Cardiology Flashcards
1
Q
What is the main cause of coronary artery disease
A
atherosclerosis
2
Q
What are the types of coronary artery disease
A
- stable angina
* acute coronary syndrome
3
Q
What are the types of acute coronary syndrome
A
unstable angina
NSTEMI
STEMI
4
Q
Describe acute coronary syndrome
A
sudden, new-onset angina or increase in severity of angina
5
Q
what is the difference pathologically between a STEMI and an NSTEMI
A
In a STEMI, the ruptured plaque occludes 100% of the lumen and causes acute transmural infarction
6
Q
What are the main arteries supplying the heart
A
- Right coronary artery
- LAD
- Left coronary artery
- Circumflex artery
7
Q
which artery is occluded in an inferior wall MI, and where might the pain be felt in this MI
A
Occlusion of the right coronary artery
Epigastric abdominal pain
8
Q
What will an ECG show in posterior MI
A
ST-depression and tall R waves in V1-V3
9
Q
What life-threatening arrhythmias may occur after an MI
A
ventricular tachycardia and fibrillation
10
Q
What is the treatment for unstable angina/NSTEMI
A
GTN spray Beta-blocker ACE-inhibitor Ticagrelor/clopidogrel Aspirin Statins Fondaparinux
+ morphine +/- anti-emetic (eg ondansetron)
11
Q
give an example of a beta-blocker used for acute coronary sydrome
A
metoprolol IV
12
Q
What loading dose of aspirin should be given in ACS
A
300mg
13
Q
What management option needs to be undertaken for a STEMI
A
PCI
14
Q
What medication should be prescribed for a STEMI
A
Aspirin 300mg loading dose
15
Q
What would an anterior MI show on ECG
A
ST-elevation in leads V1-V3
16
Q
What would ST depression in leads V1-V3 raise the suspicion of?
A
posterior MI
17
Q
What is a subendocardial infarct
A
when the blood supply returns to an ischaemic area so only the inner third of the myocardium has been damaged,
This is an NSTEMI
18
Q
What will a transmural infarct show on ECG
A
ST-elevation
19
Q
What is a normal troponin
A
<6
20
Q
Which investigations should be ordered for a 49M presenting with 2hr hx of chest pain and arm pain
A
- troponin
- FBC, U&E, LFT, TFT
- ECG
21
Q
Give an example of an ACE-inhibitor you would prescribe for hypertension
A
ramipril, lisinopril, perindopril
22
Q
What are the important side-effects of ACE-inhibitors
A
persistent cough, hypotension, hyperkalaemia
23
Q
What type of medication would you give if lisinopril was not tolerated?
A
An angiotensin receptor blocker
24
Q
Give examples of angiotensin receptor blockers
A
Losartan
25
What additional medication should be offered to patients over 55 with hypertension
calcium channel blockers
26
name some calcium channel blockers
Amlodipine, diltiazem, verapamil
27
Which calcium channel blocker can be prescribed with bisoprolol
amlodipine
| diltiazem and verapamil are contraindicated
28
why might a calcium channel blocker like amlodipine not be tolerated?
oedema
29
which type of diuretic can be offered in hypertension
a thiazide-like diuretic
30
Give an example of a thiazide-like diuretic
bendroflumethiazide, indapamide
31
What are the two types of tachyarrhythmia
narrow QRS complex and broad QRS complex
32
what rate is considered tachycardia
>100bpm
33
What QRS complex is considered narrow
<120ms
34
what are the 4 types of narrow complex tachyarrhythmia`
* atrial fibrillation
* atrial flutter
* supraventricular tachy
* Wolf-Parkinson-White syndrome
35
What are the two types of supraventricular tachycardia
* atrioventricular re-entrant tachy (AVRT)
| * AV nodal re-entrant tachy (AVNRT)
36
What causes AVRT
accessory pathway
37
Which types of SVT is Wolff-parkinson-white syndrome?
AVRT
38
What causes AVNRT
loop in AV node
39
What ECG signs are seen in SVT
absent P wave/P wave inverted after QRS
40
What ECG sign is distinctive in wolff-parkinson-white
delta wave (slurred upstroke in QRS)
41
What is the management of atrial fibrillation
```
Rhythm control
- amiodarone/flecanide
Rate control
- CCB, Beta blocker, digoxin
Anticoagulant
```
42
When should flecanide be given? When should it NOT be given
good in structural heart disease, BAD in ischaemic heart disease
43
What investigation MUST you do before giving flecanide
Echo
44
What comorbidity is digoxin particularly good for in AF
heart failure
45
How is atrial flutter managed
```
Rhythm control
- amiodarone/flecanide
Rate control
- CCB, beta blocker
Anti-coag
```
46
What is the main difference between AF management and atrial flutter management
digoxin has less of a role in atrial flutter
47
What management knocks out 1/4 of SVTs?
Valsalva manouevre or carotid massage
48
What drug management can be given for SVT
adenosine
49
what should be given if SVT is adenosine resistant
rate control
| - CCB, beta blockers, digoxin
50
What surgical management option is required in SVT? Why?
ablation to control the accessory pathway
51
What management option must be given if severe acute tachycardia?
DC cardioversion
52
What must be given before patient with AF is brought back for cardioversion?
anti-coagulation
53
Why must patients with AF be given anticoagulation before cardioversion?
risk of thrombus
54
Which tachyarrhythmia presents with no pulse and complete loss of conscioussness?
ventricular fibrillation
55
What is ventricular fibrillation also known as?
pulseless VT
56
What happens if you do not cardiovert v-fib?
death
57
What is the long-term management of v-fib
implantable defibrillator-cardioverter
58
is ventricular tachycardia pulseless?
may be
59
Torsades de pointes looks like v-fib, but is actually ___ with ___
Torsades de pointes looks like v-fib, but is actually v-tac with varying axis
60
What are the types of broad complex tachyarrhythmias
* v fib
* v tac
* torsades de pointes
* bundle branch block
61
What is bundle branch block
delay or blockage somewhere along the heart's conduction pathway
62
V1 up, V5 down pattern on ECG is ____
right bundle branch block
63
In ventricular tachycardia, if there is a pulse, what medication can you give IV?
IV amiodarone
64
What MUST you give in torsades de pointes?
IV magnesium
65
What might cause torsades de pointes?
medication, ie macrolides
| electrolyte disturbances
66
Impulses travel from the __ node to the __ node
impulses travel from the SA node to the AV node
67
Bradyarrhythmia is bpm
Bradyarrhythmia is <60bpm
68
If bradycardia is asymptomatic and >40bpm, treatment is ___
nothing
69
What is the treatment for symptomatic brady or brady <40bpm?
IV atropine or insertion of temporary pacing wire
70
What are symptoms of bradycardia?
* lightheadedness
* syncope/presyncope
* fatigue
71
What are the three types of AV block
First degree AV block
Second degreer (Mobitz) AV block
Complete (third degree) block
72
What are the ECG changes on first degree AV block
prolonged PR interval
73
What are the types of second degree AV block
Mobitz type I and type II
74
What are the ECG changes on Mobitz type I
Progressively prolonging PR interval culminating in non-conducted P wave (dropped QRS complex)
75
What are the ECG changes on mobitz type II
Non-conducted P wave without progressively prolonging PR interval
76
How is the relationship between the non-conducted P wave and the PR intervals described in Mobitz type II block
1:1, 2:1, 3:1 etc
77
What is third degree AV block
Complete heart block
78
What ECG changes are seen in complete heart block
no relationship between atrial and ventricular contraction
79
What is a long-term management option for AV block?
permanent pacemaker
80
What is systolic dysfunction
heart failure with reduced ejection fraction
enlarged ventricles fill adequately but do not empty into the vessels adequately, reducing the blood ejected from the ventricles
81
What % is considered reduced ejection fraction?
<40%
82
What is diastolic dysfunction?
HF with preserved ejection fraction
| Blood fills into small ventricles, which then pump most of that blood back out into the vessels
83
What are common causes of HF with reduced ejection fraction?
* ischaemic heard disease
* chronic HTN
* dilated cardiomyopathy
84
What are common causes of HF with preserved ejection fraction?
* ventricular hypertrophy
* sarcoidosis
* HTN with left ventricular hypertrophy
85
What cases right ventricular dysfunction
* left ventricular dysfunction
| * increased pulmonary artery pressure (pulmonary stenosis, COPD)
86
What can cause increased pulmonary artery pressure
COPD, pulmonary artery stenosis
87
What can cause left ventricular dysfunction?
* coronary artery disease
* HTN
* MI
88
What are symptoms of decompensated heart failure?
* dyspnoea
* orthopnoea
* paroxysmal noctural dyspnoea
* pulmonary oedema
89
What signs of heart failure would you find on cardiovascular examination?
* raised jugular venous pressure
* Heart sound 3
* peripheral oedema
90
What signs of heart failure would you find on a respiratory + abdominal exam
* signs of pulmonary oedema/pleural effusion
* ascites
* hepatojugular reflex
91
What investigations would you order for suspected heart failure?
* BNP
* CXR
* Echo
92
What signs of heart failure could you see on CXR
* cardiomegaly
* pleural effusion
* Kerley B lines
93
What treatment could you give for heart failure?
* diuretics
* ace-inhibitors (or ARBs if not tolerated)
* beta blocker
* digoxin
* possibly anticoagulation
94
Why would you give anticoagulation in heart failure?
If the patient had AF or a history of thromboembolism
95
What is infective endocarditis
an infection of the endocardium, usually caused by bacteria colonising a thrombus on an area of damage
96
Where does infective endocarditis most commonly occur
tricuspid valve is affected in 50% of cases
97
What are some predisposing factors for infective endocarditis?
* IVDU
* prosthetic valve
* valvular disease
* surgery
* poor dental hygience
98
What are the two types of endocarditis presentation
acute and subacute
99
What kind of patient is predisposed to subacute endocarditis
patients with structurally abnormal valves: valvular disease or prosthetic valves
100
Fever and new murmur should be treated as ___ until proven otherwise
fever and new murmur should be treated as infective endocarditis until proven otherwise
101
What are the potential complications of infective endocarditis?
* local destruction (may cause valve regurgitation or stenosis in particularly large vegetations)
* septic emboli - may cause infections or thromboemboli
* type III autoimmune reactions - may cause glomerulonephritis
102
What investigations should be conducted in suspected infective endocarditis
* blood cultures - 3 sets from different sites at different times
* FBC - shows raised inflammatory markers
* urinalysis - shows microhaematuria
* CXR - may show cardiomegaly
* ECG - may show PR lengthening
* Echo - vegetations
103
What are the two types of echocardiogram? Which is most sensitive for vegetations?
TTE - thransthoracic echo
| TOE - transoesophageal echo - this is more sensitive
104
What antibiotics should be prescribed for infective endocarditis?
Whatever the sensitivies are
* blind treatment for native valve is amox + gent
* blind treatment for prosthetic valve is vanc + gent + rifampicin
105
What is the most common bacteria found in infective endocarditis?
* strep viridans
| * then staph aureus
106
What are Dukes major criteria for infective endocarditis
* 2 positive cultures for a typical bacteria
* consistent (>3) positive cultures
* evidence of endocarditis on echo
107
What are Dukes minor criteria for infective endocarditis
* fever
* immunological signs (eg glomerulonephritis)
* vascular phenomena (eg janeway lesions)
* positive cultures that don't fit the major criteria
* predisposing heart condition/IVDU
108
What combination is needed for a positive dukes criteria
2 major
1 major + 3 minor
5 minor
109
Clubbing is seen in ____ infective endocarditis
finger clubbing is seen in subacute infective endocarditis
110
What hand signs might be seen in infective endocarditis?
* finger clubbing (subacute)
* splinter haemorrhages
* Osler's nodes/janeway lesions
111
What is the difference between osler's nodes and janeway lesions?
osler's nodes are painful, janeway lesions are not
112
What might be heard on listening to the heart in infective endocarditis?
new murmur - typically a new regurgitative murmur although stenosis can occur in very large vegetations
113
What is heart sound S3 indicative of?
heart failure
114
What is postural hypotension
transient fall in BP when a patient moves from sitting/lying to standing
115
how is postural hypotension diagnosed
by doing a lying and standing blood pressure
| A drop of >20mmHg along with symptoms when a patient stands is diagnosed as postural hypotension
116
High levels of the lipid ____ in the blood are strongly correlated with coronary artery disease
High levels of LDLs in the blood are stongly correlated with coronary artery disease
117
Which type of lipoprotein is protective against coronary artery disease?
HDLs (high density lipoproteins)
118
What is the main medical treatment for hyperlipidaemia
statins
119
What is the most common cause of mitral valve regurgitation
mitral valve prolapse
120
What kind of murmur would mitral regurgitation cause
a systolic murmur
121
What is mitral regurgitation
incomplete closure of the mitral valve allowing blood to flow back from the left ventricle to the left atrium during systole
122
What can be some causes of mitral regurgitation
- connective tissue disorders (eg marfan's)
- cardiomyopathy
- left-sided heart failure
- post MI changes
123
What are some symptoms of mitral regurgitation
- dyspnoea
- fatigue
- palpitations
- infective endocarditis
124
what signs of mitral regurgitation might you find on examination
- displaced, hyperdynamic apex
| - systolic murmur
125
The more severe the mitral regurgitation, the ____ the left ventricle
the more severe the mitral regurgitation, the larger the left ventricle
126
what test is diagnostic of mitral regurgitation?
echo
127
What is the most common cause of mitral valve stenosis
rheumatic fever
128
Describe the pathogenesis of mitral valve stenosis leading to right-sided heart failure
Stenosis of the mitral valve causes congestion in the left atrium which causes increased pressure in the pulmonary circulation, which backs up into the right ventricle, causing right sided heart failure
129
How might mitral stenosis cause atrial fibrillation
stretching of the cells in the enlarged left atrium can cause atrial fibrillation
130
What are some symptoms of mitral stenosis
* dyspnoea
* orthopnoea
* dysphagia
* haemoptysis
131
What signs might you find in mitral stenosis
* malar flush
* 'snap' sound at S2 and diastolic rumble before S1
* signs of pulmonary congestion
132
Why might mitral stenosis cause malar flush
due to decreased cardiac output
133
What is aortic stenosis?
incomplete opening of the aortic valve
134
What is the most common cause of aortic stenosis?
senile calcification
135
What is the classic triad of symptoms in aortic stenosis?
* syncope
* angina
* signs of heart failure
136
Explain the pathophysiology of the classic triad of symptoms in aortic stenosis
not enough blood is pumped out of the left ventricle so the organs are hypoperfused, causing syncope and angina, and eventually signs fo heart failure
137
What changes happen to the left ventricle in aortic stenosis? why?
more pressure is required to expell blood from the left ventricle through the stenosed valve, so the left ventricle undergoes hypertrophy
138
What is the murmur heard in aortic stenosis?
ejection systolic murmur (a classic snap noise) radiating to the carotids
139
What is aortic regurgitation?
aortic insufficiency. The aortic valve closes incompletely, allowing blood to flow backwards into the left ventricle
140
What happens to the left ventricle in aortic regurgitation?
It becomes enlarged
141
give a cause of aortic regurgitation?
infective endocarditis
142
What kind of murmur is heard in aortic regurgitation?
an early diastolic murmur
143
What happens to the blood pressure in aortic regurgitation?
The systolic blood pressure increases and diastolic decreases, causing a wide pulse pressure
144
What causes the 'water hammer' pulse in aortic regurgitation?
The wide pulse pressure
145
What other signs would you see in aortic regurg?
* water-hammer pulse
* Quincke's sign
* Carotid pulsation
* head bobbing with pulse
146
What is Quincke's sign?
capillary pulsation in nail beds in aortic regurgitation
147
what are the three main types of cardiomyopathy?
* dilated cardiomyopathy
* hypertrophic cardiomyopathy
* restrictive cardiomyopathy
148
what is the most common type of cardiomyopathy?
dilated cardiomyopathy?
149
What happens in dilated cardiomyopathy?
enlarged ventricles result in poor systolic function
150
What is the presentation of dilated cardiomyopathy?
* dyspnoea
* fatigue
* pulmonary oedema
* right ventricular failure
* ventricular tachy
* atrial fibrillation
151
What usually causes hypertrophic cardiomyopathy?
genetic causes
152
____ cardiomyopathy is a leading cause of sudden death in the young
hypertrophic cardiomyopathy is a leading cause of sudden death in the young
153
how does hypertrophic cardiomyopathy cause sudden death?
hypertrophic ventricles cause left ventricular outflow tract obstruction (LVOTO) which causes blood not to get into the aorta
154
Why might hypertrophic cardiomyopathy cause angina?
increased oxygen demand of hypertrophic cardiac muscles
155
What are some symptoms of hypertrophic cardiomyopathy
* angina
* palpitations
* syncope
* sudden death
156
What happens in restrictive cardiomyopathy
ventricle walls become stiffened, so they do not fill properly in diastole
157
(diastolic/systolic) function can be normal in restrictive cardiomyopathy
systolic function can be normal in restrictive cardiomyopathy
158
Describe ventricular septal defect
an abnormal opening in the heart between the two ventricles
159
is ventricular septal defect a cyanotic congenital heart condition? why?
No
| The blood shunts from left-to-right, so deoxygenated blood will not flow into the left ventricle and through the aorta
160
What are the complications of ventricular septal defect?
* right ventricular hypertrophy
| * pulmonary HTN
161
What is atrial septal defect?
Where a hole exists between the artium, causing shunting of blood from the left atrium to the right
162
When is atrial septal defect commonly discovered?
* coincidentally
| * in late adulthood with dyspnoea/heart failure
163
What symptoms might an adult with atrial septal defect have?
dyspnoea or heart failure
164
What genetic condition predisposes to atrial septal defect?
down's syndrome
165
How might atrial septal defect lead to cyanosis?
left-to-right shunt might cause pulmonary hypertension which then causes increased right heart pressure which would cause the shunt to reverse, causing cyanosis
166
what is a common complication of bicuspid aortic valve?
aortic stenosis
167
What murmur might be heard in atrial septal defect?
split S2
168
What is coarctation of the aorta?
a congenital narrowing of the aorta typically distal to the left subclavian artery
169
what does coarctation of the aorta cause?
raised blood pressure in the upper extremities and low BP in the lower extremities
170
What is the pericardium
the protective sac around the heart
| composed of an outer fibrous and inner serosal layer
171
Give some causes of secondary pericarditis
EBV, HIV, staphylococcus, TB, fungal infection, neoplasm, rheumatoid arthritis
172
What are the symptoms of pericarditis
* dyspnoea (worse on lying flat or inspiration)
| * may have fever
173
What might you hear on auscultation with pericarditis
pericardial friction rub
174
What will an ECG in pericarditis look like
NSR or saddle-shaped ST elevation
175
What is treatment for pericarditis
treat underlying cause
176
what is a pericardial effusion?
fluid accumulation in the pericardial sac
177
what causes pericardial effusion
any cause of pericarditis
178
what signs are seen in pericardial effusion
* dyspnoea
| * raised JVP
179
What is a haemopericardium
blood in the pericardial sac
180
What is cardiac tamponade
fluid in the pericardial sac causes the ventricles to fill insufficiently, causing poor cardiac output
It is a medical emergency
181
What is aortic dissection
tearing of the inner layer of the aorta, allowing blood to pool there causing haemorrhage and occlusion of the vessels distally
182
What might someone present with aortic dissection
a sudden sharp pain radiating to their back
183
What would uneven pulses indicate
aortic dissection
