Cardiology Flashcards
RBBB +left anterior or posterior hemiblock + 1st-degree heart block = –
trifasicular block
Aspirin
Antiplatelet - inhibits the production of –
Clopidogrel
Antiplatelet - inhibits – binding to its –
Enoxaparin
Activates—, which in turn potentiates the inhibition of coagulation factors —
Fondaparinux
Activates – which in turn potentiates the inhibition of coagulation factors –
Bivalirudin
Reversible —- inhibitor
Abciximab, eptifibatide, tirofiban
— receptor antagonists
Aspirin Antiplatelet - inhibits the production of thromboxane A2
Clopidogrel Antiplatelet - inhibits ADP binding to its platelet receptor
Enoxaparin Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa
Fondaparinux Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa
Bivalirudin Reversible direct thrombin inhibitor
Abciximab, eptifibatide, tirofiban Glycoprotein IIb/IIIa receptor antagonists
Ventral septal defect - classically associated with a – murmur
heard best at the – sternal border. Paradoxically, the larger the defect, the quieter the murmur.
Other clinical findings might including a heaving – beat, a split S– and signs of – hypertension and —heart failure.
Ventral septal defect - classically associated with a pansystolic murmur
heard best at the lower left sternal border. Paradoxically, the larger the defect, the quieter the murmur.
Other clinical findings might including a heaving apex beat, a split S2 and signs of pulmonary hypertension and right heart failure.
ECG features of hypokalaemia -- waves small or absent -- waves (occasionally inversion) prolong -- interval ST -- long --
ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
P Mitrale represents left — hypertrophy/strain e.g. in mitral —
P Mitrale represents left atrial hypertrophy/strain e.g. in mitral stenosis
The following ECG changes are considered normal variants in an athlete: sinus -- -- rhythm -- heart block -- phenomenon
The following ECG changes are considered normal variants in an athlete: sinus bradycardia junctional rhythm first degree heart block Wenckebach phenomenon
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be – or a direct – or factor– inhibitor
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be warfarin or a direct thrombin or factor Xa inhibitor
Massive PE + hypotension -
Massive PE + hypotension - thrombolyse
PE
Choice of anticoagulant
– or – (both —) should be offered first-line following the diagnosis of a PE
Choice of anticoagulant
the big change in the 2020 guidelines was the increased use of DOACs
apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a PE
A – is an essential investigation when investigating a PE
A chest xray is an essential investigation when investigating a PE
If a PE is ‘likely’ (more than 4 points) arrange an immediate —
If there is a delay in getting the — then interim therapeutic — should be given until the scan is performed.
interim therapeutic anticoagulation used to mean giving low-molecular weight heparin
NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
this means normally a–such as – or –
If a PE is ‘unlikely’ (4 points or less) arranged a –
if positive arrange an immediate–
if there is a delay in getting the— then give interim – until the scan is performed
if negative then PE is unlikely - consider an alternative diagnosis
If a PE is ‘likely’ (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed.
interim therapeutic anticoagulation used to mean giving low-molecular weight heparin
NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
If a PE is ‘unlikely’ (4 points or less) arranged a D-dimer test
if positive arrange an immediate computed tomography pulmonary angiogram (CTPA)
if there is a delay in getting the CTPA then give interim therapeutic anticoagulation until the scan is performed
if negative then PE is unlikely - consider an alternative diagnosis
ECG
the classic ECG changes seen in PE are:
1. a large S wave in lead –,
2. a large Q wave in lead - and an inverted T wave in lead – -
‘S-Q-T-‘. However, this change is seen in no more than 20% of patients
right bundle branch block and right axis deviation are also associated with PE
sinus tachycardia may also be seen
ECG
the classic ECG changes seen in PE are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III - ‘S1Q3T3’. However, this change is seen in no more than 20% of patients
right bundle branch block and right axis deviation are also associated with PE
sinus tachycardia may also be seen
In the context of a tachyarrhythmia, a systolic BP < 90 mmHg →
DC cardioversion
Hypertrophic obstructive cardiomyopathy - is associated with sudden death in young athletes due to–
ventricular arrhythmia
For a person < 80, with stage 1 hypertension, only treat medically if:
For a person < 80, with stage 1 hypertension, only treat medically if: diabetic, renal disease, QRISK2 >10%, established coronary vascular disease, or end organ damage
ABPM/HBPM >= –/– mmHg (i.e. stage 1 hypertension)
treat if < – years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to –% or greater
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
in 2019, NICE made a further recommendation, suggesting that we should ‘consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. ‘. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease
Blood pressure targets
Clinic BP ABPM / HBPM Age < 80 years 1--/-- mmHg --5/-5 mmHg Age > 80 years 1--/-- mmHg 1--/-- mmHg
Blood pressure targets
Clinic BP ABPM / HBPM
Age < 80 years 140/90 mmHg 135/85 mmHg
Age > 80 years 150/90 mmHg 145/85 mmHg
New onset AF is considered for electrical cardioversion if :
New onset AF is considered for electrical cardioversion if it presents within 48 hours of presentation
Medication
Agents used to control rate in patients with atrial fibrillation:
x3
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation:
Medication
Agents used to control rate in patients with atrial fibrillation
beta-blockers
a common contraindication for beta-blockers is asthma
calcium channel blockers
digoxin
not considered first-line anymore as they are less effective at controlling the heart rate during exercise
however, they are the preferred choice if the patient has coexistent heart failure
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
– is used to treat torsades de pointes
IV magnesium sulfate is used to treat torsades de pointes
Inhaled foreign objects are most likely to be found in the –
Inhaled foreign objects are most likely to be found in the right main bronchus
First line management of acute pericarditis involves combination of –and –
Investigations
ECG changes
the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ –
– depression: most specific ECG marker for pericarditis
all patients with suspected acute pericarditis should have —
First line management of acute pericarditis involves combination of NSAID and colchicine
ECG changes Coronary artery Anteroseptal Inferior Anterolateral Lateral Posterior
ECG changes Coronary artery
Anteroseptal V1-V4 Left anterior descending
Inferior II, III, aVF Right coronary
Anterolateral V4-6, I, aVL Left anterior descending or left circumflex
Lateral I, aVL +/- V5-6 Left circumflex
Posterior Tall R waves V1-2 Usually left circumflex, also right coronary
The main ECG abnormality seen with hypercalcaemia is
l
shortening of the QT interva
Pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during – → faint or absent pulse in —
severe —, cardiac —
Slow-rising/plateau= aortic —
Collapsing
aortic —
patent —
hyperkinetic states (a—, t—, f– e–/p–)
Pulsus alternans
regular alternation of the force of the arterial pulse
severe–
Bisferiens pulse
‘double pulse’ - two systolic peaks
mixed – disease
‘Jerky’ pulse=
Pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
severe asthma, cardiac tamponade
Slow-rising/plateau
aortic stenosis
Collapsing
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulsus alternans
regular alternation of the force of the arterial pulse
severe LVF
Bisferiens pulse
‘double pulse’ - two systolic peaks
mixed aortic valve disease
‘Jerky’ pulse
hypertrophic obstructive cardiomyopathy*
*HOCM may occasionally be associated with a bisferiens pulse
–can lead to a decrease in INR
Phenobarbital can lead to a decrease in INR
Inducers of the P450 system include - INR will decrease
CR(b)A(r)PS
Inducers of the P450 system include - INR will decrease
CR(b)A(r)PS
antiepileptics: phenytoin, carbamazepine
barbiturates: phenobarbitone
rifampicin
St John’s Wort
chronic alcohol intake
griseofulvin
smoking (affects CYP1A2, reason why smokers require more aminophylline)
Inhibitors of the P450 system include - INR will increase
antibiotics:
PPI’s
imidazoles:
SSRIs:
Inhibitors of the P450 system include - INR will increase
Bifascicular block
combination of — with —hemiblock
e.g. — with – axis deviation
Trifascicular block
features of bifascicular block as above + —-degree heart block
Bifascicular block
combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
Trifascicular block
features of bifascicular block as above + 1st-degree heart block
– pulse is a feature of aortic regurgitation, PDA, and hyperdynamic states (anaemia, thyrotoxicosis, fever, exercise/pregnancy)
Collapsing pulse is a feature of aortic regurgitation, PDA, and hyperdynamic states (anaemia, thyrotoxicosis, fever, exercise/pregnancy)
Glycaemic control in patients with diabetes mellitus
in 2011 NICE issued guidance on the management of hyperglycaemia in acute coronary syndromes
it recommends using a — insulin infusion with regular monitoring of blood glucose levels to glucose below –.0 mmol/l
intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as ‘DIGAMI’) regimes are not recommended routinely
Glycaemic control in patients with diabetes mellitus
in 2011 NICE issued guidance on the management of hyperglycaemia in acute coronary syndromes
it recommends using a dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as ‘DIGAMI’) regimes are not recommended routinely
Statins + — - an important and common interaction
Statins + erythromycin/clarithromycin - an important and common interaction
Statins
Adverse effects
x3
Contraindications x2
Who should receive a statin?
all people with established– disease
following the 2014 update, NICE recommend anyone with a 10-year cardiovascular risk >= –%
patients with – should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins
patients with – who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
Statins inhibit the action of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis.
Adverse effects
myopathy
liver impairment:
statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a stroke. This effect is not seen in primary prevention. For this reason the Royal College of Physicians recommend avoiding statins in patients with a history of intracerebral haemorrhage
Contraindications
macrolides (e.g. erythromycin, clarithromycin)
pregnancy
Who should receive a statin?
all people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
following the 2014 update, NICE recommend anyone with a 10-year cardiovascular risk >= 10%
patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins
patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
Agents used to control rate in patients with atrial fibrillation:beta-blockers
a common contraindication for beta-blockers is —
Agents used to control rate in patients with atrial fibrillation
beta-blockers
a common contraindication for beta-blockers is asthma
Constrictive pericarditis
Causes
any cause of pericarditis
particularly–
Features d-- right heart failure: elevated --, a--, o--, --megaly JVP shows prominent - and - descent pericardial knock - loud S- Kussmaul's sign is ---
The JVP — with inspiration is known as Kussmaul’s sign and can be a feature of constrictive pericarditis.
Causes
any cause of pericarditis
particularly TB
Features dyspnoea right heart failure: elevated JVP, ascites, oedema, hepatomegaly JVP shows prominent x and y descent pericardial knock - loud S3 Kussmaul's sign is positive
The JVP increasing with inspiration is known as Kussmaul’s sign and can be a feature of constrictive pericarditis.
INR 5.0-8.0 (no bleeding) - withhold –doses of warfarin, — subsequent maintenance dose
INR 5.0-8.0 (no bleeding) - withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose
A — infarct supplies the AV node so can cause arrhythmias after infarction
A right coronary infarct supplies the AV node so can cause arrhythmias after infarction
The following ECG changes may be seen in hypothermia
–cardia
–wave - small hump at the end of the QRS complex
— degree heart block
long —
atrial and ventricular arrhythmias
The following ECG changes may be seen in hypothermia
bradycardia
‘J’ wave - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
Wenckebach phenomenon : – degree atrioventricular block Mobitz type -
Wenckebach phenomenon (2nd degree atrioventricular block Mobitz type 1)
‘Global’ T wave inversion (not fitting a coronary artery territory) - think
- cause of abnormal ECG
e. g.-
- cause of abnormal ECG
‘Global’ T wave inversion (not fitting a coronary artery territory) - think non-cardiac cause of abnormal ECG
e.g. head injury
–waves are associated with hypothermia
J-waves are associated with hypothermia
– cardiomyopathy is a differential for ST-elevation in someone with no obstructive coronary artery disease
Takotsubo cardiomyopathy is a differential for ST-elevation in someone with no obstructive coronary artery disease
Posterior MI typically present on ECG with tall - waves in-
Posterior MI typically present on ECG with tall R waves V1-2
ECG findings -- T waves (occurs first) Loss of - waves Broad -- Sinusoidal wave pattern --fibrillation
ECG findings Peaked or 'tall-tented' T waves (occurs first) Loss of P waves Broad QRS complexes Sinusoidal wave pattern Ventricular fibrillation
ECG features of hypokalaemia - waves small or absent - waves (occasionally inversion) prolong --- -- depression long --
In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
digoxin ECG features
down-sloping –(‘reverse tick’, ‘scooped out’)
flattened/inverted - waves
short – interval
arrhythmias e.g. –block, –cardia
digoxin
ECG features
down-sloping ST depression ('reverse tick', 'scooped out')
flattened/inverted T waves
short QT interval
arrhythmias e.g. AV block, bradycardia
A posterior MI causes – on a 12-lead ECG
A posterior MI causes ST depression not elevation on a 12-lead ECG
A posterior MI can cause reciprocal changes on an ECG. This is commonly ST depression and tall R waves in the anterior leads. A good way to think about reciprocal change is an ‘upside down’ ST elevation seen in leads opposite to the site of infarction.
Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation:
-
– (if no structural heart disease)
others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone
Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation
amiodarone
flecainide (if no structural heart disease)
others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone
Heart Failure
The first-line treatment for all patients is both an – and a –
Second-line treatment is an –
.Examples include–
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first
beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction
Second-line treatment is an aldosterone antagonist
these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone
it should be remember that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored
