Cardiology Flashcards
S4 coincides with which part of the ECG
P wave
S4 is due to atrial contraction against a stiff, non-compliant ventricle
e.g. Aortic stenosis
GI bleeding + murmur
What murmur?
Aortic stenosis
Heyde’s syndrome = GI bleeding (colonic angiodysplasia) + Aortic stenosis
What coronary artery supplies posterior heart
posterior heart
Posterior interventricular artery (PIVA)
RCA (90%)
or LCx (10%)
Also supplies AVN
What coronary artery supplies SAN and AVN
What is coronary artery dominance
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
What is the flow of coronary veins
All cardiac veins* meet at the coronary sinus –> empties into right atrium
*Except anterior cardiac veins which empty directly into the RA
What are the waves of the JVP
What causes the following JVP pathology
large a waves
Cannon a waves
Absent a wave
Prominent X descent
Giant V waves
Slow Y desscent
What is Kussmaul’s sign
What causes it
Kussmaul’s sign = paradoxical ↑ JVP during inspiration
Caused by Constrictive pericarditis
ACS
DVLA rules?
Acute coronary syndrome
- If PCI –> 1 week off driving
- If CABG or conservatively managed –> 4 weeks off driving
Wellens syndrome
What is it?
ECG findings?
Osborn wave
What is it?
What causes it?
Epsilon wave
What is it?
What causes it?
ECG changes in hyperkalaemia
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
ECG changes in hypokalaemia
hypokalaemia
TWI
U waves
Prolonged PR interval
ST depression
Long QU interval
ECG changes in hypercalcaemia
hypercalcaemia
Shortening of QTc
Osborn waves / J waves
ECG changes in hypocalcaemia
hypocalcaemia
Prolonged QTc
ECG changes in hypomagnesaemia
hypomagnesaemia
Prolonged QTc
ECG changes in TCA overdose
Treatment
TCA overdose
Broad QRS complex
Dominant secondary R’ wave in aVR (M appearance in aVR)
Sinus tachycardia
Treatment –> IV Sodium Bicarbonate + Activated Charcoal
Digoxin toxicity
Sx
Tx
Digoxin toxicity
Abdominal pain
Yellow-hue vision
Haloes
Ventricular ectopics
Bradycardia
Tx: Digibind (Digoxin-specific antibody)
ECG changes in incomplete and complete tri-fascicular block
ECG changes in bifascicular block
ECG criteria for Bifascicular block:
- RBBB
- Either Right axis deviation or Left axis deviation
Prolonged QTc
- Causes
- Treatment
Tip: “Hypos, Anti(medication), MI and Congenital”
Tx: β blockers
Treatment of tachyarrhythmia
Prophylaxis for recurrent SVT
Prophylaxis for recurrent SVT
(1) β blockers
(1) Catheter ablation
Tx of atrial flutter
(1) Rate control, Anticoagulation, Rhythmn control
(2) Catheter ablation of cavotricuspid isthmus (curative)
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
Features of VT
Broad complex tachycardia
Capture beats
Fusion beats
Tx for VT
- Pulseless VT
- –> Cardiac Arrest
- VT with pulse
- Haemodynamically unstable
- Synchronised DC cardioversion
- Haemodynamically stable
- IV Amiodarone
- Haemodynamically unstable
What is C/I in VT
Avoid CCBs (Verapamil) in VT
Blocking the AVN may trigger VF –> Cardiac arrest
Tx for Torsades de Pointes
IV Magnesium sulphate 1-2g
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
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)
Exercise or emotion-induced VT
Diagnosis?
Cause?
Catecholaminergic polymorphic ventricular tachycardia
Autosomal dominant mutation in RYR2
Onset < 20 years old
Exercise/Emotion –> VT
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
Tx of AV block
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’
Tx of PDA
Closure of the PDA
(1) NSAIDs (Indomethacin)
(2) Surgical ligation
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
Causes of HOCM
Autosomal dominant (50%)
Mutation in β-myosin heavy chain protein (15-25%)
or myosin-binding protein C (15-25%)
Features of HOCM
Bifid carotid pulse (jerky pulse)
Double apex beat
ESM (louder with valsalva, quieter with squating)
S4 murmur (palpable –> double apex beat)
Echo features of HOCM
Echo features of HOCM
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
Treatment of HOCM
Treatment of HOCM
Tip: ABCD
- Amiodarone
- β blockers
- CCB
- Defibrillator/ICD
Drugs to avoid in HOCM
Tip: Avoid IAN in HOCM
- Avoid Inotropes
- Avoid ACEi
- Avoid Nitrates
Classification of severity of HF
Where is BNP secreted from
What factors affect BNP
BNP is secreted by ventricular myocardium
Drugs with mortality benefits in heart failure with ↓ EF
Drugs with mortality benefits in HF
- ACE inhibitors
- β blockers
- EF < 35% –> Aldosterone antagonists (Spironolactone)
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
Causes of myocarditis
myocarditis
Trypanosomiasis (Chagas disease) = most common cause worldwide
HHV6
Coxsackie B
HIV
Post-streptococcal
2 weeks ago, fever, cough, myalgia
now SOB with orthopnoea + chest pain
Diagnosis?
Treatment?
Myocarditis
Prednisolone
Treat underlying cause
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
Features of constrictive pericarditis
Kussmaul’s sign = ↑ JVP with inspiration
Pulsus paradoxus = ↓ SBP during inspiration
Beck’s triad
What is it?
Indicates?
Cardiac tamponade
- Beck’s triad:
- ↑ JVP
- ↓ BP
- Muffed heart sounds
Troponin in myocarditis and pericarditis
DDx: Myocarditis (↑ Troponin) vs Pericarditis (normal Troponin)
Tx for pericarditis
Treat underling cause
(1) NSAIDs + Colchicine
(2) Corticosteroids
+/- Periardiocentesiss
+/- IV ABx
Cardiac tamponade vs Constrictive pericarditis
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
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
Empirical ABx for IE
Native valve
- (1) Amoxicillin + Gentamicin
- (2) If penicillin allergy –> Vancomycin + Gentamicin
Prosthetic valve
- (1) Vancomycin + Gentamicin + Rifampicin
IE + prolonged PR interval on ECG
Diagnosis
Aortic root abscess
Due to pressure on AVN –> prolonged PR interval
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
Tx for rheumatic fever
Prophylaxis
(1) Aspirin +/- Corticosteroids
+/- Antibiotics (IV Benzylpenicillin)
+/- Valve replacement
Oral Pencillin V daily as prophylaxis until 18 years old
Complications of rheumatic fever
Chronic rheumatic heart disease (30-50%)
ANY valve
Most commonly causes mitral stenosis
Definition
Decubitus angina
Prinztmetal angina
Syndrome X
Tx for cocaine related MI
- ACS Treatment
- + IV Benzodiazepine
-
AVOID β blockers
- Β blockers may cause unopposed α1-mediated vasoconstriction –> worsen coronary spasm
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
MI + new murmur
Diagnosis?
Post-MI mitral regurgitation (15-30%)
Associated with infero-posterior infarction
Tx: Urgent surgical repair
MI + persistent ST elevation with Q waves on ECG
No chest pain
Diagnosis?
Ventricular aneurysm
MI + persistent ST elevation with Q waves on ECG
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
Ix for anginal chest pain
(1) CT coronary angiogram with contrast
(2) Non-invasive functional imaging (stress ECHO, stress cMRI)
(3) Invasive angiography
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
Causes of Loud S1
Mitral stenosis
Soft S1
Mitral regurgitation
Split S1
RBBB
Variable intensity of S1
Complete heart block
Loud S2
Hypertension (systemic or pulmonary)
Soft S2
Aortic stenosis
Split S2
Fixed split S2 –> ASD
Widely split S2 –> Deep inspiration or RBBB
Reversed split S2
LBBB
S3
What does it mean?
Causes?
DCM (S3 = DCM, 3 letters)
MR
Diastole –> blood hits overly compliant LV –> S3
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
Tx for aortic regurgitation
Indications?
Aortic valve replacement
if symptomatic
or asymptomatic + LVEF < 50%
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)
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
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)
Tx for mitral stenosis
(1) Percutaneous mitral commissurotomy (PMC)
(2) Mitral valve replacement
- Symptomatic
- Asymptomatic AND worsening function (e.g. AF)
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)
Tx for aortic dissection
Type A (ascending aorta) –> Medical + Surgical
Type B (desecending aorta) –> Medical
Aggressive BP control with IV Lebetalol
Changes in hypertensive retinopathy
Tx of Hypertension
ACS cardiac enzymes
Myoglobin is the first to rise
CK-MB is useful to look for re-infarction
Troponin stays elevated for 10 days
Tx for uraemic pericarditis
Haemodialysis
