Cardiology/ECG Flashcards by Yasheen Sewnarain

What is this?

Complete Heart Block

P waves aren’t followed by the QRS

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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

Verapamil 5-10mg, intravenously given over 2 minutes

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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

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Patient presents with chest pain. What is the diagnosis?

Anterolateral ST elevation Myocardial Infarction

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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)

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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.

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What are risk factors associated with getting AF?

Obesity
Hypertension
T2DM
Smoking
OSA
CAD
valvular heart disease
Heart Failure
CKD

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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

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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.

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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)

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What is this SPECIFICALLY

AF with rapid ventricular response

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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.

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Signs of heart failure?

Elevated JVP
Hepatojugular reflex
Third Heart Sound
Laterally displaced apical impulse
Crackles
Hepatomegaly

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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%

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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.

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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)

1. betablockers 2. NHD CCB 3. Amlodipine 4. Long acting nitrate (ISMN) 5. Nicorandil or perhexiline *perhexiline probably will be best left to a specialist given narrow therapeutic window