Cardiology Conditions Flashcards
1
Q
In which leads would you see an inferior MI?
A
II , III and aVF
2
Q
In which leads would you see a septal MI?
A
V1 and V2
3
Q
In which leads would you see a lateral MI?
A
V5, V6 and I
4
Q
In which leads would you see a anterior MI?
A
V3 and V4, aVR and aVL
5
Q
what are the tree stages of atherosclerosis?
A
Fatty streaks, Intermediate lesions, Fibrous plaque and rupture
6
Q
What are RF for atherosclerosis?
A
age, smoking, high cholesterol, obesity, diabetes, HTN, family history
7
Q
What happens in fatty streaks?
A
appear very early, aggregations of lipid laden macrophages and T-lymphocytes in intimal layer
8
Q
What happens in intermediate lesions?
A
layers of foam cells, t lymphocytes and smooth muscle cells, platelets start to adhere to vessel wall
9
Q
What happens in fibrous plaques?
A
Lesion is covered by dense fibrous cap that impedes flow and is prone to rupture
10
Q
what is the Qrisk2?
A
Risk of developing CVD in the next 10 years
11
Q
What is prinzmetal’s angina?
A
angina due to a coronary artery spasm
12
Q
What is decubitus angina?
A
angina occurring when laying down
13
Q
What is angina pectoralis?
A
chest pain or discomfort arising from the heart as a result of ischaemia
14
Q
What is stable angina?
A
chest pain exacerbated when exercising
15
Q
what are three criteria for typical angina?
A
central radiating chest pain, precipitated precipitated by exertion and relieved by rest of GTN spray
16
Q
What does angina present with?
A
chest pain induced by effort and relieved by rest, dyspnoea, palpitations and syncope
17
Q
what tests do you order for stable angina?
A
12 lead ECG (usually normal), CT angiography (shows narrowing), FBC and Cxr
18
Q
How do you treat stable angina?
A
lifestyle changes, gtn spray and PCI or CABG
19
Q
What is unstable angina?
A
crushing chest pain at rest
20
Q
How do you test for unstable angina?
A
FBC, cardiac enzymes, ECG (ST depression) and CT angiogram
21
Q
How do you treat unstable angina initially?
A
aspirin and fondaparinux
22
Q
what is the mechanism of fondaparinux?
A
indirect inhibitor of factor Xa
23
Q
If you established low risk for a MI what do you do?
A
no angiography, ticagrelor and aspirin or clopidogrel and aspirin (high bleeding risk)
24
Q
if you established high risk what do you do?
A
angiography within 72 hours, prasugrel (if PCI) or ticagrelor or clopidogrel with aspirin
25
What are complications of unstable angina?
DARTH VADER: death, arrhythmia, renal failure, tamponade, HF, valve disease, aneurism, dressler's syndrome, embolism and reoccurrence
26
What is dressler's syndrome?
pericarditis following an MI (1-6 weeks)
27
What is the pathology of acute coronary syndromes?
rupture or plaque erosion with subsequent clot formation and vasoconstriction
28
What are the types of MI?
1: spontaneous due to primary coronary event
2: secondary due to increased demand or decreased supply of oxygen
29
What is a STEMI?
necrosis of cardiac tissue due to complete occlusion
30
What are RF for a STEMI?
age, male, CHD, HTN, hyperlipidaemia, family history
31
How does a STEMI present?
crushing central chest pain, sweating, SoB, fatigue, nausea, vomiting
occurs at rest, not relieved by GTN, longer than 20 min, 4th heart sound, pansystolic murmur
32
What tests do you order for a STEMI?
ECG (ST elevlation, tall T waves, LBBB, Q waves follow (evidence of previous infarction)), cardiac markers, CT angiography, FBC
33
How do you treat a STEMI initially?
MONA: morphine, oxygen (if under 94), nitrates, fondaparinux and aspirin
34
Within what time frame can you do reperfusion therapy?
12 hours
35
What do you give if you are performing a PCI?
pasugrel with aspirin
36
What do you do if you cannot deliver PCI within 120 minutes?
Fibrinolysis (IV alteplase) and aspirin with ticagrelor/clopidogrel
37
What is ticagrelor and clopidogrel?
Antiplatelet: P2Y12 receptor antagonist (ADP cannot bind and glycoprotein 2b/3a is not activated)
38
What is secondary prevention for STEMI?
ACEi: ramipril
BB: atenolol or bisoprolol
statin: atorvastatin
dual anti platelet therapy
39
What is a NSTEMI?
complete occlusion of a minor artery or partial of a major
40
How do you test for a NSTEMI?
ECG (St depression and T wave inversion), cardiac enzymes (troponin rise (3-12 hours) or fall)
41
How do you treat a NSTEMI?
initial aspirin and fondaparinux (antithrombin)
- Establish high or low risk with GRACE score (6 month mortality), troponin and ECG
- low risk: no angiography, ticagrelor and aspirin or clopidogrel and aspirin (high bleeding risk), assess LV function
- high risk: angiography within 72 hours, prasugrel (if PCI) or ticagrelor or clopidogrel with aspirin, assess LV function
42
What is the tetralogy of fallot?
ventricular septal defect, enlarged aorta, Left ventricle hypertrophy and pulmonary stenosis
43
What is a true aneurism?
dilations involve all layers of arterial wall
44
What is a false aneurism?
outer layer (adventitia) only
45
when do you speak of a AAA?
aortic diameter over 3 cm
46
What are some RF or aetiology of AAA?
Fhx, smoking, male, increasing age, HTN, COPD, trauma and atherosclerotic damage
47
How does an unruptured AAA present?
asymptomatic, pain in abdomen, vague pulsatile abdominal swelling
48
How does a ruptured AA present?
intermittent or continuous abdominal pain, pulsatile swelling, collapse, hypotension, tachycardia
49
How do you test for a AAA?
ultrasound, CT and MRI angiography
50
How do you treat a AAA?
below 5.5 cm: monitor
| above: surgical repair
51
What is a thoracic abdominal aneurism?
if aorta reaches crucial diameter (6 or 7 cm) is looses distensibility and raise in BP can trigger dissection or rupture
52
What is aortic dissection?
medical emergency that begins with a tear in the intima. Blood then penetrates and flows between layers which forces lasers apart (false lumen) and results in dissection
53
How does aortic dissection present?
sudden onset of severe and central chest pain (mimics MI), pain is described as tearing, HTN, may develop neurological symptoms
54
How do you confirm a diagnosis of dissection?
transoesophageal echo
55
How do you treat aortic dissection?
IV metoprolol (BB) if hypertensive, analgesia, surgery to replace arch
56
What is a shock?
acute circulatory failure with inadequate perfusion resulting in hypoxia
57
How do you recognise shock?
pale, cold and sweaty skin
weak and rapid pulse
confusion, weakness, collapse and coma
58
What are different types of shock?
hypovolaemic, cariogenic (heart is not pumping), anaemic, cytotoxic, septic, anaphylactic
59
What is peripheral vascular disease?
Partial blockage of leg or peripheral vessels by an atherosclerotic plaque and/or thrombus resulting in insuffucient perfusion and ischaemia
60
What are RF for PVD?
smoking, diabetes, HTN, obesity, inactivity
61
How does PVD present?
claudication (pain) when exercising, ulcers that aren't healing, colour changes (elevation pallor and dependent rubor)
can progress to rest pain when legs are elevated and relieved then leg is lowered
62
How to you test for PVD and what do you expect?
Bruit sound when asculation, doppler ultrasound, ankle brachial index below 0.9
63
How do you treat PVD?
Treat with lifestyle changes, revascularistaion for critical ischaemia
64
What is mitral stenosis?
Narrowing of mitral valve
65
What causes mitral stenosis?
rheumatic fever, annular calcification, congenital
66
How does mitral stenosis present?
Symptoms when area is less than 2cm: exertion dyspnoea, haemoptysis, palpitations, chest pains, malar flush, a fib
67
What heart sounds do you expect in mitral stenosis?
mid diastolic murmur with opening snap (expiration and lying on left side) and loud S1
68
What tests do you order for mitral stenosis?
CXR, ECG and echo (gs)
69
How do you treat mitral stenosis?
percutaneous mitral ballon valvotomy, replacement
70
What is mitral regurgitation?
Mitral valve doesn't shut completely
71
What causes mitral regurgitation?
papillary muscle rupture or dysfunction, mitral valve prolapse, rheumatic heart disease, infective endocarditis
72
What are RF for mitral regurgitation?
low BMI, females, age, previous MI
73
How does mitral regurgitation present?
palpitations, fatigue, weakness, a fib, displaced apex
74
What type of murmur do you hear in mitral regurgitation?
pan systolic, sort or absent S1
75
What tests do you order for mitral regurgitation?
ECG, cxr and echo
76
How do you treat mitral regurgitation?
ACEi, control a fib with BB+CCB+digoxin, diuretics for fluid overload, serial echo
- symptoms at least or asymptomatic with ejection fracture below 60% means surgery
77
What is aortic stenosis?
Narrowing of aortic valve?
78
What causes aortic stenosis?
calcification, congenital bicuspid valve and rheumatic heart disease
79
How does aortic stenosis present?
triad of syncope, angina and dyspnoea
| sustained heaving apex, slow rising pulse, narrow pulse pressure
80
What murmur do you hear in aortic stenosis?
ejection systolic murmur
81
How do you treat aortic stenosis?
regular dental care and valve replacement
vasodilators are contraindicated
82
What is aortic regurgitation?
aortic valve doesn't fully shut
83
What causes aortic regurgitation?
aortic dissection and infective endocarditis in acute disease, rheumatic HD and connective tissue disorders
84
How does aortic regurgitation present?
Can be asymptomatic for years and then palpitations, angina and dyspnoea, wide pulse pressure and displaced apex
Corrigan’s sign (carotid pupation)
De musset’s sign (head nodding with heart beat), Quincke’s sign (capillary pulsation in nail bed
85
What murmur do you hear in aortic regurgitation?
early diastolic murmur (expiration and sat forward)
86
What do you see on an ECG in aortic regurgitation?
tall R waves, inverted t waves in left leads
87
How do you treat aortic regurgitation?
Treat with vasodilator if symptomatic and surgery if heart is enlarged or deterioration
88
What is infective endocarditis?
Infection of inner lining of the heart and valves
89
What causes infective endocarditis?
staph. aureus, strep. viridans (mouth or oral surgery) and staph. epidermis (prosthetic valve)
90
How does infective endocarditis present?
signs of infection, splinter haemorrhages, osler nodes (fingers), Janeway lesions (nodules on palms), roth spots (haemorrhage with clear centre on fundoscopy)
91
How do you investigate infective endocarditis?
Echo
92
What are modified duke's criteria?
blood cultures positive (2 separate ones), evidence of endocardial involvement (regurgitation or echo positive)
93
How do you treat infective endocarditis?
treat with antibiotics for 4-6 weeks
1st line: FAG fluoxacillin, ampicillin, gentamicin
staph aureus: flucloxacillin, rifampicin, gentamicin
MRSA: vancomycin, rifampicin, gentamicin
not staph: benzylpenicillin and gentamicin
94
What is pericarditis?
Inflammation of pericardium
95
What causes pericarditis?
ideopathic, infection (HIV, echovirus, coxsackie B), trauma
96
How does pericarditis present?
chest pain (relieved when leaning forward and worsened by inspiration), fever, pericardial friction rub
97
What tests do you order for pericarditis and what do you expect?
ECG (saddle shaped ST elevation, PR depression) and echo
98
How do you treat pericarditis?
NSAIDS and colchicine
99
What is cardiac tamponade?
accumulation of fluid in pericardial space, compression of chambers
100
How does a cardiac tamponade present?
Beck’s triad: falling BP, rising JVP and muffled heart sounds
101
How do you treat a cardiac tamponade?
pericardiocentesis
102
What is sinus arrhythmia and how does it present?
fluctuations in autonomic tone lead to changes in sinus discharge rate
inspiration: parasympathetic tone falls and HR quickens
expiration: parasympathetic tone increases and HR slows
103
What is atrial fibrillation?
chaotic irregular atrial rhythm at 300-600 bpm with the AV node responding intermittently causing an irregular ventricular rate
104
What are the different types of A.fib?
- acute: within 48 hours
- paroxysmal: stops spontaneously within 7 days
- recurrent: 2 or more episodes
- persistent: continuous for more than 7 days and not self terminating
- permanent
105
What causes A.fib?
includes idiopathic, HTN, HF, CAD, valvular heart disease (mitral stenosis)
anything resulting in raised atrial pressure, atrial muscle mass, atrial fibrosis or inflammation
106
What are RF for A.fib?
older than 60, diabetes, HTN, CAD, prior MI, structural heart disease
107
How does A.fib present?
variable symptoms (sometimes asymptomatic): palpations, dyspnoea, fatigue
108
What will you see in A.fib on the ECG?
absent P waves and irregular and rapid QRS
109
How do you treat acute A.fib?
treat provoking cause, cardioversion with defibrillator (give enoxaparin with it)
if that fails give amiodarone
ventricular rate control by blocking AV node: CCB, BB, digoxin and amiodarone
110
what are the two strategies for LT a.fib control?
Rate control: BB, CCB and if that fails digoxin then amiodarone
Rhythm control: BB, warfarin and flecainide (or amiodarone if structural heart defect)
111
What do you use to calculate stroke risk after a.fib and how do you act upon result?
CHA2DS2VASc:
congestive HF, HTN, 75 or over, diabetes, stroke, vascular disease, 65-74 years, female
- 1: consider anticoagulation
- 2 and above: anticoagulation needed
112
What is atrial flutter?
organised atrial rhythm with atrial rate between 250 and 350 bpm
113
What causes atrial flutter?
idiopathic, CHD, obesity, HTN, HF, COPD, pericarditis and excess alcohol
114
How does atrial flutter present?
palpitations, breathlessness, chest pain, dizziness, syncope and fatigue
115
What do you see on an ECG in atrial flutter?
regular f waves (saw tooth flutter) between QRS complexes
If F waves not visible, they can be unmasked by slowing AV conduction through IV adenosine
116
How do you treat atrial flutter?
electrical cardioversion (enoxaparin before if acute), catheter ablation or IV amiodarone with BB
117
Where is an atrioventricular heart block located?
block in AV node or bundle of his
118
What are the types of AV block?
First degree, Mobitz I, Mobitz II and 3rd degree
119
What causes first degree HB?
hyperkalaemia, myocarditis, inferior MI and AV node blocking drugs (BB, CCB and digoxin)
120
Describe the ECG of a first degree HB
prolongation of PR interval to more than 0.22 but every atrial polarisation is followed by QRS complex
121
How do you treat 1st degree block?
Asymptomatic so no treatment
122
What causes Mobitz I block?
AV node blocking drugs and inferior MI
123
How does a Mobitz I block present?
dizziness, light headed and syncope
124
Describe the ECG of Mobitz I block
progressive PR prolongation until P wave fails to conduct. then starts again with PR prolonging until dropping QRS
125
How do you treat Mobitz I block?
only needs a pacemaker if poorly tolerated
126
What causes a Mobitz II block?
anterior MI, SLE, rheumatic fever or mitral valve surgery
127
How does Mobitz II present?
shortness of breath, postural hypotension and chest pain
128
Describe the PCR of Mobitz II
PR interval constant and QRS is dropped occasionally
129
How do you treat Mobitz II?
Pacemaker
130
What is a third degree heart block?
Complete block and P waves are fully independent from QRS complex
131
What causes 3rd degree block?
structural HD, CHD, HTN and endocarditis
132
What is a narrow complex escape rhythm in 3rd degree block and how do you treat it?
QRS is less than 0.12 seconds: originates in bundle and can respond to atropine if acute or requires pacemaker if chronic
133
What is a broad complex escape rhythm in 3rd degree block and how do you treat it?
more then 0.12 sec: block is below bundle and permanent pacemaker is needed
134
What is a bundle branch block?
block lower in conduction system
135
How does BBB present?
usually asymptomatic
136
How can you tell between a complete and incomplete BBB?
- incomplete block: slight widening of QRS
| - complete block: wider QRS
137
What is a RBBB?
late activation of right ventricle
138
What is a LBBB?
late activation of left ventricle
139
What causes a RBBB?
PE, CHD, atrial or ventricular septal defect
140
What causes a LBBB?
CHD and aortic valve disease
141
Describe the ECG of a RBBB
(maRRow) deep S wave in I and V6, tall late R wave in V1, QRS looks like an M in V1 and W in V5 and 6
142
Describe the ECG of a LBBB
abnormal QRS waves, (William) W in leads V1,2 and M in leads V4-6
143
What do you hear in RBBB?
wide splitting of S2
144
What do you hear in LBBB?
reverse splitting of S2: splitting heard in expiration and not inspiration
145
What are the two types of Supraventricular tachycardia?
Atrioventricular nodal re-entrant tachycardia (AVNRT) and Atrioventricular re-entrant tachycardia (AVRT)
146
Where does a supraventricular arise?
arises from atria or atrioventricular junction
147
How do you treat SVT?
1. emergency cardioversion if haemodynamically unstable
2. once stable then vagal manoeuvres: hold breath, carotid massage and valsalva manoeuvre (abrupt increase in pressure by straining)
3. if unsuccessful then IV adenosine
148
What is AVNRT?
accessory pathways is used to stimulate AV node rather than the usual slow pathway resulting in not having to wait for depolarisation
149
What are RF for AVNRT?
exertion, emotional stress, coffee, tea and alcohol
150
How does AVNRT present?
brupt onset palpitations with sudden termination, chest pain, breathlessness, neck pulsations (JV), polyuria
151
What does an ECG with AVRNT look like?
no visible P waves or normal
152
What is AVRT?
atrial activation after ventricular activation
153
Give an example of AVRT
Wolff-parkinson-White syndrome
154
How does AVRT present?
palpitations, severe dizziness and syncope
155
What does a ECG with AVRT look like?
short PR, wide QRS with slurred start
156
What is ventricular ectopy?
Type of ventricular tachycardia: premature ventricular contraction
157
How does ventricular ectopy present?
Commonly post MI: usually asymptomatic but can present with irregular pulse, faint and dizziness
158
Describe an ECG with ventricular ectopy
widened QRS complex (0.12)
159
How do you treat ectopy?
beta blocker
160
What is prolonged QT syndrome?
Type of ventricular tachycardia: OT interval greatly prolonged
161
What is HTN?
140/90 on at least two readings on separate occasions
162
What are two types of HTN?
- primary/essential: 95%
| - secondary: CKD, drugs, acromegaly
163
What are RF for HTN?
family history, age, male, obesity, lack of exercise
164
How does HTN present?
Asymptomatic presentation except in malignant, occasional headache
165
What is malignant HTN?
rapid rise leading to vascular damage (180/110 and bilateral renal haemorrhage)
166
How do you treat malignant HTN?
sodium nitroprusside
167
How do you decide whether to treat HTN?
If BP classifies as high then confirm using ABPM (or multiple measurements)
- below 135/85: no treatment
- 135/85 (stage 1): lifestyle advice, consider drug treatment in over 80, under 80 with organ damage/CVD/renal disease/diabetes, high QRISK
- 150/95 (stage 2): lifestyle advice and drug treatment
168
How do you treat HTN?
1. diabetes or white under 55: ACE or ARB (ramipril), 2nd CCB (amlodipine), 3rd thiazide diuretic (bendroflumethiazide)
2. over 55 or black: CCB, 2nd ACE or ARB, 3rd thiazide diuretic
169
What is HF?
clinical syndrome where breathlessness, fluid retention and fatigue are associated with cardiac abnormality that reduces CO
170
What are the two types of HF and what causes them?
- systolic: failure to contract (MI, CHD, HTN)
| - diastolic: inability to relax (pericarditis, HTN, tamponade)
171
What are two compensation mechanisms leading to HF and how do they work?
1. adrenergic activation: vasoconstriction causes increased afterload and increased HR. HR increases cardiac work and both lead to damage and decreased CO
2. renin angiotensin activation: salt and water retention leading to increased preload therefore increased work therefore damage and decreased CO
172
What causes HF?
CHD, HTN, dilated and hypertrophic cardiomyopathy, aortic stenosis, congenital heart disease, factors increasing work
173
What are RF for HF?
previous MI, male, obesity, age
174
What causes left HF?
HTN and cardiomyopathy
175
What causes right HF?
caused by LV failure, pulmonary stenosis, cor pulmonale, shunts
176
How does left HF present?
3 and 4 sounds, cardiomegaly, pulmonary oedema, cool peripheries, weight loss
177
How does right HF present?
raised JVP, hepatomegaly, pitting oedema, ascites, weight gain
178
What tests do you order for HF and what will have increased?
CXR, ECG and FBC
| brain natriuretic peptide increased
179
What do you see on an xray with HF?
ABCDE: alveolar oedema, kerley B lines, cardiomegaly, dilated upper vessels, effusions
180
How do you treat acute HF?
OMFG: oxygen, GTN spray, IV opiates, IV furosemide
181
How do you treat chronic HF?
lifestyle improvement and AABCDD:
- 1st: ACE and BB
- 2nd ARB and nitrate
- 3rd: cardiac resynchronisation or digoxin
- diuretics: furosemide
