Cardiology Flashcards
Effect of inspiration on JVP?
causes JVP to fall. - inspiration generates negative intrathoracic pressure + suction of venous blood towards the heart
what causes the normal a wave in JVP waveform?
due to right atrial contraction
- peak of a wave demarcates end of atrial systole
- actively pushes up into SVC
what causes the c wave in the normal JVP waveform?
- corresponds to closure of the tricuspid valve, bulging towards the R atrium during the start of ventricular systole
what causes the x descent in the normal JVP waveform?
- corresponds to atrial relaxation, stretch and rapid atrial filling due to drop in pressure
what causes the v wave in the normal JVP waveform?
due to passive filling of venous blood into the atrium against a closed tricuspid valve
- occurs during and following the carotid pulse
what is the y descent in the normal JVP waveform?
- opening of the tricuspid valve with passive movement of blood from R atrium into the R ventricle
causes of raised JVP with normal waveform?
- Heart failure: biventricular or isolate R HF
- fluid overload of any cause
- severe bradycardia
Causes of Kussmaul’s sign?
kussmaul’s sign: raised JVP on inspiration and drops with expiration
- implies R heart chambers cannot increase in size to accommodate increased venous return
- due to pericardial disease (constriction) or fluid in pericardial space (pericardial effusion and cardiac tamponade)
Causes of Raised JVP with loss of normal pulsations?
SVC syndrome
- obstruction caused by mediastinal malignancy such as bronchogenic malignancy -> head, neck, arm swelling
causes of absent a waves in JVP?
atrial fibrilation
- no coordinated atrial contraction
causes of large a waves in JVP?
Tricuspid stenosis, right heart failure, pulmonary hypertension
Causes of cannon a wave in JVP?
caused by AV dissociation - allowing atria and ventricles to contract at same time
- atrial flutter, atrial tachycardias
- complete heart block
- ventricular tachycardia, ventricular ectopics
causes of giant v waves in JVP?
tricuspid regurgitation
- increased RA volume during ventricular systole causes prominent v wave
causes of steep x descent and diminished y descent in JVP?
cardiac tamponade
causes of steep y descent in JVP?
cardiac constriction e.g. constrictive pericarditis
cause of slow y descent in JVP?
tricuspid stenosis
causes of absent radial pulse?
- iatrogenic: post catheterisation or art line
- Blalock-Taussig shunt for Congen heart disease, eg TOF
- Aortic dissection with subclavian involvement
- trauma
- Takayasu’s arteritis
- peripheral arterial embolus
causes of collapsing pulse?
aortic regurg
AV fistula
patent ductus arteriosus
or other large extracardiac shunt
causes of slow rising pulse?
aortic stenosis
causes of jerky radial pulse?
HOCM
cause of bisferiens radial pulse?
double shudder due to mixed aortic valve disease w significant regurgitation
causes of pulsus alternans?
severe LV dysfunction
- pulses alternate from weak to strong
- EF reduced meaning that end diastolic volume is elevated -> may sufficiently stretch the myocytes to improve EF of next heart beat
causes of pulsus paradoxus?
- excessive reduction in pulse with inspiration
- LV compression, tamponade, constrictive pericarditis or severe asthma
where venous return is compromised
Causes of absent apical impulse?
- obesity/ emphysema
- pericardial effusion/ constriction
- dextrocardia
- right pneumonectomy with displacement
cause of heaving apical impulse?
LVH
+/- fourth HS
cause of thrusting/ hyperdynamic apical impulse?
high LV volume e.g. Mitral regurg, aortic regurg, PDA, VSD
tapping apex beat?
palpable first heart sound in mitral stenosis
displaced/ dyskinetic apex beat?
LV impairment and dilation
e.g. dilated cardiomyopathy, MI
pericardial knock?
constrictive pericarditis
double impulse apex beat?
with dyskinesia: LV aneurysm
without dyskinesia: HOCM
parasternal heave?
RVH
e.g. Pulmonary hypertension, ASD, COPD, pulmonary stenosis
palpable third HS?
due to HF / severe mitral regurg
Poor prognostic factors in ACS?
- age
- development (or hx of) heart failure
- peripheral vascular disease
- reduced systolic BP
- Killip class
- initial serum [Cr]
- elevated trop
- cardiac arrest on admission
- ST segment deviation
Medications to continue post MI?
ACEi + BB
Statin
Aspirin lifelong
Clopidogrel for 1 year
What additional medication to add to patients who have had an acute MI and who have symptoms +/- signs of heart failure and LV systolic dysfunction?
Spironolactone
- initiated within 3-14 days of the MI, preferably after ACEi therapy
In an MI, what is the first cardiac enzyme to rise?
Myoglobin
What cardiac enzyme is most useful to look for reinfarction?
CK-MB
- as it returns to normal after 2-3 days post MI
(Trop T remains elevated for up to 10 days)
Causes of ST elevation?
STEMI
acute pericarditis
early repolarization/ high take off
coronary artery spasm
ventricular aneurysm
oesophageal spasm
cardiac contusion
acute cerebral injury
What is the latest cardiac enzyme to rise post MI?
LDH
- peaks at 72 hours
- starts at 24-48h
- returns to normal after 8-10 days
Trop vs CK-MB as markers in MI?
Troponin is not related to infarct size
CK is directly proportional
What vaccines should be offered to those with heart failure?
annual influenza
+
once off pneumococcal
vaccine
management of poorly controlled heart failure despite medical management + broad QRS complex?
Cardiac resynchronisation therapy
ie. biventricular pacing
*insertion of electrodes in the L + R ventricles, as well as on occasion the right atrium, to treat HF by coordinating the function of the ventricles via a pacemaker
Ix of Constrictive pericarditis?
Echo - thickened pericardium, pericardial effusion, constrictive physiology
CT -
can reveal a calcified pericardium
Right + Left heart catheterisation -
ventricular inter-dependence
Most likely cause of calcification with constrictive pericarditis?
prior TB infection
Management of constrictive pericarditis?
very difficult to manage
- medical management for CCF
- surgical: ‘pericardial stripping’
causes of pericardial effusion?
Acute pericarditis
all causes of constrictive pericarditis
aortic dissection
iatrogenic due to pacing/ cardiac cath (rare)
ischaemic heart disease with ventricular rupture (rare)
anticoag assoc w acute pericarditis
Differences in JVP character in cardiac tamponade vs constrictive pericarditis?
tamp:
absent Y descent
constrictive pericarditis:
x + y present.
y steep
pulsus paradoxus in cardiac tamp vs constrictive pericarditis?
pulsus paradoxus present in cardiac tamponade , absent in constrictive pericarditis
what is the strongest risk factor for developing infective endocarditis?
previous episode of IE
risk factors of IE?
normal valves (50%, typically acute presentation)
rheumatic valve disease (30%)
prosthetic valves
congenital heart defects
IVDU
immunocompromise
instrumentation
what organism is assoc with colorectal cancer (in infective endocarditis)?
Strep bovis
what infective endocarditis organism is most assoc with IVDU/ acute presentations?
staph aureus
what infective endocarditis organism is assoc w prosthetic valves?
staph epidermidis
most common cause of subacute IE?
strep viridans
what are some other causes of infective endocarditis?
SLE - libman-sacks
malignancy: marantic endocarditis
- which has platelet- fibrin thrombi prone to embolising
Culture negative causes of infective endocarditis?
prior abx therapy
coxiella burnetii
bartonella
brucella
HACEK: haemophilus, actinobacillus, cardiobacterium, eikenella, kingella - slow growing
non-infective
What is the most common cause of IE following prosthetic valve surgery?
Staph epidermidis
- most common in the first 2 months
- usually the result of periop contamination
- late endocarditis 2 years post surgery might be strep viridans
Modified Duke criteria for IE?
- 2 major,
1 major + 3 minor
5 minor
or pathological criteria is positive:
- postive histology/ microbiology of pathological material obtained at autopsy/ cardiac surgery
Major criteria in IE?
Positive Blood cultures:
- 2 positive cultures showing typical organisms e.g. Strep viridans/ HACEK
- 3 or more cultures where pathogen less specific e.g. staph aureus/ staph epidermidis
- positive seriology for Coxiella burnetii, bartonella, chlamydia
- positive molecular assays for specific gene targets
evidence of endocardial involvement:
positive echo
e.g. mobile masses, abscess formation, new valvular regurg/ dehiscence of prosthetic valves
Minor criteria for IE?
predisposing heart condition or intravenous drug use
microbiological evidence does not meet major criteria
fever > 38ºC
vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots
poor prognostic features in IE?
- staph aureus infection
- prosthetic valve
- culture negative endocarditis
- low complement levels
Indications for surgery in IE?
- severe valvular incompetence
- aortic abscess (often indicated by a lengthening PR interval)
- infections resistant to abx/ fungal infections
- HF refrac to standard medical tx
- recurr emboli after abx therapy
most common causes of restrictive cardiomyopathy?
amyloidosis
idopathic myocardial fibrosis (freq after a heart transplant)
causes of restrictive cardiomyopathy?
idiopathic fibrosis
amyloid
carcinoid
sarcoid
haemochromatosis
rare - endomyocardial fibrosis, Loeffler’s syndrome
scleroderma
neoplasms of heart
symptoms of restrictive cardiomyopathy?
symptoms of HF usually develop slowly
features of aortic stenosis?
narrow pulse pressure
slow rising pulse
ESM radiating to carotids
soft/ absent S2
LV heave
CCF
pulmonary HTN
causes of aortic stenosis?
degenerative calcification (most common in elderly)
bicuspid aortic valve (most common in young)
rheumatic valve disease
William’s syndrome (supravalvular AS)
Subvalvular: HOCM
Echo findings in Aortic stenosis?
- Valve area (Mild >1.5cm2, mod: 1-1.5, severe: <1cm2)
- transvalvular gradient (severe >50mmHg)
- LVH
- LV dysfunction and Pulmonary HTN in advanced disease
what is classified as severe AS according to echo findings of valve area?
severe = <1cm2
mild = >1.5
mod = 1- 1.5
what transvalvular gradient in echo demonstrates severe Aortic stenosis?
>50 mmHg
When to surgically treat Aortic stenosis?
symptomatic: chest pain/ SOB/ syncope/ CCF
AND/or
prognostic (severe AS on echo, LV dysfunction on echo, pulmonary hypertension on echo)
indications for aortic valve replacement in aortic regurg?
symptomatic
or
progressive LV dilatation
or
systolic ventricular diameter >55 mm on echo
or
immediately if acute
If Onset >48h + wanting to cardiovert someone in AF?
- should have therapeutic anticoag for at least 4 wks before
- following electrical cardioversion, anticoag for at least 4 wks
- if high risk of cardioversion failure (e.g. recurrence) -> at least 4 wks of amiodarone or sotalol prior to electrical cardioversion
pharmacological cardioversion of AF?
amiodarone
- if structural heart disease
flecainide
- if NO structural heart disease
ECG findings of hypotehermia?
bradycardia
J waves - small hump at end of QRS
first degree HB
long QT
atrial/ ventricular arrhythmias
causes of a prolonged PR interval?
idiopathic
ischaemic heart disease
digoxin toxicity
hypokalaemia*
rheumatic fever
aortic root pathology e.g. abscess secondary to endocarditis
Lyme disease
sarcoidosis
myotonic dystrophy
causes of short PR interval?
pre-excitation:
wolff parkinson white
low-ganong-levine
other:
AV junctional rhythm
ventricular extrasystole after P wave
low atrial rhythm
coronary sinus escape rhythm
associations of wollf-parkinson-white?
HOCM
mitral valve prolapse
Ebstein’s anomaly
thyrotoxicosis
secundum ASD
what drug should NOT be used in VT?
Verapamil
- Verapamil may cause fatal hypotension in VT
due to negative inotropic and peripheral vasodilatory effects
management of VT if drug therapy fails?
elecrophysiological study
Implantable cardioverter-defibrillator- esp if significantly impairved LV fn
features of broad complex tachy consistent w VT?
RBBB + LAD
very wide QRS
chest lead concordance
p wave dissociation
capture beats
fusion beats
most common cause of VT?
ischaemic heart disease
most commonly through scar-related VT from prev infarct
or acute MI with VT
causes of Long QT syndrome - congenital?
Jervell-Lange-Nielson syndrome:
deafness + long QT
Romano-Ward: QT prolongation + T wave abnormalities
- most common
Brugada syndrome: may present w sudden cardiac death
deafness + long QT?
Jervell-Lange-Nielsen
most common cause of congenital Long QT syndrome?
Romano-Ward syndrome
- affects 1 in 7000
Drugs that cause Long QT?
Amiodarone
Sotalol
TCAs
chloroquine
class 1a antiarrhythmics: quinidine, procainamide
terfenadine
erythromycin
what intracranial abnormalities cause long QT?
subarachnoid haemorrhage
Management of Long QT?
Beta blockers
e.g. propranolol, nadolol
metoprolol, atenolol
if high risk: ICD
Ejection systolic murmur feature of HOCM?
ESM increases with valsalva and decreases on squatting
features of HOCM on echo?
- systolic anterior motion of the anterior mitral valve leaflet
- LVH, with asymmetric septal hypertrophy
- mitral regurg
- elevated gradient across the LV outflow tract
ECG findings in HOCM?
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
atrial fibrillation may occasionally be seen
findings of holter monitoring in HOCM?
non sustained VT
poor prognostic factors of HOCM?
syncope
family history of sudden death
young age at presentation
non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
abnormal blood pressure changes on exercise
increased septal wall thickness
management of HOCM?
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
2 main complications of PCI?
Stent thrombosis:
most commonly in first month.
1-2%
presents with acute MI
Re-stenosis:
due to excessive tissue proliferation around stent
most commonly in 3-6 mo
5-20% of pts
risk factors of re-stenosis post PCI?
diabetes, renal impairment and stents in venous bypass grafts
Most important management to prevent stent thrombosis post PCI?
antiplatelet therapy - aspirin should be continued indefinitely
*length of clopidogrel depends on type of stent, reason for insertion and consultant preference
PCI:
bare metal stent
vs drug eluting stent
drug eluting stent - paclitaxel/ rapamycin whcih inhibits local tissue growth
- this reduces restenosis rates
but Increases thrombosis rates (as process of stent endothelisation is slowed)
1st line drug prophylaxis of non-sustained VT?
sotalol
indications for ICD insertion for secondary prevention?
- for those who survived cardiac arrest secondary to venticular arrhythmia
- sustained VT w haemodynamic compromise
- sustained VT with poor LV fn
in the absence of any identifiable cause of VF/VT
indications for ICD insertion in family conditions w high risk of sudden cardiac death?
Long QT
HOCM
Brugada syndrome
Arrhythmogenic Right Ventricular Dysplasia
what ix might support the diagnosis of vasovagal syncope?
tilt table test
cyanotic causes of congenital heart disease?
TGA
TOF
Tricuspid atresia
Pulmonary valve stenosis
what test can help determine management for primary pulmonary hypertension?
acute vasodilator testing
management of primary pulmonary hypertension if +ve response to acute vasodilator testing?
oral CCB
management of primary pulmonary hypertension if -ve response to acute vasodilator testing (vast majority)?
prostacyclin analogues: treprostinil, iloprost
endothelin receptor antagonists: bosentan, ambrisentan
phosphodiesterase inhibitors: sildenafil
management of secondary pulmonary HTN?
treating any underlying conditions
complications of malignant hypertension
can lead to cerebral oedema → encephalopathy
retinal haemorrhages
haematuria due to renal damage (benign nephrosclerosis)
management of choice in malignant hypertension?
most patients: oral therapy e.g. atenolol
if severe/encephalopathic: IV sodium nitroprusside/labetolol
ix of choice for patent foramen ovale?
Transoesophageal Echo
what medication might be started for postural hypotension in certain patients?
fludrocortisone
features (signs) of tricuspid regurgitation?
- pan-systolic murmur
- prominent/giant V waves in JVP
- pulsatile hepatomegaly
- left parasternal heave
Stages of Valsalva manoeuvre?
- Increased intrathoracic pressure
- -> reduces venous return
- -> Reduced preload leads to a fall in the cardiac output (Frank-Starling mechanism)
- fall in cardiac output
- Return of normal cardiac output
first step management after witnessed cardiac arrest (VF/VT) on a monitor?
up to three quick successive shocks before CPR
which Infective endocarditis organism is most linked with colorectal cancer?
Streptococcus bovis
- subtype: Streptococcus gallolyticus
most common cause of Infective endocarditis?
staph aureus
STEMI criteria in ecg?
ECG features in ≥ 2 contiguous leads of:
- 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in V2-3 in men <40yo,
or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in V2-3 in men >40yo
- 1.5 mm ST elevation in V2-3 in women
- 1 mm ST elevation in other leads
- new LBBB
first line medication to start as SVT prophylaxis in pregnancy?
metoprolol
most likely organism of IE in patient with poor dentition?
strep viridans
e.g. strep sanguinis
features of Takayasu’s arteritis?
- systemic features of vasculitis e.g. fever/ malaise/ headache
- unequal BP in upper limbs
- carotid bruit
- intermittent claudication
- aortic regurgitation (~20%)
association of Takayasu’s arteritis?
renal artery stenosis
management of takayasu’s arteritis?
steroids
risk factors for steroid induced myopathy?
advanced age, female, low BMI, DM
Target INR for mechanical aortic valve vs mechanical mitral valve?
aortic: 3.0
mitral: 3.5
what causes false negative BNP levels?
obesity
+ medications e.g. diuretics, ACEi, ARBs
risk factors for asystole?
- one should consider need for transvenous pacing
- complete Heart block with broad complex QRS
- recent asystole
- Mobitz type II AV block
- ventricular pause >3 seconds
irregular cardiac rhythm caused by at least 3 diff sites in the atria, which may be demonstrated by morphologically distinctive P waves
Multifocal atrial tachycardia
management of multifocal atrial tachycardia?
1st line: Rate limiting CCBs e.g. verapamil
- correction of hypoxia/ electrolyte disturbances
DVT -> stroke
Patent foramen ovale
best investigation for PFO?
transoesophageal echo
- provides superior views of the atrial septum
(preferred over TTE)
JVP waveform: cardiac tamponade vs constrictive pericarditis?
tamponade: absent Y descent
constrictive pericarditis: X + Y present
causes of slow rising pulse?
aortic stenosis
causes of collapsing pulse?
aortic regur, patent ductus arteriosus
hyperkinetic states (e.g. pregnancy, anaemia, fever, thyrotoxic)
Causes of pulsus paradoxus?
- faint or absent pulse in inspiration
- > tamponade, severe asthma
causes of pulsus alternans?
severe LVF
causes of bisferiens pulse?
ie. “double pulse” - 2 systolic peaks
- mixed aortic valve disease
management of pulmonary arterial hypertension if there is a positive response to acute vasodilator testing (ie. IV epoprostenol or inh nitric oxide)
oral CCB
e.g. nifedipine, diltiazem and increasingly amlodipine
management of pulmonary arterial hypertension if there is a NEGATIVE response to acute vasodilator testing (ie. IV epoprostenol or inh nitric oxide)
- prostacyclin analogues: treprostinil, iloprost
- endothelin receptor antagonists: bosentan, ambrisentan
- phosphodiesterase inhibitors: sildenafil
management of progressive symptoms in pulmonary arterial hypertension?
heart-lung transplant
e.g.s of endothelin receptor antagonists
(used in pulm arterial HTN)
bosentan, ambrisentan
management of complete heart block secondary to inferior MI?
conservative management if asymptomatic / haemodynamically stable
Indications for a temporary pacemaker?
- symptomatic/haemodynamically unstable bradycardia, not responding to atropine
- post-ANTERIOR MI: type 2 or complete heart block*
- trifascicular block prior to surgery
management of acute pericarditis?
NSAID + colchicine
Associations of Coarctation of Aorta?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
management of SVT in patient with asthma? if vagal manouevres have failed
verapamil
as adenosine CI in asthma
pulmonary hypertension.
Which one of the following is the best method for deciding upon management strategy?
acute vasodilator testing
Strep gallolyticus
- in infective endocarditis
assoc w?
Colorectal cancer
- strep gallolyticus is the subtype of strep bovis
what infective endocarditis organism is most common in the 2 months following prosthetic valve surgery/ most commonly colonize indwelling lines?
Staph epidermidis
What organism is the most common cause of infective endocarditis in prosthetic valve patients >2 months post surgery?
staph aureus, as with everyone else
streptococcus mitus,
streptoccocus sanguinis
assoc w?
poor dental hygiene/ following dental procedure
- they are subtypes of strep viridans
- cause IE
What part of the ECG does S4 coincide with?
P wave
- s4 is caused by atrial contraction against a stiff ventricle, occuring just before the S1 sound.
- coincides with P wave, which represents atrial depolarisation.
S4 heart sound assoc w?
aortic stenosis, HOCM, HTN
- in HOCM, a douple apical impulse may be felt as a result of a palpable S4
S3 heart sound assoc w?
LV failure e.g. dilated cardiomyopathy
constrictive pericarditis
mitral regurg
What medications should be avoided in patients with Wolff-Parkinson White?
Verapamil, Digoxin
- these might precipitate VT/ VF
Associations of WPW?
HOCM
Mitral valve prolapse
Thyrotoxicosis
Ebstein’s anomaly
ASD (Secundum)
Management of wolff parkinson white?
- definitive
radiofrequency ablation of the accessory pathway
medical management of wolff parkinson white?
sotalol*, amiodarone, flecainide
*sotalol should be avoided if coexistent AF as might increase rate of transmission through accessory pathway & precipitate VF.
Echo findings in HOCM?
MR SAM ASH
- Mitral regurgitation (HOCM might impair mitral valve closure)
- systolic anterior motion (SAM) of the ant mitral valve leaflet
- Asymmetric hypertrophy (ASH)
Associations of HOCM?
- conditions
Friedreich’s ataxia
Wolff Parkinson White
ECG findings in HOCM?
- LVH
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
atrial fibrillation may occasionally be seen
yMyofibrillar hypertrophy with chaotic and disorganized fashion myocytes “disarray” and fibrosis on biopsy
HOCM
1st line Ix for stable angina?
CT Coronary angio with contrast
What radiotracer is used in PET (Positron Emission Tomography) scans?
FDG - Fluorodeoxyglucose
What radiotracer is used in cardiac SPECT scans?
- used to assess myocardial perfusion and myocardial viability.
technetium (99mTc) sestamibi
What agents can cause stress in myocardium?
exercise or adenosine/ dipyridamole
what is the valvular gradient cut off where patients with aortic stenosis should be considered for surgery?
if valvular gradient >40 mmHg + features such as LV systolic dysfunction
JVP waveform in tricuspid regurgitation?
deep V waves
Causes of a loud S2?
HTN: systemic (loud A2) or Pulmonary (loud P2)
ASD w/o pulm HTN
hyperdynamic states
causes of a soft S2?
aortic stenosis
causes of fixed split s2?
atrial septal defect
Causes of a widely split S2?
Deep inspiration
RBBB
Pulmonary stenosis
severe mitral regurg
Most common causes of viral myocarditis?
Parvovirus B19, HHV 6 now most common
used to be enteroviruses/ coxsackievirus
MOA of fondaparinux?
activates antithrombin III
MOA of dabigatran?
direct thrombin inhibitor
signs of complete heart block on examination?
wide pulse pressure
JVP: cannon a waves
Variable intensity of S1
management of left ventricular aneurysm?
anticoagulation
- as thrombus may form within the aneurysm and increase risk of stroke
management of SVT in asthmatics?
verapamil
prevention of episodes of SVT?
Beta blockers
Radio frequency ablation
Drugs to avoid in HOCM management?
Nitrates, ACEi, inotropes
features of mitral stenosis?
mid-late diastolic murmur
loud S1, opening snap
low volume pulse
malar flush
AF
features of severe mitral stenosis?
length of murmur increases
opening snap becomes closer to S2
CXR features of mitral stenosis?
left atrial enlargement may be seen
Echo findings of mitral stenosis?
- cross sectional area of the mitral valve <1 cm2
1st line managment of Stable angina?
BB OR a CCB
- if CCB used alone: should be rate-limiting, ie. verapamil, diltiazem
- if used TGT: use modified release nifedipine
what medication is contraindicated in ventricular tachycardia?
verapamil
- IV administration of CCB can precipitate cardiac arrest
Causes of myocarditis?
viral: coxsackie B, HIV
bacteria: diphtheria, clostridia
spirochaetes: Lyme disease
protozoa: Chagas’ disease, toxoplasmosis
autoimmune
drugs: doxorubicin
Ix of myocarditis?
Bloods: raised inflammatory markers, troponin, BNP
ECG: tachycardia, arrhythmias, ST/T wave changes including ST-segment elevation and T wave inversion
Management of myocarditis?
tx underlying cause
supportive tx of HF/ arrhythmias
What is the most important factor assoc w risk of sudden death in the first six months after MI?
Presence of new systolic Heart failure
- up to 10x more likely to die
adenosine:
which medications enhance vs reduces the effect?
DEAR
Dipyridamole - enhances
Aminophylline - reduces
Definition for HTN in pregnancy?
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
concurrent use of which drug might make clopidogrel less effective?
PPIs - omeprazole, esomeprazole
*lansoprazole seems okay
genetics of arrhythmogenic right ventricular cardiomyopathy? (ARVC)
Auto dominant
- right ventricular myocardium replaced by fatty and fibrofatty tissue
ECG findings in ARVC (arrhythmogenic RV cardiomyopathy)?
V1-3 abnormalities, typically TWI.
- epsilon wave found in 50% - terminanl notch in QRS complex
Echo findings in ARVC (Arrhythmogenic RV cardiomyopathy)?
may show enlarged, hypokinetic RV with a thin free wall
MRI findings in ARVC (Arrhythmogenic RV cardiomyopathy)?
useful to show fibrofatty tissue
Management of ARVC (arrhythmogenic RV cardiomyopathy)?
sotalol (anti-arrhythmic)
catheter ablation to prevent VT
Implantable Cardioverter-defibrillator
Features of Naxos disease?
- auto recess variant of ARVC
- triad of ARVC + palmoplantar keratosis + woolly hair
2nd line anti-hypertensive for Black african or Afro-Caribbean pt who is already on CCB?
Angiotensin receptor blocker
empirical treatment for native valve infective endocarditis?
IV amoxicillin + gentamicin
-> if pen allergic/ MSRA/ severe spesis: vancomycin + gentamicin
empiric management of infective endocarditis in patients with prosthetic valve?
IV vancomycin + rifampicin + gentamicin
management of native valve endocarditis caused by staphylococcus?
Flucloxacillin
If penicillin allergic or MRSA:
vancomycin + rifampicin
management of
Prosthetic valve endocarditis caused by staphylococci
flucloxaciliin + rifampicin + gentamicin
if Pen allergic/ MSRA:
vancomycin + rifampicin + gentamicin
Management of infective endocardits caused by streptococci?
if fully sensitive Ie. viridans: Benzylpenicllin
If less sensitive: Benzylpenicllin + gentamicin
if MSRA/ pen allergic: vancomycin + gentamicin
Indications for surgery in infective endocarditis?
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
MOA of dipyridamole?
inhibits phosphodiesterase -> elevates platelet cAMP levels -> reduces intracellular calcium lvls
- increases cellular uptake of adneosine
- inhibits thromboxane synthase
MOA of clopidogrel/ ticagrelor?
ADP receptor antagonist
- PGY12 receptor inhibitor
MOA of aspirin?
COX inhibitor
MOA of tirofiban/ abciximab?
gpIIb/IIIa inhibitor
Management of severe mitral stenosis?
percutaneous mitral commissurotomy
ICD + HGV drivers license?
permanent bar
what conditions cause Eisenmenger’s?
VSD
ASD
PDA
note TOF does not cause eisenmengers as it is a R-> L shunt
Type A aortic dissection: what is the target systolic BP
100-120 mmHg
Electrical cardioversion is synchronised to which part of the ECG QRS complex?
R wave
- to minimize the risk of inducing VF
CXR findings of Transposition of great arteries?
“egg on side” or “egg on a string” appearance
ejection systolic murmurs which are louder on inspiration?
atrial septal defect
Pulmonary stenosis
rate limiting agent for AF if coexistent heart failure?
Digoxin
management of INR 5-8, no bleeding?
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
management of INR 5-8, minor bleeding?
stop warfarin
IV Vit K 1-3mg
Restart when INR <5.0
Management of INR >8.0, no bleeding?
Stop warfarin
Vit K 1-5mg PO
Recheck INR after 24h +/- repeat Vit K
Restart when INR <5.0
management of INR >8.0, with minor bleeding?
stop Warfarin
Give Vit K 1-3mg IV
Recheck INR after 24h +/- rpt Vit K
Restart warfarin when INR <5.0
management of major bleeding and high INR?
stop warfarin
give IV Vit K 5mg
Prothrombin complex concentrate +/- FFP
management of uraemic pericarditis?
haemodialysis
Bundle branch blocks/ Hemi blocks: Which side axis deviation?
LBBB = LAD
Left anterior hemiblock = LAD
Left posterior hemiblock = RAD
What types of MI correspond to which side axis deviation?
Inferior MI = LAD
Lateral MI = RAD
Wolff-Parkinson-White: which side accessory pathway corresponds to which side axis deviation?
right sided accessory pathway = LAD
left sided accessory pathway = RAD
hyperkalaemia may cause what side axis deviation?
LAD
ASD, what type corresponds to which type of axis deviation?
ostium primum ASD = LAD
ostium secundum ASD = RAD
features of coarctation of aorta?
infancy: heart failure
adult: HTN
radio-femoral delay
mid systolic murmur, maximal over back
apical click from aortic valve
notching of the inferior border of the ribs (due to collateral vessels) in adults
Coarctation of the aorta associations?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
ECG features of hypokalaemia
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
neprilysin inhibitor, sacubitril
- MOA in heart failure?
prevents the degradation of natriuretic peptides such as BNP and ANP.
BNP acts to promote natriuresis and vasodilation. Atrial stretch leads to the production of ANP which has similar biological properties to BNP.
ANP & BNP are inactivated by a membrane bound endopeptidase, neprilysin.
poor prognostic factors in infective endocarditis?
Staphylococcus aureus infection
prosthetic valve (especially ‘early’, acquired during surgery)
culture negative endocarditis
low complement levels
Jvp: cannon waves?
Regular cannon waves:
- VT (with 1:1 ventricular- atrial conduction)
- AVNRT
irregular:
complete heart block
dilated cardiomyopathy: may be caused by which vitamin deficiency?
selenium
thiamine (wet beri beri)
Histological findings in rheumatic heart disease?
Aschoff bodies (granuloma with giant cells)
Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)
pathogenesis of rheumatic heart disease?
- strep pyogenes infection
- molecular mimicry
- antibodies against M protein cross-react with myosin and smooth muscle of arteries
Diagnosis of rheumatic fever?
Evidence of recent strep infection
(Raised streptococci abs, +ve throat swab, +v strep antigen test)
+
2 major / 1 major + 2 minor criteria
major criteria in rheumatic heart disease?
erythema marginatum
sydenhams chorea
polyarthritis
pancarditis - carditis, valvulitis
subcutaneous nodules
minor criteria of rheumatic fever?
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
management of rheumatic fever?
oral Pen V
NSAIDs 1st line anti-inflammatory
Tx complications
following electrical cardioversion for AF, how long should patients be anticoagulated for if AF onset was more than 48h ago?
At least 4 wks
if there is a high risk of cardioversion failure, what should be given to patients in addition to electrical cardioversion for AF?
At least 4 wks amiodarone or sotalol prior to electrical cardioversion
dental procedures in pts on warfarin - what to do?
check INR 72 hours before procedure, proceed if INR < 4.0
features of eisenmenger’s syndrome
original murmur may disappear
cyanosis
clubbing
right ventricular failure
haemoptysis, embolism
Causes of eruptive xanthoma
Eruptive xanthoma are due to high triglyceride levels and present as multiple red/yellow vesicles on the extensor surfaces (e.g. elbows, knees)
familial hypertriglyceridaemia
lipoprotein lipase deficiency
causes of
Tendon xanthoma, tuberous xanthoma, xanthelasma
familial hypercholesterolaemia
remnant hyperlipidaemia
Management of xanthelasma?
surgical excision
topical trichloroacetic acid
laser therapy
electrodesiccation
Causes of palmar xanthoma?
remnant hyperlipidaemia
may less commonly be seen in familial hypercholesterolaemia
Causes of Aortic regurgitation due to valve disease?
rheumatic fever
infective endocarditis
connective tissue diseases e.g. RA/SLE
bicuspid aortic valve
Causes of aortic regurgitation due to aortic root disease?
aortic dissection
spondylarthropathies (e.g. ankylosing spondylitis)
hypertension
syphilis
Marfan’s, Ehler-Danlos syndrome
What is the main reason for checking the urea and electrolytes prior to commencing a patient on amiodarone?
to detect hypoK.
-> coexistent hypoK significantly increases the risk of arrhythmia
Causes of widely split S2?
- NOTE S2 is caused by closure of Aortic valve followed by pulmonary
deep inspiration
RBBB
pulmonary stenosis
severe mitral regurgitation
Causes of a reversed (paradoxical) split S2 (P2 occurs before A2)?
LBBB
severe aortic stenosis
right ventricular pacing
WPW type B (causes early P2)
patent ductus arteriosus
Cause of fixed split S2?
ASD
features of severe aortic stenosis
narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure
management of patent ductus arteriosus?
indomethacin
Ix of choice for aortic dissection in patients who are too risky to take to CT scanner?
Transoesophageal echo
what medication used in ACS treatment might cause dyspnoea several days after?
Ticagrelor - related dysponea
- transient, generally within 1st wk
- due to impaired clearance of adenosine
Contraindications to prasugrel use?
prior stroke/ TIA
high risk of bleeding
prasugrel hypersensitivity
Contraindications to ticagrelor use?
high risk of bleeding (ie. Prev intracranial haemorrhage, liver dysfunction)
use in caution in asthma/ COPD as higher rates of ticagrelor- assoc dyspnoea
Associations of Ebstein’s Anomaly?
WPW syndrome
PFO or ASD in ~80%
Features of Ebstein’s Anomaly?
cyanosis
prominent A wave in the distended JVP
hepatomegaly
Tricuspid regurg
RBBB -> widely split S1 and S2
causes of ST depression on ECG?
secondary to abnormal QRS (LVH, LBBB, RBBB)
ischaemia
digoxin
hypokalaemia
syndrome X
Stent thrombosis in PCI: what is the biggest risk factor?
withdrawal of antiplatelets
- aspirin indefinitely, length of clopi depends on type of stent, reason for insertion and consultant preference
Risk factors for restenosis post PCI?
- usually in first 3-6 mo due to excessive tissue proliferation around stent
- T2DM
- renal impairment
- stents in venous bypass grafts
Effects of BNP?
vasodilator
diuretic and natriuretic
suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
PCI: drug eluting stents
- effect on duration of clopidogrel therapy?
drug-eluting stents-> require a longer duration of clopi
as restenosis rates are reduced, but stent thrombosis rates are increased with drug eluting stents
What is the most accurate investigation to measure LV function?
MUGA
Multi Gated Acquisition Scan,
aka radionuclide angiography
SE of nicorandil?
headache
flushing
skin, mucosal and eye ulceration
gastrointestinal ulcers including anal ulceration
Contraindication of nicorandil?
LVF
In TIA secondary to AF, when to start anticoagulation?
CT head to rule out cerbreal haemorrhage/ infarct
-> start anticoagulation therapy asap
Heart failure + driving?
if symptomatic -> NO group 2 license
if on asymptomatic, LVEF<40% -> NO group 2 license
group 1 license okay
What investigations are most useful in predicting symptomatic response to cardiac resynchronisation therapy?
TTE and ECG
- Those with LVEF <35% and a LBBB (QRS duration greater than 120 ms) on ECG are excellent candidates for CRT (biventricular pacing).
- The echo will show asynchronous contraction of the LV and RV and subsequently reduced ejection fraction.
thiazide diuretics: what common adverse effects?
dehydration, postural hypotension
hypoNa, hypoK, hyperCa*
gout
impaired glucose tolerance
impotence
thiazide diuretics: rare side effects?
thrombocytopaenia
agranulocytosis
photosensitivity rash
pancreatitis
Where is the most common site for primary cardiac tumours to occur in adults?
at the fossa ovalis border in the left atrium
congenital heart defects associated with a bicuspid aortic valve
coarctation of the aorta
features of bicuspid aortic valve?
- eventually -> AS/ AR
- assoc w left dominant coronary circulation (the posterior descending artery arises from the circumflex instead of the RCA) and Turner’s syndrome
- 5% have coarctation of aorta
Complications of Bicuspid aortic valve
aortic stenosis/ regurgitation
higher risk for aortic dissection and aneurysm formation of the ascending aorta
What is the most important ECG change to monitor for in Infective endocarditis of aortic valve?
prolonged PR interval - aortic root abscess
classical presentation of pulmonary hypertension
progressive exertional dyspnoea
when to start statin?
- ALL with cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
- 10 year QRISK >=10%
- T1DM + diagnosed more than 10 yrs ago OR >40 OR established nephropathy
RF for myopathy with statins?
advanced age, female sex, low BMI and presence of multisystem disease such as diabetes mellitus.
- more common with simvastatin/ atorvastatin
What should be monitored while on IV MgSo4 for pre-eclampsia?
urine output, reflexes, Resp rate, oxygen sats
- resp depression can occur
1st line mx of Respiratory depression secondary to IV MgSO4
Calcium. gluconate
pathophysiology of cholesterol embolisation?
cholesterol emboli may break off causing renal disease
the majority of cases are secondary to vascular surgery or angiography. Other causes include severe atherosclerosis, particularly in large arteries such as the aorta
BP target in age <80
Clinic: 140/90
ABPM/HBPM: 135/85
BP target in age> 80
clinic: 150/90
ABPM/ HBPM: 145/ 85
features of cardiac syndrome X?
angina-like chest pain on exertion
ST depression on exercise stress test
but normal coronary arteries on angiography
Management of syndrome X?
nitrates may be beneficial
ostium secundum ASD - ECG findings?
RBBB w RAD
ostium primum ASD - ECG findings?
RBBB with LAD, prolonged PR
Rate control in AF?
Beta blockers
CCB
Digoxin - preferred choice if there is coexistent heart failure
Bleeding on rivaroxaban/ apixaban?
Andexenet alfa - recombinant form of fXa
Bleeding on Dabigatran?
idarucizumab
- binds and inactivates dabigatran
JVP waveform - what corresponds to closing of the tricuspid valve?
c wave
JVP waveform - what corresponds to opening of the tricuspid valve?
y descent
half life
why is a loading dose used with amiodarone?
very long half life (20-100 days)
Why does amiodarone have proarrhythmic effects?
lengthens QT interval
Main MOA of amiodarone?
block K+ channels which inhibits repolarisation -> prolongs action potential
Which part of the jugular venous waveform is associated with the fall in atrial pressure during ventricular systole?
x descent
time frame for primary PCI in STEMI?
should be within 2 hours
if not, deliver thrombolysis within 12h onset of symptoms
What medications should be given during PCI with radial access?
unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor (e.g. tirofiban)
Drug therapy during PCI with femoral access?
bivalirudin (thrombin inhibitor)
with bailout glycoprotein IIb/IIIa inhibitor (e.g. tirofiban)
-
Normal oxygen saturation levels in right atrium (RA), right ventricle (RV) and pulmonary artery (PA)
~70%
normal oxygenation levels in left atrium (LA), left ventricle (LV) and aorta
98-100%
Management of warfarinised patient undergoing emergency surgery?
give four-factor prothrombin complex concentrate 25-50 units/kg
Management of warfarinised patient if surgery can wait 6-8 hours?
5mg Vit K IV
Features suggesting VT rather than SVT with aberrant conduction
AV dissociation
fusion or capture beats
positive QRS concordance in chest leads
marked left axis deviation
history of IHD
lack of response to adenosine or carotid sinus massage
QRS > 160 ms
mx of WPW + AF?
flecainide / procainamide
what cardiac enzyme rises first post MI?
myoglobin
- rises 1-2h post MI
what cardiac enzyme is most useful to look for reinfarction?
CK-MB
- returns to normal after 2-3 days
curative management of Atrial flutter?
radiofrequency ablation of the tricuspid valve isthmus is curative for most
ASD murmur?
ejection systolic murmur louder on inspiration
Associations of Aortic Dissection?
hypertension: the most important risk factor
trauma
bicuspid aortic valve
collagens: Marfan’s syndrome, Ehlers-Danlos syndrome
Turner’s and Noonan’s syndrome
pregnancy
syphilis
what medication should be avoided in the likely diagnosis of right ventricular myocardial infarct
nitrates
- due to their peripheral venodilatory effects, which would reduce right ventricular filling and thus preload.
- responsible for severe drops in systolic blood pressure and exacerbation of symptoms
what is catecholaminergic polymorphic VT? (CPVT)
- genetics
inherited cardiac disease assoc w sudden cardiac death
- auto dominant
- defect in RYR2 (ryanodine) receptor which is found in the muocardial sarcoplasmic reticulum - most common cause
features of Catecholaminergic polymorphic ventricular tachycardia
exercise or emotion induced polymorphic VT resulting in syncope
sudden cardiac death
symptoms generally develop
management of Catecholaminergic polymorphic ventricular tachycardia
Beta blockers
Implantable cardioverter-defibrillator
what gene abnormality is seen in Brugada syndrome?
20-40% mutation in SCN5A gene -> encodes the myocardial sodium ion channel protein
Management of Prinzmetal angina?
dihydropyridine calcium channel blocker e.g. felodipine
what channel is affected in Long QT syndrome?
usually due to blockage of K+ channels
If high-risk of failure of cardioversion (previous failure), offer electrical cardioversion after at least 4 weeks treatment with…?
amiodarone
Contraindications of Exercise tolerance test?
MI less than 7 days ago
unstable angina
uncontrolled hypertension (systolic BP > 180 mmHg) or hypotension (systolic BP < 90 mmHg)
aortic stenosis
LBBB
MOA of Nicorandil
- vasodilatory drug used to treat angina
- K+ channel activatior
- activation of guanylyl cyclase which results in increased cGMP
features of carcinoid heart disease?
- assoc Tricuspid stenosis / regurg
+ pulmonary stenosis/ regurg
Features of supravalvular aortic stenosis?
- narrowing usually found just beyond the origin of left subclavian artery
- HTN in arms, weak femoral pulses
- Difference in carotid pulsation/ arm BP measurements
- murmur of aortic stenosis may be present
Tuboeruptive xanthomas
Type III hyperlipoproteinaemia
- high numbers of chylomicrons and high intermediate density lipoprotein
- high VLDL
- assoc w Hypercholesterolaemia, hypertriglyceridaemia, normal [apoprotein B]
- assoc palmar xanthomata/ orange discoloration of skin creases
- tuberoeruptive xanthomata on elbows/ knees
eruptive xanthomas
type I and type IV hyperlipoproteinaemia
Loud S1 / opening snap in mitral stenosis is due to?
mobile leaflets of mitral valve
- high left atrial pressure causes snap
most likely lipid abnormality in asian man?
low HDL/ high triglycerides
- measurement of LDL alone may underestimate their CV risk
palmar crease xanthomas?
type III hyperlipidaemia
- aka broad beta disease
what type of cell receptor does adenosine act on?
G protein coupled receptor agonist of the adenosine A1 receptor
Absolute contraindications to carotid sinus massage?
Carotid artery occlusion / atherosclerosis
MI
TIA in last 3 mo
CVA in last 3 mo
Prev ventricular arrhythmia
Features of carotid sinus hypersensitivity?
- cardioinhibitory: cardiac asystole >3s
- vasodepressor: systolic BP drop >50 mmHg
- AV block: some form of ventricular +/- atrial pacing generally required
Most likely cause of STEMI in young lady with no conventional risk factors for coronary artery disease, just after giving birth?
Coronary artery dissection
- well recognised cause of MI in relation to pregnancy
Sinus bradycardia management in heart transplant patient?
IV theophylline - atropine CI bc hearts of heart transplant patients are denervated and do not respond to vagal blockade by atropine, which might precipitate paradoxical sinus arrest of high-grade block
What is the most reliable indicator of prognosis at 72 hours post-arrest?
lack of pupillary light or corneal reflex at 72 hours = reliable predictor of death.
Ventricular tachycardia: what drug therapy has to be used in caution with severe Left ventricular impairment?
Lidocaine
Brugada syndrome: what medications make the ECG changes more apparent?
flecainide or ajmaline
management of symptomatic trifascicular block with pre-syncope or syncope on exertion?
pacemaker
Dextrocardia: associated ECG changes?
inverted P wave in lead I, right axis deviation, and loss of R wave progression
What is the criteria for starting ivabradine in HF patients as a third line?
HR >75 And LVEF <35%
In what population is hydralazine and nitrate most indicated for third line treatment in HF?
Afro Caribbean patients
Digoxin use in cardiac amyloidosis?
higher risk of digoxin toxicity, as the drug binds avidly to amyloid fibril
most sensitive investigation for diagnosing myopericarditis?
Cardiac MRI
Mitral valve gradient calculation?
capillary wedge pressure (same as the left atrial pressure) MINUS diastolic left ventricular pressure
Normal mitral valve gradient?
5 mmHg If >5, suggests mitral stenosis
Aortic dissection: Indications for endovascular stenting ?
- Rapidly expanding dissections (>1cm per year) - Critical diameter (>5.5cm) - Refractory pain - Malperfusion syndrome - Blunt chest trauma - Penetrating aortic ulcers
Pacemaker: Increasing the pacing output?
when there is insufficient capture (the pacing spikes are not at a sufficient voltage to elicit a corresponding QRS complex)
Pacemaker: increase of pacing sensitivity?
increases the voltage required to inhibit the pacemaker > helpful if the pacemaker was being inappropriately inhibited (potentially by noise)
Pacemaker: reduction in the pacing output?
to preserve the pacemaker’s battery life > the lowest output required to safely and reliably achieve capture should be used at all times
Pacemaker: Reducing the pacing sensitivity?
reduces the voltage required to inhibit the pacemaker > if the patient’s native rhythm was faster than the rate of the pacemaker but was still not inhibiting the pacemaker from firing
Accelerated idioventricular rhythm: what is this?
benign ectopic rhythm of ventricular origin > usually following the reperfusion of an ischaemic myocardium > 50-110 bpm, which helps differentiate it from ventricular bradycardia or ventricular tachycardia
Treatment of Accelerated idioventricular rhythm?
usually self-limiting > occasionally atropine can be used to increase the sinus rate to overcome AIVR
Normal ecg variants in athletes?
- sinus bradycardia - junctional rhythm - first degree heart block - Mobitz type 1 (Wenckebach phenomenon)
What scan can help to look for phaeochromocytoma?
MIBG scan - radioactive iodine as a tracer for phaeochromocytoma tumour cells, then use a gamma camera to look
Management of symptomatic HOCM despite mono therapy with BB/ CCb?
disopyramide - a negative inotropic 1a anti-arrhythmic that demonstrated a significant decrease of LVOT gradients and mortality when compared to placebo
Oxygen saturations in SVC vs IVC?
Should always be lower in SVC due to higher oxygen demand in the brain > if SVC oxygen sats higher than IVC, might demonstrate a left to right shunt
