Cardiology Flashcards
Which ECG leads give a lateral view of the heart?
Lateral = Left
I, avL, v6
Which ECG leads give an inferior view of the heart?
II, III, avF
Which ECG leads give an anterior view of the heart?
V2, V3, V4
What are the lateral ECG leads and which coronary artery do they correspond to?
I, avL, V6
Lateral Circumflex or diagonal branch of LAD
What are the inferior ECG leads and which coronary artery do they correspond to?
II, III, avF
Right Coronary Artery
What are the anterior ECG leads and which coronary artery do they correspond to?
V2, V3, V4
Left Anterior Descending (LAD)
How do a STEMI and an NSTEMI differ?
- STEMI = ST elevation +/- Q wave formation OR NEW ONSET LBBB i.e. specific ECG changes
- NSTEMI = Symptoms but non-specific ECG changes + elevated cardiac enzymes
Define Acute Coronary Syndrome
A collection of symptoms that can be due to one of either:
Unstable Angina
MI (STEMI OR NSTEMI)
What are the 5 categories of MI?
Due to acute ischaemia =
1 - Spontaneous, due to primary coronary event e.g. plaque rupture or dissection
2 - Secondary to ischaemia from ↑ o2 demand or ↓ o2 supply e.g. severe HTN or tachyarrhythmia
Other
3 - Sudden Cardiac Death
4 - Associated with PCI or Stenting
5 - Associated with cardiac surgery
How can unstable angina be differed from an MI?
Symptomatically
unstable angina = -ve trops
MI = +ve trops
What are the classic symptoms of an MI?
Central, crushing chest pain +/- radiates to left arm or jaw Sweating, N&V Pallor Palpitations Feeling of impending doom
What is the GRACE score?
Scoring system to estimate the risk of death following acute coronary syndrome
What is the medical management of a STEMI?
(MONAA B)
Morphine (5-10mg IV) and Metoclompramide (10mg IV)
Oxygen
Nitrates (more of a role in NSTEMI than STEMI)
Aspirin 300mg PO
Antiplatelet - Clopidogrel
B-Blocker - Atenolol
What is the management of an NSTEMI?
MONAA B
Do a GRACE score = high risk = angioplasty, low risk = observe + OP assessment
What is the surgical/definitive management of a STEMI and when can this be offered?
Primary Percutaneous Intervention
ONLY IF within 12hr of symptom onset OR can get to a PCI centre in 120 minutes
If not, do thrombolysis
Give 4 short term and 4 long term complications of an MI
◦ Short Term ‣ Death ‣ Cardiogenic Shock ‣ Thrombosis embolisation ‣ Pulmonary Oedema
◦ Long Term ‣ Heart Failure ‣ Arrhythmias ‣ Recurrence ‣ Psychosocial e.g. depression
What are the medications required for long term prevention of an MI?
- Dual anti platelet therapy - Aspirin and Clopidogrel
- Statin
- ACEI
- B-Blocker
What is a pathological Q wave? When does it become pathological?
ECG waves that occur when the myocardium becomes damaged to the point of no return. Shows as a negative deflection before the R wave
in V1-V3 >2mm deep >1mm/40s wide >5% of QRS = pathological
What are the classical features of heart failure on chest x ray?
A - alveolar oedema (bat wing opacities) B - Kerley B lines C - cardiomegaly D - dilated upper lobe vessels E - pleural effusion
What are the causes of left ventricular systolic dysfunction?
Things that impair proper contraction of the ventricle
Ischaemic heart disease
Hx MI
Cardiomyopathy
What are the causes of left ventricular diastolic dysfunction?
Things that impair proper relaxation and filling of the ventricle
Tamponade
Restrictive cardiomyopathy
Ventricular hypertrophy
What are the causes of right heart failure?
Left heart failure
Cor Pulmonale/Lung disease
Pulmonary stenosis
What is the management of acute heart failure?
◦ IV Furosemide
◦ Diamorphine + metoclompramide/anti-emetic
◦ GTN 2 puffs
What is the management of chronic heart failure?
Conservative - smoking cessation/ risk reduction, cardiac rehab
Medical - ACEI/ARB, B Blocker, Diuretic, Spironolactone can be used if still symptomatic
What is a broad complex tachycardia? Give 3 examples
HR >100bpm
QRS >0.12s
Ventricular tachycardia, ventricular fibrillation, torsades de pointes
What is a narrow complex tachycardia? Give 3 examples
HR >100bpm
QRS <0.12s
Sinus tachy, Atrial Fibrillation, AVRT,NRT
What is torsades de points?
Polymorphic ventricular tachycardia
VT but the baseline varies and that kind of makes it look like VF but it isn’t
Has a big risk of developing into VF though
How could a patient with an arrhythmia present?
Palpitations Syncope Feeling lightheaded Shortness of breath especially on exertion Chest pain
What is the pathophysiology of atrial flutter?
Electrical activity circles the atria 300 times per minute,
The avn passes some of these impulses on = ventricular rates that are factors of 300
Gives a ‘sawtooth’ baseline
Describe an atrioventricular re-entry tachycardia
an accessory pathway e.g. the bundle of Kent in Wolff-Parkinson White allows transmission of electrical impulses from the ventricles back to the atria
creates a circuit
Describe the appearance of Wolff-parkinson white on ECG
Get delta waves = slurred upstroke of the QRS
Describe an atrioventricular nodal re-entry tachycardia
circuits form within the AVN = narrow complex tachycardia
Describe atrial fibrillation
Multiple sites of depolarisation within the atria causes them to quiver rather than properly contracting
Atrial rate is irregular and 300-600bpm
The AVN transmits intermittently leading to an irregular pulse
CO drops as ventricles are inadequately primed + stagnation of blood within the atria predisposes coagulation and therefore stroke
How should AF be managed acutely if there is haemodynamic INSTABILITY??
DC cardioversion!
How should AF be managed acutely if there is NO haemodynamic instability?
Symptoms <48hr = Rate or Rhythm Control
Symptoms >48hr = anticoagulate with a DOAC for 3 weeks and then bring back for elective cardio version
How is rate controlled pharmacologically in AF?
1st line = B Blocker
2nd line/if B blocker contraindicated = Rate limiting Ca Channel blocker e.g. Dilitiazem or Verapamil
3rd line = Digoxin
How is rhythm controlled pharmacologically in AF?
IV Amiodarone
IV Flecainide (not if there is any structural heart disease)
What is paroxysmal AF and how should it be managed?
Gets worse all of a sudden/is infrequent
Use ‘pill in the pocket’ e.g. sotalol or flecainide PRN
Give 6 common causes of AF
- Structural defects e.g. mitral valve disease
- Pneumonia
- PE
- HF/HTN
- Previous MI
- Hyperthyroidism
What do bifascicular and trifascicular block look like on ECG?
Bifascicular = RBBB + Left axis deviation
Trifascicular = RBBB + LAD + 1st degree heart block
What counts as haemodynamic instability/adverse events during an arrhythmia? (4)
Syncope
Shock
Myocardial Ischaemia
Heart Failure
What is the murmur heard with aortic stenosis? When is it the loudest?
Ejection systolic
Loudest on expiration
What is the murmur heard with pulmonary stenosis? When is it the loudest?
Ejection systolic
Loudest on inspiration
What is the murmur heard with mitral stenosis? When is it the loudest?
Mid-diastolic murmur
expiration
What is the murmur heard with tricuspid regurgitation? When is it the loudest?
Pansystolic
Loudest on inspiration
What is the murmur heard with mitral regurgitation? When is it the loudest?
Pansystolic
Loudest on expiration
What are the causes of aortic stenosis?
Old age - the valve calcifies
Rheumatic heart disease
What are the causes of aortic regurgitation?
Acute:
infective endocarditis, trauma
Chronic:
Connective tissue disorders, Takayasu’s Arteritis, PAIR athropathies, Rheumatoid arthritis
What are the causes of mitral regurgitation? (5)
Functional (lv dilatation) Calcifies in old age rheumatic fever infective endocarditis mitral valve prolapse/dysfunction Post MI
What are the causes of mitral stenosis?
Rheumatic heart disease
Congenital
What are the causes of tricuspid regurgitation? (4)
rv dilatation; eg due to pulmonary hypertension rheumatic fever
infective endocarditis
Ebstein’s Anomaly
What are the causes of tricuspid stenosis?
Rheumatic heart disease
What are the causes of pulmonary stenosis
Congenital = turner’s, TOF, Rubella
Acquired = Rheumatic Heart Disease
What are the causes of pulmonary regurgitation?
Pulmonary Hypertension
What is Beck’s triad of cardiac tamponade?
Muffled Heart Sounds
Hypotension
Distended neck veins
What is Kussmaul’s sign?
Not breathing
distension of the jugular veins on inspiration
due to constrictive pericarditis
blood can’t enter the right atrium and is more pronounced than normal as normally would have a negative inter thoracic pressure when breathing in