blockers, and the pacemaker will take over the majority of the work initiating contractions.
ESC flowchart:
https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/eurheartj/37/27/10.1093_eurheartj_ehw128/4/ehw12802.jpeg?Expires=1614428667&Signature=B06hufiT~ZHtVEAJI9iAHpw0yH6Kr8s2X9e895zX3DYBrYfHlg4BJNKxZtNWCvHNSDm6baxmFtylSp7V3NHqrzRch908mx4NADvIoDFdjI2CTnT61RCgHXK4pR~yOfhxaZxTyuKru-zWDeQ16hBuoCQgPZDPSflgrOwm6BzQOb8lfmHsU5Fs3RZRvie9KyT0p8-4PCbeC6ngJ8RF-iW9u~DLgjOg4D930KGUcq0qB7jfzBeGgv9Fvq13SkGe2sFT-xM5fgvy8NgNRVIhzo5XH3w0fGl8sq8aqFJqGzr-TPv94mjqirIHzUr~SCmUS73RqI0L9FQHxzazzd4Al3x2yQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA
Which medications should be given to a patient diagnosed with a STEMI immediately before they are sent for PCI?
Aspirin 300mg
Preferably Prasugrel 60mg (alternatively Ticagrelor 180mg or Clopidogrel 300mg)
Oxygen (if sats <90%)
Morphine (if required and not hypotensive)
Unfractionated heparin (radial access) or bivalirudin (femoral access) is offered in the cathlab
A 66 y/o man presents with a history of central constricting chest pain that is brought on by exertion and relieved by rest. He is diagnosed with stable angina. He has high cholesterol and asthma, and is taking an LRTA regularly.
Which medication should he be started on to prevent episodes from occurring?
A. Nicorandil B. Bisoprolol C. Atenolol D. Diltiazem E. GTN spray
D. Diltiazem
First line treatment for prevention of episodes of stable angina is either a CCB or a beta blocker, however this man’s asthma is a contraindication to beta blockers. GTN spray is given to these patients, but is a reliever therapy, not a preventative. Patients whose angina is not controlled with one option should then be tried either on the other option or on both. In this case, if diltiazem were insufficient in controlling angina one of the following may be added:
A long-acting nitrate
Ivabradine
Nicorandil
Ranolazine
Describe the treatment algorithm for hypertension
Hypertension is usually treated with pharmacological intervention at stage 2 or above (>160/100), but may be treated at stage 1 (140/90 - 160/100) if there are comorbidities (diabetes, renal disease, end organ damage, previous cardiovascular disease, or a QRISK of 10% or more)
NB: treatment should be started in these patients, but this does not mean patients with stage 1 hypertension and without these comorbidities should not be treated - but the decision is more individual and less clear cut.
Step 1:
Start CCB in patients if they are over 55 or black
Start ACEi or ARB in all other patients including any with T2DM (including >55 years old or black)
Step 2:
Add 1 drug from the other category (e.g. add a CCB to an ACEi, or an ARB to a CCB) or add a thiazide-like diuretic (e.g. indapamide)
Step 3:
Give a CCB, a thiazide-like diuretic, and an ACEi/ARB
Step 4: Add spironolactone (should only be given if K+ is below 4.5mmol/L) or an alpha/ beta blocker
Which drug should be given as first line for rate-control in atrial fibrillation?
Either a typical beta blocker (i.e. not Sotalol) or a rate limiting CCB
Digoxin monotherapy may be considered for very sedentary patients
If monotherapy fails, consider a combination of 2 of:
A beta blocker
Diltiazem
Digoxin
A 67 year old woman visits her GP for a check-up following her ambulatory blood pressure measurement, which has confirmed she has hypertension. She has previously been diagnosed with hypercholesterolaemia and type II diabetes, and the doctor gives her advice on lifestyle measures she can implement.
What is the next step in her management?
A. Record her BP again in 3 months B. Begin a CCB C. Begin an ACEi D. Begin a beta blocker E. Record her BP again in 6 months
C. Begin an ACEi
Hypertension is diagnosed by the presence of an in-clinic reading of ≥140/90 AND an ambulatory or home BP average of ≥135/85. Since this patient is under 80 and has diabetes, pharmacological treatment is indicated rather than lifestyle modification alone. Though a patient over 55 would normally be started on a CCB or thiazide-like diuretic, the diagnosis of type II diabetes means she should be started on an ACEi or ARB.
Which of the following medications is contraindicated in combination with beta blockers?
A. Amiodarone B. Amlodipine C. Verapamil D. GTN E. Ramipril
C. Verapamil
Verapamil and other rate-limiting CCBs (e.g. Diltiazem) produce complete heart block when used in conjunction with beta blockers.
The F1 on call is bleeped to see a patient who began to have severe central curshing chest pain 10 minutes ago. The pain radiates to their right arm and is constant, and is associated with sweating and nausea. The nurse hands the F1 an ECG which shows a normal P wave and QRS complex, but tall, broad, asymmetrical T waves in the anterior leads.
What is the most likely diagnosis?
A. Pulmonary embolism B. STEMI C. Hyperkalaemia D. NSTEMI E. Unstable angina
B. STEMI
The tall, broad, asymmetrical t waves described here are hyperacute t waves. This is a description of the very early stages of a STEMI, where hyperacute t waves may be the first change. If this ECG were repeated a short while later, it would show ST elevation in the anterior leads.
How is idiopathic pericarditis with no complications or large effusion treated?
Colchicine and Aspirin/ NSAIDs with gastroprotection (e.g. PPI)
What is the most common cause of death following a myocardial infarction?
Ventricular fibrillation
Recall which valvular defect would correspond to each auscultation finding below:
A. An early-diastolic murmur best heard in left parasternal region
B. An opening snap and mid diastolic rumbling murmur heard in the 5th intercostal space in the midclavicular line
C. Pan systolic heard louder on inspiration
D. Ejection systolic murmur that does not radiate
A. An early-diastolic murmur best heard in left parasternal region - aortic regurgitation
B. An opening snap and mid diastolic rumbling murmur heard in the 5th intercostal space in the midclavicular line - mitral stenosis
C. Pan systolic heard louder on inspiration - tricuspid regurgitation
D. Ejection systolic murmur that does not radiate - HOCM or aortic sclerosis
What do each of the following heart sounds represent?
S1
S2
S3
S4
S1: Closure of mitral and tricuspid valves
soft if long PR or mitral regurgitation
loud in mitral stenosis
S2: Closure of aortic and pulmonary valves
soft in aortic stenosis
splitting during inspiration is normal
S3 (third heart sound): Caused by diastolic filling of the ventricle
Considered normal if < 30 years old (may persist in women up to 50 years old)
Heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
S4 (fourth heart sound): Caused by atrial contraction against a stiff ventricle, and therefore coincides with the P wave on ECG
May be heard in aortic stenosis, HOCM, hypertension
In HOCM a double apical impulse may be felt as a result of a palpable S4
A 58 year old man presents to A&E with breathlessness. The problem has been bothering him for several weeks and has not resolved spontaneously. His pulse is irregularly irregular, and an ECG shows a narrow complex irregular rhythm with a lack of P waves. He is sent for an echocardiogram which shows a dilated left atrium. He has a background of an MI 5 years ago that has left him with left bundle branch block, and type 2 diabetes.
Which medication should this man be started on?
A. Flecainide B. Amiodarone C. Amlodopine D. Bisoprolol E. Adenosine
D. Bisoprolol
This man is presenting with several weeks worth of palpitations, and so the first step is to rate control him and anticoagulate him for at least 3 weeks.
Given the atrial dilatation and ischaemic heart damage, this man is unlikely to be a good candidate for rhythm control (cardioversion or an interventional procedure). Instead the goal should be rate control, for which the first line drug is either a beta blocker or a rate limiting CCB.
This man will also need anticoagulating long-term as his CHADSVASc score is 2.
Calculate each of these patients’ CHA2DS2-VASc scores:
A. A 79 year old man with HTN and hypercholesterolaemia, who had an MI 5 years ago
B. A 45 year old woman with T2DM and a DVT 2 years ago
C. A 68 year old woman with a history of stroke and congestive cardiac failure
A. A 79 year old man with HTN and hypercholesterolaemia, who had an MI 5 years ago - 4
B. A 45 year old woman with T2DM and a DVT 2 years ago - 4
C. A 68 year old woman with a history of stroke and congestive cardiac failure - 5
The scoring system is as follows:
C - congestive heart failure (or left ventricle dysfunction)
H - hypertension
A2 - age 75+
D - diabetes mellitus
S2 - previous stroke/TIA/VTE
V - vascular disease (e.g. peripheral arterial disease, MI, angina)
A - age 65-74
Sc - sex category (+1 for female, nothing for male)
NB: Hypertension is counted whether it is controlled or not
NB: Hypercholesterolaemia does not score a point on its own
NB: the threshold for considering anticoagulation is 1 or more in men, and 2 or more in women.
Which artery usually supplies the posterior descending artery, and how common is this variant?
The PDA is usually supplied by the right coronary artery (80-85% of people) with other people being either left coronary artery dominant, or co-dominant.
What are the two ways to diagnose a posterior MI on ECG?
1) Put leads on the patient’s back
2) V1-V3’s QRS complexes will become overall positive because of the loss of negative signal from the depolarisation of the posterior segment of the heart. Classically there is a positive R wave in V2
Which of the following drugs does NOT improve long-term prognosis of heart failure?
A. Furosemide
B. Bisoprolol
C. Ramipril
D. Spironalactone
A. Furosemide
Though very useful in treating acute heart failure given its properties as a loop diuretic and venodilator, the evidence does not show a long term reduction in mortality with furosemide therapy. However this does not mean it is not useful and important to give in fluid overloaded patients. All the other options have been proven to improve long term prognosis.
A 72 year old man is brought by ambulance to A&E with a 1 hour history of central crushing pain radiating to the left shoulder and jaw. His ECG in the ambulance shows ST elevation in leads II, III, and aVF. Whilst being clerked by the FY2, the man suddenly develops breathlessness. His BP is 75/40 (down from 110/78 on admission) and his SO2 is 91% (down from 97% on admission). Auscultation reveals bibasal lung crepitations.
What is the most likely cause of the sudden deterioration?
A. Ventricular aneurysm B. Ventricular rupture C. Pulmonary embolism D. Haemorrhage E. Mitral valve papillary rupture
E. Mitral valve papillary rupture
Mitral valve papillary muscle rupture is a complication of myocardial infarction particularly with infero-posterior infarction. It causes acute mitral regurgitation which leads to flash pulmonary oedema.
What is the most common cause of mitral stenosis worldwide?
Rheumatic fever
