Cardiology Flashcards
1
Q
S4 coincides with which part of the ECG
A
P wave
S4 is due to atrial contraction against a stiff, non-compliant ventricle
e.g. Aortic stenosis
2
Q
GI bleeding + murmur
What murmur?
A
Aortic stenosis
Heyde’s syndrome = GI bleeding (colonic angiodysplasia) + Aortic stenosis
3
Q
What coronary artery supplies posterior heart
A
posterior heart
Posterior interventricular artery (PIVA)
RCA (90%)
or LCx (10%)
Also supplies AVN
4
Q
What coronary artery supplies SAN and AVN
A
5
Q
What is coronary artery dominance
A
Coronary artery dominance = determined by which artery gives rise to posterior interventricular artery (PIVA)
- Right Coronary Artery (90%) ==> Right dominance
- LCx (10%) ==> Left dominance
- Equal contribution ==> Equal dominance
6
Q
What is the flow of coronary veins
A
All cardiac veins* meet at the coronary sinus –> empties into right atrium
*Except anterior cardiac veins which empty directly into the RA
7
Q
What are the waves of the JVP
A
8
Q
What causes the following JVP pathology
large a waves
Cannon a waves
Absent a wave
Prominent X descent
Giant V waves
Slow Y desscent
A
9
Q
What is Kussmaul’s sign
What causes it
A
Kussmaul’s sign = paradoxical ↑ JVP during inspiration
Caused by Constrictive pericarditis
10
Q
ACS
DVLA rules?
A
Acute coronary syndrome
- If PCI –> 1 week off driving
- If CABG or conservatively managed –> 4 weeks off driving
11
Q
Wellens syndrome
What is it?
ECG findings?
A
12
Q
Osborn wave
What is it?
What causes it?
A
13
Q
Epsilon wave
What is it?
What causes it?
A
14
Q
ECG changes in hyperkalaemia
A
hyperkalaemia
Peaked T waves
Loss of P waves
Prolonged PR interval
Bradycardia
Broad QRS –> BBB –> Sine wave –> VF –> Asysole
If bradycardia, blocks (AV block, BBB), bizarre QRS complexes –> think Hyperkalaemia
15
Q
ECG changes in hypokalaemia
A
hypokalaemia
TWI
U waves
Prolonged PR interval
ST depression
Long QU interval
16
Q
ECG changes in hypercalcaemia
A
hypercalcaemia
Shortening of QTc
Osborn waves / J waves
17
Q
ECG changes in hypocalcaemia
A
hypocalcaemia
Prolonged QTc
18
Q
ECG changes in hypomagnesaemia
A
hypomagnesaemia
Prolonged QTc
19
Q
ECG changes in TCA overdose
Treatment
A
TCA overdose
Broad QRS complex
Dominant secondary R’ wave in aVR (M appearance in aVR)
Sinus tachycardia
Treatment –> IV Sodium Bicarbonate + Activated Charcoal
20
Q
Digoxin toxicity
Sx
Tx
A
Digoxin toxicity
Abdominal pain
Yellow-hue vision
Haloes
Ventricular ectopics
Bradycardia
Tx: Digibind (Digoxin-specific antibody)
21
Q
ECG changes in incomplete and complete tri-fascicular block
A
22
Q
ECG changes in bifascicular block
A
ECG criteria for Bifascicular block:
- RBBB
- Either Right axis deviation or Left axis deviation
23
Q
Prolonged QTc
- Causes
- Treatment
A
Tip: “Hypos, Anti(medication), MI and Congenital”
Tx: β blockers
24
Q
Treatment of tachyarrhythmia
A
25
Prophylaxis for recurrent SVT
Prophylaxis for recurrent SVT
## Footnote
(1) **β blockers**
(1) **Catheter ablation**
26
Tx of atrial flutter
(1) Rate control, Anticoagulation, Rhythmn control
(2) Catheter ablation of **cavotricuspid isthmus** (curative)
27
What is **Ebstein's anomaly**
What is it caused by
Presentation
Associations
**Ebstein’s anomaly** = congenital defect where tricuspid valve is found lower in the R ventricle --\> large RA, small RV = "atrialisation of right ventricle"
Caused by **Lithium exposure in utero** (Bipolar MUM)
Features
* **Tricuspid regurgitation** / Pansystolic murmur
Associations
* PFO
* ASD
* **WPW syndrome**
28
Features of VT
**Broad complex tachycardia**
**Capture beats**
**Fusion beats**
29
Tx for VT
* Pulseless VT
* --\> Cardiac Arrest
* VT with pulse
* Haemodynamically unstable
* **Synchronised DC cardioversion**
* Haemodynamically stable
* **IV Amiodarone**
30
What is C/I in VT
**Avoid CCBs (Verapamil) in VT**
Blocking the AVN may trigger VF --\> Cardiac arrest
31
Tx for Torsades de Pointes
IV Magnesium sulphate 1-2g
32
ECG: Convex / coved ST elevation in V1-V3 followed by TWI
Diagnosis? Cause?
How to make ECG signs more apparent
Treatment?
**Brugada syndrome**
Mutation in **SCN5A gene**
ECG changes more apparent **post-flecainide or post-ajmaline administration**
Tx: **ICD**
33
Cardiac MRI: fibrofatty tissue within the myocardium
Diagnosis? ECG?
Treatment?
Complications?
**Arrhythmogenic right ventricular cardiomyopathy**
Right ventricular myocardium is replaced by fatty and fibrofatty tissue
**ECG: Epsilon wave, TWI V1-V3**
*_Management_*: Treat arrhythias, Catheter ablation to prevent VT, **ICD**
*_Complications_*: 2nd most common cause of sudden cardiac death in the young (HCM is 1st)
34
Exercise or emotion-induced VT
Diagnosis?
Cause?
**Catecholaminergic polymorphic ventricular tachycardia**
Autosomal dominant mutation in **RYR2**
Onset \< 20 years old
Exercise/Emotion --\> VT
35
Bradyarrhythmias - tx
If adverse features --\> IV Atropine 500 micrograms +/- Repeat +/- Transcutaneous pacing +/- IV Isoprenaline +/- IV Adrenaline
If no adverse features
* If at risk of asystole (2nd/3rd AV block) --\> See above
* If low risk --\> Observation
36
Tx of AV block
37
Coarctation of the Aorta (Adult)
Definition
Features
Association
CXR
**Coarctation of the Aorta (Adult)**
= Narrowing of the aorta distal to the L subclavian artery
Features
* **hypertension in the R arm**
* **Ejection systolic murmur** (similar to Aortic stenosis)
* **Radio-femoral delay**
* **Radio-radial delay**
CXR:**‘Rib-notching’**
38
Tx of PDA
Closure of the PDA
(1) NSAIDs (**Indomethacin**)
(2) **Surgical ligation**
39
**Dilated cardiomyopathy**
Causes
Features
Tx
**Dilated cardiomyopathy**
Causes: Idiopathic, **Alcohol, post-viral myocarditis**
Systolic dysfunction
Heart failure symptoms
**AV valve regutation (MR/TR)**
**S3 mrumur**
Treat Heart failure
40
Causes of HOCM
**Autosomal dominant** (50%)
Mutation in **β-myosin heavy chain protein** (15-25%)
or **myosin-binding protein C** (15-25%)
41
Features of HOCM
**Bifid carotid pulse (jerky pulse)**
**Double apex beat**
**ESM** (louder with valsalva, quieter with squating)
**S4 murmur** (palpable --\> double apex beat)
42
Echo features of HOCM
_Echo features of HOCM_
## Footnote
Tip: MR SAM ASH
(MR) **Mitral regurgitation**
(SAM) **Systolic anterior motion of anterior mitral valve leaflet**
(ASH) **Asymmetrical hypertrophy of ventricles** (disproportionate septal involvement)
Diastolic dysfunction
43
Treatment of HOCM
Treatment of HOCM
Tip: ABCD
* Amiodarone
* β blockers
* CCB
* Defibrillator/ICD
44
Drugs to avoid in HOCM
Tip: Avoid IAN in HOCM
* Avoid **Inotropes**
* Avoid **ACEi**
* Avoid **Nitrates**
45
Classification of severity of HF
46
Where is BNP secreted from
What factors affect BNP
BNP is secreted by **ventricular myocardium**
47
Drugs with mortality benefits in heart failure with ↓ EF
Drugs with mortality benefits in HF
* **ACE inhibitors**
* **β blockers**
* *_EF \< 35%_* --\> **Aldosterone antagonists** (Spironolactone)
48
Tx of HF
EF \> 55%
* +/- Loop diuretics (symptomatic)
* +/- Aspirin
* +/- Statin
EF \< 55% (ABCD HI DI ICD)
* (1) **ACE inhibitor + B blocker** + **Spironolactone + SGLT-2 inhibitor**
* (2) +/- Hydralazine + Isosorbide dinitrate combination
* (3) +/- Digoxin +/- Ivabradine
* (4) +/- ICD or CRT (if LBBB)
* (5) Heart transplant
49
Causes of myocarditis
myocarditis
## Footnote
**Trypanosomiasis** (Chagas disease) = most common cause worldwide
**HHV6**
**Coxsackie B**
HIV
Post-streptococcal
50
2 weeks ago, fever, cough, myalgia
now SOB with orthopnoea + chest pain
Diagnosis?
Treatment?
_Myocarditis_
**Prednisolone**
Treat underlying cause
51
Triad of pericarditis
**Chest pain**
* Pleuritic
* Relieved by leaning forward, worse on flying flat
**Pericardial frictional rub – “walking on snow”**
**Serial ECG changes**
* Global PR depression
* PR depression is the most specific finding in acute pericarditis
* Global ST elevation
52
Features of constrictive pericarditis
**Kussmaul’s sign** = ↑ JVP with inspiration
**Pulsus paradoxus** = ↓ SBP during inspiration
53
**Beck's triad**
What is it?
Indicates?
Cardiac tamponade
* Beck’s triad:
* ↑ JVP
* ↓ BP
* Muffed heart sounds
54
Troponin in myocarditis and pericarditis
DDx: Myocarditis (↑ Troponin) vs Pericarditis (normal Troponin)
55
Tx for pericarditis
Treat underling cause
(1) **NSAIDs + Colchicine**
(2) **Corticosteroids**
**+/- Periardiocentesiss**
+/- IV ABx
56
Cardiac tamponade vs Constrictive pericarditis
57
Duke's criteria
Tip: IF BER (Major, Minor)
* **Blood culture** (2 cultures from 2 sites \> 12 hours apart)
* **Echo**
* **Regurgitation**
* Immunological / Vascular signs
* Fever
**Need 2 major** or **1 major + 1 minor** or **5 minor**
58
Causes of IE
Acute (days-weeks)
* **Staph aureus** ==\> **Tricuspid valve**
* most common ause
* **Staph epidermidis**
* most common cause post-prosthetic valve surgery (up to 2 months)
Subacute (weeks-months)
* **Strep viridans** (Strep mitis, Strep sanguinis) ==\> **Aortic + Mitral valve**
* Associated with Dental procedures
* **Strep bovis** (Strep gallolyticus)
* Associated with GI cancer
* Culture negative
* HACEK
Non-infective
* SLE / Libman Sacks endocarditis
59
Empirical ABx for IE
Native valve
* **(1) Amoxicillin + Gentamicin**
* **(2)** *_If penicillin allergy_* --\> **Vancomycin + Gentamicin**
Prosthetic valve
* (1) **Vancomycin + Gentamicin + Rifampicin**
60
IE + prolonged PR interval on ECG
Diagnosis
**Aortic root abscess**
Due to pressure on AVN --\> prolonged PR interval
61
**Sore throat 2 weeks ago**
**Fever**
**Polyarthritis**
**Chest pain**
**Rash on extensor surfaces**
Diagnosis? Cause? Diagnostic criteria? Ix?
**Rheumatic fever**
**Group A B-haemolytic streptococcus pyogenes**
JONES criteria
* Joints --\> **Polyarthritis**
* O --\> **Carditis**
* Nodules --\> **Subcutaneous nodules**
* **Erythema marginatum** - pink macules with central clearing
* **Sydenham's chorea**
**Ix: ASOT / Throat culture**
62
Tx for rheumatic fever
Prophylaxis
(1) Aspirin +/- Corticosteroids
+/- Antibiotics (IV Benzylpenicillin)
+/- Valve replacement
Oral Pencillin V daily as prophylaxis until 18 years old
63
Complications of rheumatic fever
Chronic **rheumatic heart disease** (30-50%)
ANY valve
Most commonly causes **mitral stenosis**
64
Definition
Decubitus angina
Prinztmetal angina
Syndrome X
65
Tx for cocaine related MI
* **ACS Treatment**
* **+ IV Benzodiazepine**
* **AVOID β blockers**
* Β blockers may cause unopposed α1-mediated vasoconstriction --\> worsen coronary spasm
66
Tx for complete heart block secondary to MI
**Complete heart block due to**
* **Inferior MI** (affecting RCA) --\>Tx: **Monitor** and only Tx if adverse features
* **Anterior MI** (affected LAD) --\> Tx: **Pacing**
67
MI + new murmur
Diagnosis?
**Post-MI mitral regurgitation** (15-30%)
Associated with infero-posterior infarction
Tx: Urgent surgical repair
68
**MI + persistent ST elevation with Q waves on ECG**
No chest pain
Diagnosis?
**Ventricular aneurysm**
MI + persistent ST elevation with Q waves on ECG
69
MI + cardiac tamponade
Diagnosis
**L ventricular free wall rupture** (3%)
* Occurs 1-2 weeks **post-MI**
* **Cardiac tamponade** (↑ JVP, pulsus paradoxus, diminished heart sounds)
* Secondary acute heart failure
* Tx: Urgent pericardiocentesis and Thoracotomy
70
Ix for anginal chest pain
(1) **CT coronary angiogram with contrast**
(2) **Non-invasive** functional imaging (stress ECHO, stress cMRI)
(3) **Invasive angiography**
71
Anti-anginal Tx
* PRN sublingual GTN
* (1A) B blocker or rate limiting CCB
* **B blocker** (Atenolol)
* **Rate-limiting CCB** (Verapamil)
* (1B) Uptitrate dose *_or_* change class *_or_* combination
* **B blocker + _non_-rating limiting CCB** (Amlodipine MR, Nifedipine MR)
* (2)
* **Isosorbide mononitrate**
* **Nicorandil**
* **Ivabradine**
* **Ranolazine**
* Does not affect BP
* (3) PCI / CABG
72
Causes of Loud S1
**Mitral stenosis**
73
Soft S1
Mitral regurgitation
74
Split S1
**RBBB**
75
Variable intensity of S1
Complete heart block
76
Loud S2
**Hypertension** (systemic or pulmonary)
77
Soft S2
**Aortic stenosis**
78
Split S2
Fixed split S2 --\> **ASD**
Widely split S2 --\> **Deep inspiration** or **RBBB**
79
Reversed split S2
LBBB
80
**S3**
What does it mean?
Causes?
**DCM** *(S3 = DCM, 3 letters)*
**MR**
Diastole --\> blood hits overly compliant LV --\> S3
81
**S4**
What does it mean?
Causes?
What part of ECG does it correlate with?
**HOCM**
(S4 --\> HCOM, 4 letters)
atrial systole (P wave) --\> blood hits non-compliant ventricle
Coincides with P wave
82
Tx for **aortic regurgitation**
Indications?
**Aortic valve replacement**
## Footnote
if symptomatic
*_or_* asymptomatic + LVEF \< 50%
83
Tx for Aortic stenosis
Indications
**Aortic valve replacement**
* Symptomatic AND pressure gradient \> 40-50 mmHg
* Asymptomatic AND LVEF \< 50%
*_If unfit for surgery_* **--\> Transcatheter AV implantation** (TAVI)
or **Balloon aortic valvuloplasty** (BAV)
84
Target INR for mechanical aortic and mitral valves
**Aortic** metallic valve **--\> INR 3.0** (2.5 - 3.5)
**Mitral** metallic valve --\> **INR 3.5** (3.0 - 4.0)
Mitral --\> higher INR due to slower flow
85
Tx for mitral regurgitation
**Mirtal valve repair with annuloplasty ring**
**Mitral valve replacement**
If unfit for surgery --\> MitraClip edge-to-edge
* **Symptomatic**
* Asymptomatic AND **LVEF \< 50%**
* Asymptomatic AND **AF**
* Asymptomatic AND **Mitral valve prolapse** (most common reason)
86
Tx for mitral stenosis
**(1) Percutaneous mitral commissurotomy** (PMC)
**(2) Mitral valve replacement**
* Symptomatic
* Asymptomatic AND worsening function (e.g. AF)
87
**Left/Right Arm BP differential**
Chest pain raiating to back
CXR wided mediastinum
Diagnosis? Ix?
**Aortic dissection**
Ix: **CT aortic angiogram** (if stable)
or **TTE** (if unstable)
88
Tx for aortic dissection
Type A (ascending aorta) --\> Medical + Surgical
Type B (desecending aorta) --\> Medical
Aggressive BP control with **IV Lebetalol**
89
Changes in hypertensive retinopathy
90
Tx of Hypertension
91
ACS cardiac enzymes
Myoglobin is the first to rise
CK-MB is useful to look for re-infarction
Troponin stays elevated for 10 days
92
Tx for uraemic pericarditis
Haemodialysis
