Cardiology/ECG Flashcards
What is this?
Complete Heart Block
P waves aren’t followed by the QRS
What is the medical management for this?
This is a supra-ventricular tachycardia
You can try vagal manoeuvres first.
Otherwise
Adenosine 6mg, Intravenously given as a rapid bolus
Or
Verapamil 5-10mg, intravenously given over 2 minutes
When is a surgical opinion needed for an aortic aneurysm?
> 5.0 cm in women and >5.5 cm in men
Associated unexplained abdominal tenderness or pain
rapid expansion > 1cm/year
Patient presents with chest pain. What is the diagnosis?
Anterolateral ST elevation Myocardial Infarction
What leads would you see a inferior MI versus an antero lateral MI, and what artery is implicated?
Inferior MI in 2, 3 and aVF (usually the RCA or left circumflex)
Anterolateral in v1-v6, potentially lead 1
(v5-v6 is usually LCx or diagonal branch of LAD,
leads V1 to V4 is LAD,
leads 1 and aVL is LCx or diagonal branch of LAD)
List names and doses of medications given for secondary prevention after a MI.
- Dual antiplatelet therapy (usually decided by tertiary specialist)
Aspirin 100mg Daily, +clopidogrel 90mg Daily, orally - Statin at higher doses
Atorvastatin 80mg, oral, daily - Betablockers
Metoprolol Tartate 25-100mg, orally, 12 hourly - ACEi/ARBs
Perindopril erbumine or argnine 2/2.5mg to 8/10mg, oral, daily
Can use ARB, but aren’t first line
- Aldosterone antagonist
Can be added if LVEF <40% or diabetic. Usually started after patient stable on ACEi.
What are risk factors associated with getting AF?
Obesity
Hypertension
T2DM
Smoking
OSA
CAD
valvular heart disease
Heart Failure
CKD
What at the components of the CHA2 DS2 VA
Congestive heart failure, either HFrEF or HFPEF, 1 point
Hypertension 1, point
Age > 75, 2 points
Diabetes, 1 point
Stroke, TIA or systemic thromboembolic event, 2 points
Vascular disease; MI or PAD, 1 point
Age 65-74, 1 point
who and how should you screen for AF?
Take the pulse of everyone aged over 65 for an irregularly irregular rhythm.
Those with newer smart watches are essentially screening themselves.
investigations in newly diagnosed AF, apart from already having an ECG?
EUC with renal function
Calcium, Mg, Phosphate
FBC
Thyroid Function tests
transthoracic echo- good to evaluate for valvular disease as well as LV size and function
- Valvular disease changes anti-coagulants. with MStenosis use warfarin
-LV size (larger is a better predictor of Stroke than AF itself)
Polysomnography (if having symptomatic AF)
What is this SPECIFICALLY
AF with rapid ventricular response
when would you consider rhythm control in AF
What type or person is best suited for rhythm control in AF?
Symptomatic AF
Those with cardiomyopathy due to AF with rapid ventricular response
Anyone that becomes haemodynamically unstable
ideally younger persons with positive health behaviours: exercise, diet, non smoking, alcohol, weight.
Signs of heart failure?
Elevated JVP
Hepatojugular reflex
Third Heart Sound
Laterally displaced apical impulse
Crackles
Hepatomegaly
What is HFrEF and what is the definition of it?
Heart Failure with Reduced Ejection Fraction
the cut off ejection fraction is set at under 40%
Clinical signs of heart failure include dyspnoea, reduced exercise tolerance, fatigue, increased time to recover after exertion.
If a person has an EF > 40% what could be causes of these symptoms?
(3 main groups)
- Other causes of fluid overload: Lung disease, kidney failure, liver failure, ischemic heart disease
- Non myocardial heart disease: valvular heart disease, pericardial effusion, pericardial constriction
- HFpEF - heart failure with preserved ejection fraction. You can have heart failure symptoms, without the reduced ejection fraction.
What is the NYHC of heart failure?
1 - asymptomatic LV dysfunction
2 - Slight limitation of activities. physical activity can lead to fatigue or dyspnoea
3 -Marked limitation of physical activity. Less than ordinary physical activity leads to symptoms
4 - unable to carry out any physical activity without discomfort
What are some important causes of heart failure?
- Hypertension
- CAD
- Diabetes
- Arrhythmias
- Excess alcohol intake (may actually respond to reduction)
- Recreational stimulants
- Valvular disease
- Certain metabolic reasons for cardiomyopathy, HH (treat with venesetion), thalassaemia (iron chelation), chemotherapy (adjust dose)
- Chronic lung disease
- Hyperthyroidism (especially with an arrhythmia)
- Inherited
HAVe IT (main causes to rule out)
Hypertension, arrhythmia, valvular disease, eeee, Ischemia, Thyroid
Initial investigations for Heart Failure?
EUC
LFTs
FBC
ECG
Echo
TFTs
Iron studies
In symptomatic HRrEF what are the pharmacological classes you will utilise?
ACEi (ARB if cannot tolerate ACEi)
Betablockers
Mineralocorticoid receptor blockers
Diurectics (short term)
SGLT2i
Enestro if still symptomatic and EF<35%
Ivabradine if still symptomatic and EF<35% and doesn’t tolerate ACEi/ARB
What are the betablockers to use in Heart Failure?
What are some important rules to remember?
Metoprolol Succinate 23.75mg , orally, Daily
Bisoprolol 1.25mg, orally, daily
Notes:
Do not start B-Blockers during acute decompensation. Diuresis first.
Remember start low and go slow
What are the main co-morbidities you can treat in Heart Failure?
Hypertension
Iron Deficiency (IV carboxymaltose)
T2DM
Atrial Fibrillation
4 non-pharmacological areas of management/lifestyle management when addressing Heart Failure?
- Diet. High fibre, Low saturated fat
- Salt specifically: Sodium < 2grams, Salt <5grams
- Fluid restriction is NOT necessary - as it doesn’t take into account weather or activity
- Reduce smoking
- Regular exercise for stable patients. Increase slowly.
- Immunisation especially pneumococcal 23
What are the long term management agents started on after an ACS event?
(dosing not needed)
Dual antiplatelets aspirin + clopidogrel (or ticagrelor) started in all
Statin high dose started in all
Beta blockers if some heart failure
ACEi/ARB stated in all
Aldoseterone antagonist if LVEF<40%
In stable angina, what investigation provides the biggest predictor of long term survivability?
Echocardiogram as LV function is the biggest predictor of long term survival
What is the definition of angina?
Usually retrosternal chest pain, under 10 minutes with no evidence of cardiac damage and is exacerbated by physical or emotional stress
Investigations for stable angina?
Echo
Stress test manual or pharmacological
CT angio to define blockage
acute at home management for Stable angina?
glyceryl trinitrate spray 400 micrograms sublingually, repeat every 5 minutes if pain persists, up to a total of 3 doses if tolerated
Chest pain action plan
long term treatment of angina?
Medication classes, not dosing
(4)
Regular aspirin
Treat BP (antihypertensive)
Short acting Nitrates prior to exercise
Start an anti anginal drug
When treating Stable angina, what are some options for anti-anginal drugs?
(4)
Beta blockers then CCB (hydropiridine) if BB doesn’t work
CCB - nondihydropiridine e.g. diltiazem and verapamil. Do not use WITH a BB.
Long acting nitrate (ISMN or transdermal GTN)
Specific: nicorandil or perhexilline (if other options fail)
What tests other than an Echocardiogram, can you order to support your diagnosis of heart failure?
remember it is primarily a clinical diagnosis
ECG
BNP (apparently more of a ‘rule out’ heart failure)
CXR
left sided heart failure means that blood isn’t getting to the body and fluid is building up in the lungs. Apart from dyspnoea what are other symptoms of heart failure?
PND and orthopnoea
Fatigue
reduced exercise tolerance/ increased time to recover
less commonly- bendopnoea (SOB when standing up after bending down)
What are risk factors for an abdominal aortic aneurysm?
(8)
Advancing age
Male Gender
Smoking
Family History
Atherosclerosis
Hypertension
Hypercholesterolemia
Other vascular aneurysm
Aortic Aneurysms do tend to expand. What is the cut off diameter for referral?
and what is the rate of expansion?
> 5.5 cm in men
5.0 cm in women
rate of expansion is about 2-3 mm a year
There is value in screening for aortic aneurysms, but there is no formal screening in Australia. Right now who is it most beneficial to screen?
Primarily men over 65.
Can increase cost effectiveness by screening those at higher risk (smoking, family history, atherosclerotic disease)
Screen using an U/S
What are the various screening intervals for AAA?
-dependent on diameter
(4)
3.0–3.9cm= 24 months
4.0–4.5cm= 12 months
4.6–5.0cm= 6months
>5.0cm= 3months
When can/should you refer to vascular surgery for a AAA?
Can actually do this at diagnosis, at many facilities/centres will co-ordinate the subsequent surveillance.
Otherwise definitely refer if >5.5cm in men and >5.0cm in women.
If off course there are symptoms: abdominal or back pain, syncope or tenderness, then get an urgent referral.
What medications can you use to prevent stable angina?
NO DOSING
(5)
- betablockers
- NHD CCB
- Amlodipine
- Long acting nitrate (ISMN)
- Nicorandil or perhexiline
*perhexiline probably will be best left to a specialist given narrow therapeutic window
