Cardiology Flashcards
Murmur and signs in mitral stenosis
Mid diastolic murmur
Loud and palpable S1
AF
Opening snap
Complication of mitral stenosis
Pulmonary hypertension
Murmur and signs in mitral regurgitation
Pansystolic murmur, radiating to axilla, ‘blowing’.
Soft S1
S3 sound
Murmur and signs in mitral prolapse
Late systolic murmur
Mid-systolic click
Murmur and signs in aortic stenosis
Harsh, ejection systolic murmur
Delayed and diminished carotid pulse = parvus et tardus
LV heave
Aortic thrill
Management of aortic valve pathology
Transcatheter aortic valve implantation
Valve replacement
Murmur and signs in aortic regurgitation
High pitch diastolic murmur
Waterhammer/collapsing pulse
Austin flint murmur if severe
Hyperdynamic apex beat
Most common cause of tricuspid stenosis
Rheumatic fever
Most common cause of tricuspid regurgitation
Functional e.g. LV failure.
Murmur in tricuspid stenosis
Diastolic murmur on inspiration
Murmur in tricuspid regurgitation
Parasternal pansystolic murmur.
Most common cause of pulmonary stenosis
Congenital e.g. Noonan’s, Turner’s.
Murmur in pulmonary stenosis
Ejection systolic murmur radiation to back/shoulder.
Most common cause of pulmonary regurgitation
PULMONARY HTN AND ITS CAUSES
Murmur in pulmonary reurgitation
Crescendo diastolic murmur.
Graham-Steell murmur
Kussmaul sign
Rise in JVP on inspiration, or lack of fall when inspiring due to right side of heart unable to hold venous return. e.g. constrictive pericarditis, cardiac tamponade
Pathophysiology triad for ACS symptoms
Virchow’s triad. Hypercoagulability + endothelial damage + blood flow stasis
Differences between unstable angina, STEMI and NSTEMI
Biochemical and and clinically:
UA = can have no ECG changes. No rise in troponin.
STEMI = ST elevation in leads anatomically correlated to infarct. Rise in troponin.
NSTEMI = no ST elevation. Troponin elevation.
Initial management of ACS
MONA = (oxygen), GTN, aspirin, morphine.
ECG!!!!!
Anti-platelet: Aspirin 300mg and ticagrelol 180mg (or clopidogrel)
Anticoagulation: Fondaparinux
Long term management of ACS and beneficial pharmacology effect
Beta blockers (Bisprolol) - decrease HR, decrease contractility, ACE inhibitor (ramipril) - vasodilator to decrease preload, block sympathetic activity, inhibit remodelling. Statin - lower cholesterol. Lifelong aspirin, continue ticagrelol for 1yr - prevent clots. Definitive treatment = percutaneous coronary intervention.
Driving after ACS
4 weeks
Sex after ACS
2 weeks
Working after ACS
6 weeks
Name of a non-pathological arrhythmia seen in young people
Sinus arrhythmia. Respiration cycle causes change in P-R interval.
Causes of sick sinus syndrome
Amyloidosis, Sarcoidosis. Idiopathic degeneration and fibrosis of sinus node. Surgical injury Digoxin, CCBs, beta-blockers. Cardiomyopathies
Name for alternating bradycardia and paroxysmal tachycardia
Bradycardia-tachycardia syndrome. Can get syncope in transition as node recovers.
Drugs causing sinus bradycardia
Opiates, beta-blockers, CCB, digoxin.
Drugs causing sinus tachycardia
Caffeine, salbutamol, atropine, cocaine, carbamazepine, adrenaline.
‘Camel hump’ T waves
Sinus tachycardia as P waves morphed into T waves.
3 categories and examples for supra-ventricular tachycardias
1) Regular and originate from atria e.g. atrial flutter, sinus tachycardia.
2) Irregular and originate form atria e.g. atrial fibrillation, multifocal atrial tachycardia.
3) Regular and AV origin e.g. AV nodal re-entry tachycardia and AV re-entry tachycardia.
ECG in atrial flutter
Re-entrant circuit.
ECG =
‘saw tooth’ flutter/F waves, best seen in leads 2,3 and aVF.
rate >300bpm.
atria to ventricular activity ratio = AV block e.g. 2:1 (most common) or 3:1.
ECG in atrial fibrillation
No P waves
Oscillating baseline
Narrow QRS
Assessing risk of AF in patients
HAS-BLED - risk of major bleed for AF patients on anticoagulation.
CHA2DS2VASc - risk of an AF patient having a stroke.
Slow AF
<60bpm
Seen in hypothermia and digoxin toxicity.
4 categories and examples of AF treatment
1) Anticoagulate e.g. Apixaban.
2) Rate control e.g. cardioselective beta-blocker (bisoprolol) or CCB.
3) Rhythm control e.g. amiodarone or cardioversion.
4) Definitive e.g atrial ablation and pacemaker.
ECG in multifocal atrial tachycardia
3 distinct P wave morphologies in a single lead.
Patients at higher risk of multifocal atrial tachycardia
COPD and CHF
Typical patient and presentation of AVNRT
Female.
Paroxysmal but can be triggered by exertion, caffeine, alcohol.
2 circuits in AVNRT
alpha/slow
beta/fast
Subtype depends on which pathway has retrograde activity.
Idiopathic disease for heart block
Lev’s Disease
1st degree heart block ECG
Long PR interval
2nd degree, type 1 heart block ECG
Progressively longer PR interval and then a dropped beat/no QRS.
2nd degree heart, type 2 block ECG
Random dropped beats but no changes in PR interval.
3rd degree heart block ECG
No conduction to ventricles results in random QRS complexes (via escape beats) with no relation to P waves.
Management of 3rd degreee heart block
Atropine to increase HR
Transcutaneous pacing
Causes of bundle branch block
Both = MI, myocarditis, cardiomyopathy. Right = PE Left = HTN, digoxin toxicity.
ECG of LBBB
Small R wave and deep S wave in V1 (W)
Upgoing broad R wave in V6, can be notched (M)
Impulses are travelling towards V6 away from V1 as travels from RV to LV.
ECG of RBBB
Tall and late terminal R wave in V1, RSR configuration (M)
Wide and deep, slurred S wave in V6 (W)
Life threatening ventricular TC
Which arrhythmias can you shock?
Life threatening = Sustained VT and VF
Shockable = pulseless VT and all VF
ECG of VT
Wide QRS. Absent PR interval, can have P waves but they are no associated with QRS pattern. Fast rate (over 100bpm can be 250bpm).
Management of VT
- If haemo-dynamically unstable (shock, MI, HF or syncope) 3 attempts at synchronised DC shock + 300mg IV Amiodarone over 20mins.
- If haemo-dynamically stable give 300mg IV Amiodarone
- Correct any electrolyte imbalances.
- Sedation / muscle relaxant (benzodiazepines)
Causes of sustained VT
Sustained = HR >100bpm with broad complex QRS lasting for at least 30 seconds.
Ischaemic heart disease
Coronary artery disease
Cardiomyopathy
ECG of VF
No QRS complexes, no P waves.
No HR
Chaotic, rapid oscillating baseline.
Symptoms and signs in VF
Pulseless and unconscious.
Management of VF
- Will most likely be haemo-dynamically unstable (shock, MI, HF or syncope) so give 3 attempts at synchronised DC shock + 300mg IV Amiodarone over 20mins.
- Correct any electrolyte imbalances.
- Consider analgesia or muscle relaxant (benzodiazepines)
Causes of VF
Coronary artery disease Hypoxia Ischaemic Post DC shock Anti-arrythmic drugs
Torsades de Pointes ECG
Fast HR
Prolonged QT interval
Twisting QRS complexes rotating around the isoelectric line.
Torsades de Pointes description, Ix and Mx
Polymorphic ventricular tachycardia, QRS amplitude varies and complexes appear to twist on isoelectric baseline.
Ix: U+E, cardiac enzymes, ECG = tachycardia, twisting of QRS complexes, prolonged QT interval.
Mx: A to E
IV Magnesium
Isoprenaline (beta1-agonist, decrease QT interval but accelerates HR)
Cardioversion if VF or VT develop.
Causes of long QT interval
Congenital = Jervell-Lange-Nielson Drugs = Tricyclic antidepressants, sotalol Electrolytes = Hypokalaemia, hypomagnesia, hypocalcaemia. Acquired = Acute MI
Treatment in HF which improves prognosis (NOT symptomatic)
Beta-blockers
ACE inhibitor or ARB
Aldosterone antagonist e.g. spironolactone.
Complication of acute HF
Cardiogenic shock
Signs and symptoms of cardiogenic shock
Patient sat upright, pale, clay and coughing (can bring up frothy pulmonary oedema) Chest pain Altered consciousness Low BP High HR High respiratory rate Low PaO2 sats Cold extremities and prolonged cap refill.
Management of cardiogenic shock
A to E
Close monitor and investigations (ABG, FBC, U and E)
IV glyceryl trinitrate
Morpcine
Consider IV fluids, IV dobutamine (inotropic).
Angina
Constricting discomfort in front of chest, shoulders, jaw and arms.
Precipitated by physical exercise.
Relieved by rest to GTN spray
Investigations for angina
FBC - anaemia
ECG
Fasting lipid profile
CT coronary angiogram
What percentage of stenosis can cause angina?
70%
4 modifiable and 4 non-modifiable risk factors for unstable angina
Modifiable = obesity, smoking, high cholesterol, hypertension, anaemia. Non-modifiable = male, DM, Fx, advancing age.
Management of angina
REFER TO RAPID ACCESS CHEST PAIN CLINIC!!
1) Lifestyle = stop smoking, dietary advice, optimise co-morbidities treatment.
2) PRN = Short-acting nitrate spray e.g. glyceryl-trinitrate.
3) Stable angina Rx = 1st line is beta-blocker or CCB e.g. atenolol/amlodipine. 2nd line add long-acting nitrate (isosorbide mononitrate), Ivabradine or Nicorandil.
4) Secondary CVD prevention = aspirin, ACE inhibitor if diabetic.
5) Not satisfactory control with medical therapy = CABG or PCI.
Complications of an MI
Cariogenic shock Mitral regurgiation Arrythmias Cardiac arrest RVF Dressler's syndrome - recurrent pericarditis
Investigations in hospital wit ?ACS
DO ECG! Give 300mg aspirin, morphine and GTN. Troponin I and T (better than CK-MB in first 6hrs). FBC Blood glucose Coronary angiography
Discuss the cardiac biomarkers ❤️
Troponin = Marker of cardiac cell necrosis but can also be raised in skeletal muscle injury. Raised 4-6hrs after injury and stay high for 10 days with peak at 12-24hrs. Test at admission, 6 and 12hrs after pain onset. CK-MB = more specific than Troponins.
Treatment for STEMI
- Immediate = morphine, glyceryl trinitrate, aspirin, ECG.
- Assess eligibility for re-perfusion therapy - Can they get to Cath lab within 120 mins = PIC, if no = fibrinolysis.
Percutaneous coronary intervention = +angiography. Within 120mins of time of onset.
Fibrinolysis = present after 120min, use alteplase/reteplase/streptokinase/tenecteplase. - Fondaparinux until discharge!
- Long term management and secondary prevention = lifestyle advice, aspirin + ticagrelol, beta-blocker, atorvastatin.
Scores for risk after ACS
GRACE rise score - Global Registry for Acute Cardiac Events (6 month mortality) Components = Age Heart rate Systolic BP Creatinine/Renal function Cardiac arrest on admission? ST changes on ECG Abnormal cardiac enzymes (tropI+T) Signs of congestive HF
Management of NSTEMI or unstable angina
1) Drugs = Aspirin 300mg and Fondaparinux.
2) Assess risk using GRACE risk score.
3) Low and high risk give Clopidogrel. High risk also give glycoprotein inhibitor e.g. tirofiban.
4) Assess appropriateness for revascularisation. Offer coronary angiography within 96hrs of admission if mod-high risk
5) Long term CVD prevention e.g. beta-blocker, aspirin + clopidogrel, atorvastatin.
ECG in STEMI
STEMI = ST elevation, tall T waves, Over hours T wave inversion and pathological Q waves.
Modifiable and non-modifiable risk factors for ACS
Modifiable = smoking, cocaine use, hypertension, hyperlipidaemia, sedentary lifestyle, obesity. Non-modifiable = age, male, FHx, DM
3 common pathophysiological processes in all ACS
Plaque rupture
Thrombus
Inflammation
S+S of ACS
Acute onset, central, crushing chest pain, radiate down arm or up jaw. Nausea Sweating Palpitations Light-headedness
O/E:
Tachycardia
Pallor
Added heart sounds
Differentials for acute onset chest pain
ACS Aortic dissection Pneumothorax Pulmonary embolism Pericarditis Panic attack
Aortic stenosis signs and symptoms
Elderly patient.
Symptoms = Chest pain, syncope, HF (exertional dyspnoea).
Signs = ejection systolic murmur which can radiate to carotid, delayed and diminished carotid upstroke (parvus and tardus), LV and apex heave.
Ix and Mx for aortic stenosis
Ix = ECG, CXR. Diagnostic = echocardiogram. Mx = valve replacement/TAVI and longterm anticoagulant (warfarin)
Most common cause of aortic stenosis
Senile calcification.
What valve pathology has lots of associated diseases and what are the associated diseases?
Aortic regurgitation.
Associated with: SLE, Marfan’s syndrome, Ehler-Danlos, Turner’s syndrome, ankylosing spondylitis
Signs and symptoms for aortic regurgitation
Can be acute cardiovascular collapse.
Symptoms = exertional dyspnoea, palpitations, paroxysmal nocturnal dyspnoea.
O/E:
High-pitch diastolic murmur (expiration, patient sat forward), collapsing water-hammer pulse, wide pulse pressure, Austin-flint murmur (rumbling diastolic murmur at apex).
Ix and Mx for aortic regurgiation
Ix = ECG, CXR, diagnose with echocardiogram. Mx = reduce HTN with ACE inhibitor, valve replacement + anticoagulation.