Cardiology COPY Flashcards

Question

What to keep in mind about Troponin?

Answer 1

It has high sensitivity (can be detected easily even at very low levels) but low specificty to MI (other conditions e.g. acute HF, Myocarditis, pericarditis, PE, renal failure & sepsis)

Answer 2

Full thickness (transmural) infarction. No Q wave= subendocardial infarction

Answer 3

ST-Elevation of \>/ 1mm in limb leads or \>/2mm in 2 adjacent chest leads OR new LBBB in the context of cardiac sounding chest pain (ST segments cannot be meaningfully assessed if LBBB. (not all new LBBB=acute coronary occlusion)

Answer 4

ST depression, T wave inversion, Flat T waves, pseudonormalisation of T waves, no ECG changes!

Answer 5

MONAC: IV Morphine 2.5mg bolus + IV metoclopramide, O2 if deSat \<94% or \<88-92% in COPD, Nitrates sublingually, Aspirin (300mg STAT) + Dual antiplatelet loading dose (clopidogrel 300mg STAT or ticagrelor 180mg STAT) Continious cardiac monitoring & Coronary Artery unit.

Answer 6

A-ACE Inhibitor: Ramipril 1.25mg OD (CI= Renal failure of BP S \<90mmHg.) B- B-Blocker: Bisoprolol 2.5mg OD C- Cholestrole lowering: Atorvastatin 80mg. D-Dual antiplatelet therapy: Aspirin for life 75mg +Clopidogrel 75mg OD/Ticagrelor 90mg BD for at least 1 year. E-Echo: to assess Left ventricle & HF signs. G-Gastroprotection: Lansoprazole 30mg OD G-Glucose= keep b/w 4-11mmol/L (Start IV insulin if \>11)

Answer 7

Driving: 1-week after angioplasty. 4-weeks if no angioplasty. Sexual intercourse- 1 week (inc. physical exercise). Air travel- 2 months.

Answer 8

Sudden Death (VT or VF), P- Pump failure or Pericarditis R-Rupture (LV free wall, septum or papillary m.-MR) A-Aneurysm or Arrhythmia E-Embolism (ischemic leg or stroke) D-Dressler Syndrome

Answer 9

CK-MB biomarker: useful in detecting reinfarction upto 36hours because when level drop after MI then Increase again it could mean a second infarction while Troponin takes 14 days to normalise.

Answer 10

A-Causes: 1- Atheroscleorosis 2- Aortic Stenosis =LVH (to compensate O2 demand) Worsens-Anaemia, HCM, Tachyarrhythmias. So basically: mismatch b/w O2 supply and demand→ Myocardial Ischemia. B- 1. constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms \<15mins 2. precipitated by physical exertion 3. relieved by rest or GTN in about 5 minutes patients with all 3 features have typical angina patients with 2 of the above features have atypical angina patients with 1 or none of the above features have non-anginal chest pain

Answer 11

Diagnosis is often clinical. For patients in whom stable angina cannot be excluded by clinical assessment alone NICE recommend the following (e.g. symptoms consistent with typical/atypical angina OR ECG changes): 1st line: CT coronary angiography 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia) 3rd line: invasive coronary angiography Non-invasive Ix examples: myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or stress echocardiography or first-pass contrast-enhanced magnetic resonance (MR) perfusion or MR imaging for stress-induced wall motion abnormalities

Answer 12

Management: Lifestyle changes, Medication, Percutaneous Coronary Intervention & Surgery. ① Medication→ _1-All patients receive_ **Aspirin**, **Statin** (esp. if total cholesterol \>4mmol/l) and **Sublingual GTN or Spray** (Glyceryl Trinitrate) for pain symptom. 2-First line: Either **Beta-Blocker** or **Calcium Channel Blocker** (*monotherapy* rate limiting ones) e.g. Verapamil or Diltiazem \*NEVER PRESCRIBE VERAPAMIL + B-BLOCKER= Complete Heart Block If poor response to first-line then *titrate medication to max-tolerated* e.g. Atenolol 100mg od Second-line: if titration doesn’t work then: *Combination therapy* of **B-Blocker and CCB L-Type**= long-acting modified release dihydropyridine e.g. Nifedipine) . Third-Line: If still Symptomatic then add a 3rd drug whilst waiting for PCI or CABG. e.g. (Nicorandil, Ivabradine, Ranolazine). \*Nitrate→ Prophylaxis: Isosorbide Mononitrate (have 8hr free period to prevent tolerance). ②Modifying lifestyle: DM and HTN control, stop smoking, exercise and weight loss. ③ Percutaneous Transluminal Coronary Angioplasty (PCTA): → A balloon that dilates stenotic vessel (Stent). NOTES: \*angina + asthma =verapamil, CCB is CI in LV dysfunction. B-blockers short acting can be trialed as not every asthma is triggered by it.

Answer 13

If QRisk3 is \>10% then offer atorvastatin 20mg for primary prevention. If patient has pre-existing CVD = 80mg for secondary prevention. LFTs should be measured within 3months of starting treatment & at 12 months. (Statins are safe to start as long as liver transaminase results are less than 3x upper limit of normal).

Answer 14

\*It's important to remember that Nitrates should be give if Systolic BP \>90mmHg/60mmHg (otherwise vasodilation will cause hypotension). It's given for pain as well.

Answer 15

Anterior: V1-V4 = Left anterior descending Lateral: I, aVL +/- V5-6 = Left circumflex Inferior: II, III, aVF = Right coronary Posterior: Tall R waves V1-2 = Left circumflex + right coronary

Answer 16

Acutely unwell (pale,clammy, cyanosis, frothy blood in sputum, cardiac wheeze & use of accessory muscle) Left ventricular failure signs: Sinus tachycardia or AF, Systolic hypotension, Signs of cardiomegaly on CXR, 3rd/4th heart sounds, right sided or bilateral pleural effusions/oedema. Right ventricular signs: elevated JVP, Hepatomegaly, Ascites, peripheral oedema. Other Clinical Features: Dyspnoea, Orthopnoea & paroxysmal nocturnal dyspnoea

Answer 17

Investigations: 1-Bloods: FBC, U&E's, LFT's TFT's, Lipid levels & glucose 2-Assess BNP (released upon myocardial stretch): if \>=100pg/ml Ix & refer within 6 weeks. If \>=400pg/ml, refer to ECHO & specialist within 2w. 3-CXR: ABCDE (alveolar oedema (bat-wing), Kerley B-lines, cardiomegaly, Upper lobe diversion, Pleural effusion) 4-ECHO: to assess ventricular function (EF), valvular function & structural abnormalities. 5-ECG: to check for potential causes (remember that HF must be caused by soemthing) Others if needed: Angiography, CT, cardiac MRI

Answer 18

Oxygen 15L/min via non-rebreathe mask or consider CPAP in ITU if not improving or developing acute respiratory acidosis. IV opiates= only if chest pain or distress Loop Diuretic = IV furosemide 40mg Vasodilators = If systolic BP \>90mm give IV GTN or IV isosorbide infusion Inotropic agents = if systolic \<90mm Dobutamine Others: ultrafiltration mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices \*\*\*\*Consideration should be given to discontinuing beta-blockers in the short-term.

Answer 19

NYHA classification: I= no limitation or symptoms during ordinary activity II=Normal at rest, ordinary activity produces mild symptoms III= Normal at rest, less than ordinary activity produces symptoms (e.g. walking short distances of 20-50m) IV=Symptoms at rest, patient is bed-bound

Answer 20

Management: Aim is to manage symptoms & reduce episodes of acute on chronic decompensation. **Lifestyle Modification:** Smoking cessation – adequate fluid & salt restriction (\<3g salt/day). Can weight body to assess fluid. – alcohol restriction & optimise diet & exercise. **Medication:** _First-line (combined therapy):_ ACE-Inhibitor + B-blocker (bisoprolol, carvedolol, nebivolol) _Second-line (becomes triple therapy):_ Aldosterone antagonist (spironolactone, eplerenone) \*\* both ACE-I & Spironolactone cause hyperkalaemia so K+ must be monitored. _Third-line (when triple therapy fails):_ Initiated by specialist, one of these: Ivabradine: Sinus rhythm \>75/min & LVEF \<35% Sacubitril-valsartan: LVEF \<35% & symptomatic on ACE-I or ARBs (should allow wash out period of ACE-I & ARBs) Digoxin: improves symptoms due to inotropic properties. Indicated esp. with co-existing AF Hydralazine in combo with Nitrate: in afro-Caribbean patients Cardiac resynchronisation therapy: if widened QRS (e.g. LBBB) _Other:_ If fluid overload = Loop diuretics, Annual influenza vaccine, One-off pneumococcal vaccine (although booster every 5 years in CKD, Asplenia or splenic dysfunction)

Answer 21

A number of drugs have been shown to improve mortality in patients with chronic heart failure: ACE inhibitors (SAVE, SOLVD, CONSENSUS) spironolactone (RALES) beta-blockers (CIBIS) hydralazine with nitrates (VHEFT-1) No long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide. ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction

Answer 22

Acute Pericarditis: inflammation of pericardium (the membrane that encloses heart) Constrictive Pericarditis: Chronic pericarditis → fibrosis → constrictive pericarditis

Answer 23

TRIAD: chest pain = Sharp retrosternal that’s worst on leaning back & better forward (e.g. patient sat up in tripod position) Can have associated Friction rub = via stethoscope ECG changes = diffuse ST Elevation (Saddle-shaped) or PR depression

Answer 24

Via Modified Duke's Criteria: * Pathological Criteria Positive, or * 2 major criteria, or * 1 major & 3 minor, or * 5 minor \*As Tom Jones would say, 'Me and Mrs Jones, we got a thing going on'. If that is indeed the case, then they very well might need a room (RHEUM) for the night. Jones criteria = Rheumatic fever \*En'duke'arditis = Duke's criteria for IE :) A-Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content) B: 1-Positive blood cultures: ●2 positive blood cultures showing typical IE organisms (e.g. strep viridans & HACEK group) HACEK group: gram -ve bacteria H-haemophilus species A-Actinobacillus species C-Cardiobacterium hominis E-Eikinella corrodens K-Kingella kingii ●2 positive blood cultures taken \>12hrs apart (persistent bacteraemia) OR 3 or more positive cultures where the pathogen is less specific/atypical to IE e.g. staph aureus & staph epidermidis ●Positive serology for Coxiella Burnetti, Bartonella species or chlamydia psittaci or an antiphase IgG antibody titre of \>= 1/800 2-Echo: ●Oscillating mass, abscess or dehiscence of prosthetic valve ● New valvular regurgitation C: 1-Microbiological evidence does not meeting major criteria. 2-Vascular phenomena (splinter haemorrhage, janeway lesion, major emboli, splenomegaly, clubbing, petechiae or purpura) 3-Predisposing heart disease or IVDU 4-Fever \>38C 5-Immunological phenomena (e.g. glomerulonephritis, Osler's nodes, Roth spots)

Answer 25

Causes: Idiopathic, viral (EBV,echovirus, coxsackie, SLE/sarcoidosis, dressler syndrome post-MI, drugs (Hydralazine, Isoniazid, Procainamide, penicillin) , Uraemia.

Answer 26

Ix: Bloods: Troponin, BNP, CRP, WCC. If troponin is high this signify myocardial involvement & ischemia! ECG: wide-spread ST elevation (no reciprocal changes). CXR: Pulmonary infiltrate + rule out other causes Echo: to check if the myocardium is involved (myocarditis) not just pericardium which will present itself by LV dysfunction (IRL RHF might follow & see both clinical signs). Also: Pericardial effusion

Answer 27

Management: 1-NSAID or Aspirin until CRP is normal 2-Colchicine: to prevent further recurrance 3-Corticosteroids: if underlying cause is connective tissue disease, immune-mediated or uraemic. 4-If LVF from myocarditis= treat like HF acutely as needed e.g. IV furosemide if fluid over-load. Long-term longevity Rx as well: e.g. ACE-Inhibitors, B-blockers & Spironolactone

Answer 28

Symptoms: Kussmaul's sign (breath in = raised JVP) + Symptoms similar to RHF Treatment: - Lower the pre-load (diuretics & salt restriction) - Pericardiectomy

Answer 29

Sudden onset tearing central chest pain radiating to the back with a PMH of HTN. Pain is maximal at onset. Other: Neurological symptoms due to occlusion of carotid, vertebral or spinal arteries, vasa nervorum of peripheral nerves, hypotensive cerebral perfusion deficit. So symptoms can include hypotension, frontal headache, neck pain. Findings: sinus tachycardia, BP is super high (OR hypotensive), radio-radial delay of pulses.

Answer 30

If type A- Ascending aorta: control BP (IV labetalol) + Surgical If type B- Descending aorta (distal to the left subclavian origin): Control BP (IV labetalol) only (+/-supportive treatment) Type A BP: Systolic 100-120mmHg whilst awaiting surgery

Answer 31

CXR: widened mediastinum CT angiography of chest, abdo & pelvis (for stable patients + surgery): A false lumen TOE (for unstable patients)

Answer 32

IE: infection of the endocardium and all its structures (valves, chordae tendinae) Acute-Subacute-Chronic presentations. Most common organisms involved in infective endocarditis (in order of incidence) are: Staph. aureus = Intravenous drug use - predisposition to Staph. aureus infection and right-sided valve disease e.g. tricuspid endocarditis Strep. viridans Enterococci Coagulase negative staphylococci e.g. Staph. epidermidis Strep. bovis - often in patients with colonic lesions, e.g. IBD or carcinoma Fungi HACEK organisms - Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella

Answer 33

Note: Black African or African Caribbean patients with DM who are diagnosed with HTN= first line is ARB e.g. Losartan regardless of age.

Answer 34

Features: Patients complain of SOB & Chest Pain (without evidence of MI on ECG or bloods) Beck's Triad: (DDD) Distention of Jagular Vein (high JVP) Distant heart sound Decreased blood pressure: Pulsus Paradoxus (low BP when we inspire) Causes: Trauma, Uremia, malignancy, proximal aortic dissection with rupture. Ix: ECG (electrical alternans) Mx:Urgent Pericardiocentesis.

Answer 35

The 'Hs': Hypoxia Hypovolaemia Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders Hypothermia The 'Ts': Thrombosis (coronary or pulmonary) Tension pneumothorax Tamponade – cardiac Toxins

Answer 36

Patients present with acute SOB & a PMHx of IHD & HF. O/E: Bilateral bibasal crackles (can go upwards like to mid-zone). Mx First-line urgently: **IV furosemide** Next: **sublingual glyceryl trinitrate** (veno-dilation and reduce preload) for quicker onset of action, **intravenous morphine** (treats the dyspnoea), **oxygen** and being positioned **upright**. This is to reduce the amount of fluid in the lung and improve symptoms.

Answer 37

* _Def:_ Uncoordinated atrial activity leading to an irregularly irregular heart rate * _Epidemiology:_ Extremely common – most common tachyarrhythmia * _Cause:_ **CHAMP** * Cardiac (HTN, Valvular disease, IHD/CAD, CCF) * Hyperthyroidism * Alcohol * Metabolic (↓Mg, ↓K) * Pulmonary causes, pneumonia/any infection

Answer 38

* _Features:_ Spectrum – symptoms get worse as ventricular rate gets faster/higher * Asymptomatic (20%) * Palpitations * Heart failure * Syncope _Ix:_ ECG= **No p-wave, irreg irreg**

Answer 39

**Onset \<48 hours:** 1-Heparin 2- below: _1-Haemodynamically unstable_ (chest pain, syncope, signs of HF) = emergency electrical cardioversion (restores sinus rhythm) _2-Haemodynamically stable_ = rate or rhythm control (if rhythm control is the preferred choice, its usually via pharmacological cardioversion) **Onset \>48 hours:** 1-Haemodynamically stable = rate control 2-Rhythm control is not usually the preferred choice but if seniors decide that it is the preferred choice you must anti-coagulate for atleast 3 weeks prior elective pharmacological cardioversion \*(An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately).

Answer 40

A- ## Footnote _Rate control drugs:_ 1**- Beta blockers** (*metoprolol* is short-half life so can adjust easily, *bisoprolol or carvedalol)*. If patient has CI to B-blockers (e.g. Asthma) then 2- **rate-limiting CCB** (e.g. *Diltiazem hydrochloride or Verapamil hydrochloride*) \*These should be given as _monotherapy_ & NEVER together = complete heart block) 3-Digoxin can be used for sedentary patients & ***HF* only**(cause of its positive inotropic affect) B-_Pharmacological cardioversion (rhythm restoration)- using antiarrhythmic drugs:_ **1- IV Flecanide:** if no structural heart disease **2-Amiodarone** (can achieve both rhythm & rate control BUT IV is avoided due to long-term SE, thats why its only used in special circumstances when patients have severe LVF) \*after electrical cardioversion, if sinus rhythm is needed to be maintained by a drug, sotalol (b-blocker) is usually used.

Answer 41

You can decide if the patient is suitable for thromboprophylaxis using the CHADVASc & HASBLED scores: ## Footnote If the score is 0= offer **TTE** to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation. If its excluded & still 0 (anti-coagulation is contraindicated) then give **Aspirin AND clopedigrol** combo. If indicated: Anticoagulant= **DOAC/ NOAC** (e.g. dabigatran, edoxaban, rivaroxaban, or apixaban) OR **Warfarin**