CARDIOLOGY Flashcards
**Cardiac Arrest
Treatment
Adrenaline dose
- Most commonly occurs due to patients developing VF & is the most common cause of death following a MI. Patients are managed as per the ALS protocol with defibrillation
1) CPR 30:2 + 02, adrenaline every 3-5 mins
2) Assess Rhythm
- Shockable –> Shock (amidarone after 3 shocks)
1 in 10,000 adrenaline every 3-5 mins
- Return of spontaneous circulation –> A-E
- Non-Shockable (PEA/systole) Repeat CPR
**Myocardial Infarction
STEMI
Syx
ECG changes
IVX
Management
STEMI –> MMONACH
- CF: Chest pain radiating to arms, back or jaw – not relieved by GTN
Nausea + Vomiting +. Sweating, Acute Dyspnoea
Extreme distress
Atypical: epigastric or back pain (silent in elderly or diabetic)
ECG:
. ECG (confirms Dx)
- First sign = peaked T wave then…
- ST elevation ≥1 mm (limb leads) ≥ 2mm (chest leads) – onset mins, lasts 2wks
1. Left anterior descending (LAD) – supplies anterior, left ventricle (V1-4)
2. Circumflex artery – supplies lateral of heart (I, AVL, V5-6)
3. Right coronary artery – supplies inferior of heart (II, III, AVF) → high risk of heart block
Blood: Troponin peaks at 12 hrs, CK increased
Management:
a) Coronary angiography + primary PCI
⇒ If presentation within 12 hrs of Sx onset and
⇒ If PCI can be delivered within 2hrs of when fibrinolysis could be given
OR if PCI not available = Fibrinolysis: Alteplase (or reteplase, streptokinase)
**Acute Coronary Syndrome
SYX
Treatment
- A set of symptoms resulting from acute myocardial ischaemia. There are two groups:
Unstable angina and NSTEMI – not treated w/ thrombolysis
STEMI – must undergo reperfusion therapy on presentation
Common symptoms: Chest pain radiating to arms, back or jaw > 15 mins Acute dyspnoea Nausea, vomiting and sweating Haemodynamic instability
IMMEDIATE treatment for suspected ACS (MONA)
Morphine, Oxygen, GTN, Aspirin 300mg PO
ECG + blood markers (Trop T+I, CK)
**Acute Left Ventricular Failure
SYx
SYX: SOB (blood buildds into lungs)
Causes: infections, LV aneurysms & Left ventricular free wall rupture –>
Seen in 3% of MIs - occurs 1-2 weeks after. Present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, ↓BP, Ejection fraction, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.
**Hypertension
stages
Ivx algorithm,
Stage 1: 140/90
Stage 2: 160/100
Stage 3: >180/110
Malignant: >200/120
RF: DM, obesity, salt, stress, conns, phaemochromocytoma
IVX: Ambulatory or home Bpm.
URGENT referral if BP >180/110 + pappiloedema, retinal haemorrage or suspected phaemochromocytoma
ECG
QRISK2
TX: Lifestype
Offer dx if level 1 and tried lifestyle
Under 55
1) A 2) A + C/D 3) A + C + D
Over 55 + afro carribean
1) C 2) C + A/D 3) C + A + D
4) = add a blocker or further diuretetic eg spironolactone
D = thiazide diuretic
**Chronic Cardiac Failure
Pump failure of L, R or Both sides of heart resulting in characteristic symptoms
Cause: Low output, increased pre-load or pump failure
SYSTOLIC: EF < 40%, ventricles cannot contract fully
DIASTOLIC: EF> 50% - ventricles cannt relax fully
LVF –> DYSPNOEA, orthopnoea, PND, nocturnal cough (pink frothy), weight loss, fatigue, basal creps, displaced apex. LEFT LOOP LUNG
RVF -> PERIPHERAL OEDEMA, calf swelling, ascites, N+Vm JVP, weight
CF: Poor exercise tolerance Confusion, Dizzy – cerebral Sx from ↓blood supply PMH – MI, AF, IHD, HTN, ascites Lungs - ↑RR, Cyanosis Heart - ↑HR, 3rd heart sound Limbs – Cachexia, muscle waste
IVX: ECG: axis deviation
BNP, CXR, bloods, urine dip
Treatment: - Pneumococcal vaccine - LOOP DIURETIC furosemide - B BLOCKER = bisoprolol (+ thiazaide diuretic)
**Deep Vein Thrombosis
Score?
Management
Legs or Pelvis and can –> PE
RF: smoking, BMI > 30, cancer, VTE hx
CF: Limb pain and tenderness along line of DV
Swelling of calf or thigh, pitting oedema
IVX: WELLS SCORE
Score >2 = likely –> D dimer test and proximal leg vein USS
Management: LMWH / fondaparinux 5 days at least (discuss long term) or warfarin
**Acute Limb Ishcaemia
- Due to embolus or thrombosis
Rapid onsent Syx • 6Ps o Pale o Pulseless o Painful o Paralysed o Paraesthetic o Perishinglycold • Onset of fixed mottling of skin implies irreversible changes
IVX: hand held doppler
bloods and ecg/echo/uss
Management: urgent admission, check for compartment syndrome, surgical emboletomy fogarty catheter, anticoag
**Superficial Thrombophlebitis
- Superficial vein (often long saphenous of leg) becomes inflamed and forms a clot within = Virchow’s triad = damage to blood vessel wall, stasis of blood flow; HYPERCOAGULABILITY of blood
RF: Obesity, Thrombophilia, Smoking, COCP, Preg, IVDU or IV infusion
CF: Erythema, swelling, tenderness. Septic = hard lump and fever
IVX: clinical (venography could aggravate conditon)
Mx: Elastic support, exericse, analgesia and LMWH + surgery if recurrent
**Cannula Related Phlebitis
- Septic phlebitis often with long term IV cannula or IVDU
- Local irritation at site
- Hard lump
- Fever, tachycardia, nausea + vomiting, ↓BP
**Complete heart block
aka 3rd degree
- Complete absence of AV conduction – none of the supraventricular impulses are conducted to the ventricles
- • Perfusing rhythm maintained by a junctional or ventricular escape rhythm
• Typically the patient will have severe bradycardia with independent atrial and ventricular rates ie AV disccociation
Cause: underlying ischaemic damage / drug induced
CF: dizziness, palpitations, sob, chest pain
IVx: ecg = complete dissociation of p waves from qrs
Acute: a-e, 02, Atropine
Chronic: pacemakers
**Postural Hypotension
drop 20 systolic
- Common in elderly
Cause: medications, hypovolaemia, autonomic neuropathy
CF: dizziness, blurred vision, syncope, palpitations
IVX: lying and standing BP
TX: review meds, lifestyle changes e.g stand slowly, stockings for legs, increase salt intake
mineralocoricodis e.g fludrocortisone !!!!
Stabile Angina
- Induced by effort, relieved by rest
- Radiate to arms, neck, jaw, teeth & N +V
Cause: atheroma
IVX: ECG- ST Depression + inverted T waves
stress echo
Management: GTN (Se flushing and headache)
- Ca channel blocker
- Aspirin
- Statins
CABG for revascularisation
Atrial Flutter
- (less common than AF)
- Re-entrant rhythm in L or R atrium causing endless loop (by over-riding SA node) →atria contract at high rate in flutter like rhythm (>300bpm often)
CF: Palpitations + chest pain Regularly irregular heart beat ● Can be regular, but always rapid ● Usually 150bpm (2:1 AV conduction) Dyspnoea, fatigue + dizzy Syncope HF – L or R
IVX: ECG - saw tooth, no p waves
CXR for HF and echo for structural
ACUTE Management: DC shock –> amiodarone, repeat shock –> amiodarone, vagal manouvres and adenosine to reduce tachy.
CHRONIC management: ablation, anticoagulate and amiodarone, atenolol for rate and pacemaker.
Atrial Fibrillation
- Disorganised electrical impulses
Causes: HF or IHD (common mid-early), MI (22%), HTN, PE, mitral valve disease, hyperthyroidism (thyrotoxicosis) - Alcohol or caffeine induced
- Abnormal impulses typically originate at pulmonary veins
Types: Acute, Recurrent, Paroxysmal, persistent, permanent
CF: Dyspnoea Dizzy/syncope, Palpitations Fast, irregular pulse, Apex pulse is faster > radial pulse, Signs of LVF → Pulmonary oedema
Refer: HR > 150bpm ± ↓BP < 90
Severe symptoms: chest pain, syncope
PMHx of Stroke, MI, TIA
IVX: ECG (irregularly ireegular R-R and narrow QRS complexes, absent p waves)
Echo- atrial enlargement
Management:
Acute: Life threatening –> DC cardioversion or Chemical - Flecanide or Amiodarone if structureal abnormalities.
Acute: not threatening –> BB or digoxin if HF
Chronic: Rate control, Digoxin for sedentry patients or Diltiazem
+ rhythm control is still syx after rate controlled via amiodarone +felcanine + anticoagulant
- LA ablatation if drugs failed + consider LA appendage occulusion
CHA2DSVaSc stroke risk
Rx: stroke, bleed, mesenteric ischameia
Heart Block - all degrees
–> FIRST degree: Slow AV node conduction
- PR interval >200ms PROLONGED INTERVAL
-All atrial impulses conducted to ventricles
- Benign
–> SECOND
Mobitz I: AV node conduction defect
Mobitz II: Conduction defect below AV node
- Degenerative: Lev’s disease = acquired complete heart block due to idiopathic fibrosis and calcification of the electrical conduction system
- Risk of progression to 3rd degree block
IVX: ECG + echo
Management: mobitz II atropine and pacing
Re-entrant supra- ventricular tachycardia
- SVT is usually paroxysmal and episodes may occur regularly or infrequently. They may last minutes or several months
Re-entrant tachycardias are due to abnormalities of impulse conduction
Cause: previous MI, mitral valve prolapse, congential heart disease, pericardiits
CF: Minimal symptoms or may present with syncope
Palpitations and light headedness which start and end abruptly
ECG –> pre excitation
Management: if haem unstable
1) valsalva and IV ADENOSINE
2) IV BETA BLOCKER
3) Synchronised Cardioversion
Example Wolf Parkinson White- delta wave (leading up)
Ventricular Tachycardia
CF: Palpitations, dizzy, SoB Tachycardia, Pallor
Worrying signs – hypotension, HF, MI, syncope, pulseless, chest pain
ECG: regular rhythm, broad complex tachy, absent p waves
IVX: bloods, U+E and CXR for HF
Management: - Pulseless VT or VF = defibrillation - With pulse: synchronised cardioversion and amiodarone A-E Implant cardioverter defirbillation
Complication: Torsades de points (QTc elongation, broad tachy- give IV mg)
Mitral regurgitation
Abnormal regurgitation of blood from left ventricle, into left atrium during systole
–> Primary
Degenerative – LV dilatation, annular calcification
Acute – papillary muscle rupture (MI), Inf endocarditis, trauma
Mitral valve prolapse (weakened chordae tendenae – mid systolic click, systolic murmur), ASD
Rheumatic fever (→leaflet fibrosis)
–> Secondary (functional)
LVF enlargement and remodelling (→abnormal valve function)
Cardiomyopathy, CAD
CF: SOBOE, cough, palpitations
Signs: displaced apex beat, RV heave, PANSYSTOLIC murmur at apex –> radiates to L axilla
Soft S1
IVX: Ecg broad P wave (left atrial enlargement)
CXR: enlarged left A +V
Management: control rate if fast AF + Anticoagulate. Repair or replace valve. Abx to prevent I endocarditis.
Aortic regurgitation
- • Caused by either problems with the aortic valve or aortic root, incl: o Bicuspid aortic valve o Rheumatic fever o Infective endocarditis o Collagen vascular diseases o Degenerative aortic valve disease
CF: exertional dyspnoea, orthopnoea, paroxysmal nocturan dyspnoea, angina, collapsing pulse
IVX: ECG –> LVH, CXR
TX: anticoagulate
Infective endocarditis
aortic now most affected above mitral
- Intracardiac and systemic effects
Sterile fibril platelet vegetation is prerequisite
Acute IE - e.g invading organism or trauma
Subacute: bacterial clumps
Cause: S. viridens, S aureus
CF: FEVER + NEW MURMER ie until proven otherwise
Immune complex deposition: vasculitis, roth spots (retinal haemorrhage), splinter haemorrhage, oslers nodes, janeway lesions, arthritis
IVX: bloods, blood CULTURES
2 sets at different times 1 hour before abx. Urine dip, ECG and Echo
DUKE CRITERIA
Major criteria:
o Positive blood culture:
- Typical organism in 2 separate cultures or
- Persistently +ve blood cultures eg 3, 12hrs apart
o A +ve serological tests for Q fever
o Endocardium involved:
- +ve echo (vegetations, abscess, new partial dehiscence of prosthetic valve)
- New valvular regurgitation (change in murmur not sufficient)
Minor criteria:
o Predisposition (cardiac lesions, IVDU)
o Fever >38°C
o Vascular/immunological signs
o +ve blood culture that do not meet major criteria
o +ve echo that does not meet major criteria
Diagnosis = 2 major + 1 minor; 1 major + 3 minor; all 5 minor
Management: 4-6 week course of iv ABX
maintain food oral health
Pulmonary Embolism
Syx
Score+ what number >
Fat, thrombosis, amniotic fluid or air embolus in pulmonary artery tree
RF: surgery, immobility, varicose veins, malignancy
CF: dyspnoea, pleuritic chest pain, dizziness, syncope, hypotension, pyrexia, tachy, raised JVP, dvt
IVX: bloods, d-dimer, ABG, CXR, ECG, CTPA !!!
Wells Score
- if likely (4+) to CTPA
Management: Large PE = o2, morphine, thrombolysis, heparin, compression stockings
Prevention: lmwh, stockings
Aneurysms
true = all 3 layers wall
Localised abnormal dilatation of an artery due to weakness in the arterial wall
Cause: syphillis, infective, atheroclorosis, vasculitits
- Cerebral anurysms
Varicose Veins
- Long, torturous and dilated vein of superficial venous system. Due to incompetent valves – venous hypertension - dilatation
RF: pregnancy, FH, prolonged standing
CF: pain, cramps, oedema
IVX: auscultate for bruits, examine for ulcers, doppler US probes
Management: refer to specialist if pain or bleeding or thrombophlebitis, can have laser or endothelial ablation
Lose weight, walk, stockings
Chronic lower limb ischaemia
when is the pain?
CF:
IVX
Management
Presence of ischaemic rest pain, and ischaemic lesions or gangrene objectively attributable to arterial occlusive disease
CF: Cramping - claudication distance relieved by rest, pain at rest (critical limb ischaemia), ulceration, absent pulses, 6 Ps
Ivx: exclude DM
CARDIO risk assessment
ABPI and duplex imaging
Management: stop smoking, exercise, antiplatelets, surgican reconstruction or amputation
Abdominal aortic aneuysm
Syx
Abdominal aortica aneurysms (50% bigger diameter)
Syx pain radiates to back, collapse, shock
IVX: fbc, ecg, exr, US, CT
- driving rules important
TX ruptured: VAsc surgeon and anaesthetist
Unruptured: monitor and elective if >5cm
2- Pericarditis
Inflammation of pericardium
Cause: Vrial (coxshachievirus), bacterial, rheumatological e.g sarcoidosis,
SYX: Chest pain, radiates to neck, aggravated by lying flat
- non-productive cough
chills, weakness, tachypnoea, fever
IVX: ECG
stage 1: concave st-segment elevation and t waves. As progress to stage 3: t wave inversion
CXR and FBC
Management; tx underlying cause, NSAIDS for 2 weeks and if recurrent then Colchine too
2- Pericardial effusions
Syx
Tx
Collection of fluid in the pericardial space- transudates or exudate.
Cause: infection, malignancy
SYX: chest pain, pericardial pain relieved by sitting, syncope, palpitation, SOB, cough --> Triad of pericardial tamponade o Hypotension o Muffled heart sounds o Jugular venous distention
IVX: bloods, troponin, echo, CXR, ECG, MRI, pericardial fluid aspiration for analysis
TX: pericardiocentesis
2- mesenteric ischamia
- Impaired blood transfusion to the intestine, bacterial translocation and systemic inflammatory response
- Caused by conditions causing arterial emboli
Syx: colicky poorly localised pain
IVX: abdo to rule out other causes
- angiograpphy gold standard
Management: resus with fluids and 02
- Thrombolytics and surgical angioplasty
- Bypass and resection of bowel if gangrene develop
2- Superior Vena Cava Thrombosis
- Malignant causes common and goitre, mediastrinal fibrosis, infection
SYX: dyspnoea, cough, chest pain at rest, dizziness, syncope
IVX: CXR, CT scan, doppler
TX: Corticosteroids dexamethasone 16mg with PPI cover
2- Cardiomyopathy
Heart muscle is structurally and functionally abnormal
1) Dialated
2) Hypertrophic
3) Restrictive
4) arrythmogenic
IVX: bloods, CXR, ECG
TX: implantable cardioverter defibrillates and ? heart transplant
CHADSVASC
- CHF (1)
- HTN controlled or uncontrolled (1)
- Age: > 65 (1) ≥ 75 (2)
- Diabetes mellitus (1)
- Stroke, TIA or thromboembolism (2)
- Vascular disease (1)
- Sex: Male (0) Female (1)
- Score ≥ 7 = 10% stroke risk (only add female gender as risk if there is at least another RF)
Give: NOAC, warfarin or aspirin
HAS-BLED
Bleed risk when on anticoagulant
HTN > 160 (1),
Abn renal + liver func (1-2), Stroke (1),
Bleeding (1),
Labile INRS (1),
Elderly >65 (1),
Drugs (anti-coag/plat, NSAIDs) or alcohol (1-2)
–> Calculates risk of bleeding with A/C treatment
Ventricular Fibrillation
MEDICAL EMERGENCY
RF: IHD, MI, hypoxia,
CF: chest pain, faigue, palpiations then sudden loss of responsiveness absent breathing and pulse
IVX: ECG- NO P, QRS OR T WAVE
Management ALS - adrenaline 1:10,000 - amiodarone 300mg IV - CPR - shock if shockable
** Myocardial infarction
NSTEMI
syx
treatment
3 distinctive features:
- Resting angina
- New-onset severe angina
- Increasing angina – prev diagnosed angina, but more frequent, longer in duration, lower in threshold
ECG: T inversion, ST depression, Q waves
Bloods: raised trop and CK
TX: Coronary reperfusion therapy PCI if within 12 hrs, LBB or on going pain or
- CABG
MMONACH
Metoclopramide, morphine, 02, gtn, aspirin, clopdigrel, heparin
Aftercare for STEMI OR NSTEMI
ABC'S Ace inhibitor Beta Blocker anti-Coagulant: aspirin and clopidogrel Statin
MI Complications:
what syndrome?
Cardiac arrest, Cardiogenic shock, CHF Tachyarrhythmias/ Bradyarrhtymias Pericarditis in first 48 hrs Mitrial regurg VSD, LV aneurysm , LV free wall rupture
-> Dresslers sydnrome (2-6 weeks post MI; autoimmune= fever, pericarditis, pleuritic pain and pericardial effusion)
Drugs side effects
Ace
ARB
CCB
Thiazide
K sparing
Ace: Postural hypotension, drug cough, dyspnoea, rash, increased K
ARB: Dizzy
CCB: Ankle oedema, headache, palpitaitions, nausea, dizzy
Thiazides: Hypokalaemia, headache, postural hypo
K sparing: = spironolactone Gynaecomastia, impotence, mesntrual irregulatirity
Mitral Stenosis
– Obstruction of mitral valve –> left atrial hypertrophy —> pulmonary congestion (LVF) → RVF
Cause: Calcification, rheumatic fever (infective endocarditis)
Signs: Dyspnoea, PND, malar flush on cheeks due to increase C02, RV HEAVE, AF common,
CXR: Left atrial enlargement, mitral valve calcification
Acute AF: GTN, BB or rate limiting CCB, mitral valve replacement, warfarin
PO penicillin if recurrent rheumatic fever
Aortic stenosis
Most frequent valvular heart disease
Tight valve - advanced from sclerosis
Cause: rheumatic heart disease, aging, congenital
CF: anginal, syncope, heart failure Triad
dizziness, LV heave, aortic thrill
IVX: ECG, CXR and see LVH, calcified aortic value,
Cardiac MRI
Management: early surgical intervetion and avoid exertion
TAVI - transcatheter aortic valve implantation
Heart Failure Treatment
Acronym
ABAL - not abal with heart failure
ACE INHIBITOR
B BLOCKER
ALDOSTERONE AGONSIT- Spironolactone
LOOP DIURETIC - Furosemide
