Cardiology I Flashcards
You suspect someone is suffering from digoxin toxicity. What would this look like on an ECG? [1]
What question would you ask them about their symptoms that might suggest this? [1]
Down-sloping ST segments = digoxin toxicty (reverse tick)
Loss of appetite is first symptom - followed by nausea and vomiting
Which of the below results is most likely in a patient taking Warfarin?
Normal PT, prolonged APTT
Prolonged PT, normal APTT
Normal PT, normal APTT
Prolonged PT, prolonged APTT
Normal PT, shortened APTT
Which of the below results is most likely in a patient taking Warfarin?
Normal PT, prolonged APTT
Prolonged PT, normal APTT
Normal PT, normal APTT
Prolonged PT, prolonged APTT
Normal PT, shortened APTT
Warfarin affects factor X, IX, VII and II. The extrinsic pathway, affecting the PT, involves factor VII.
Describe the aetiological factors that cause secondary HTN? [6]
Essential hypertension: 90%
- Unknown cause
Secondary hypertension:
R enal disease
O besity
P regnancy induced / pre-eclampsia
E ndocrine
D rugs
Which endocrine disorders significantly contribute to causing HTN? [6]
- Primary hyperaldosteronism (Conns)
- Phaechromocytoma
- Cushings
- Liddles syndrome
- Congenital adrenal hyperplasia (11 beta-hydroxylase deficiency)
- Acromegaly
What investigation should you perform if you consider renal artery stenosis is causing HTN? [1]
Duplex ultrasound
MR or CT angiogram
What are the different stages of HTN? [3] (include both clinic and home readings)
Stage 1:
- Clinic: >140/90
- Home / Ambulatory: Above 135/85
Stage 2:
- Clinic: >160/100
- Home / Ambulatory: Above 150/90
Stage 3:
- Clinic: >180/120
NICE recommends all patients who are newly diagnosed with hypertension to have which checks to investigate for end organ damage? [4]
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities, including left ventricular hypertrophy
Describe the specific management plans for treating HTN for patients who are Over 55 / NO DMT2 / Black or Afro-Caribbean [4]
Over 55 / NO DMT2 / Black or Afro-Caribbean:
STEP 1:
- CCB
STEP 2:
- CCB and ACE inhibitor
OR
- CCB and Thiazide-like diuretic
STEP 3:
ACE inhibitor and CCB and Thiazide-like diuretic
STEP 4:
- If K ≤4.5 add low dose spironolactone
- If K ≥4.5 add alpha blocker or beta blocker
- If not controlled with 4 drugs: specialist review
What are the specific treatment BP targets for patients over 80 and under 80? [2
Under 80:
- < 140/90
Over 80:
- < 150 / 90
What is meant by the term malignant / accelerated hypertension? [1]
What is the management plan for someone with ^? [1]
blood pressure above 180/120, with retinal haemorrhages or papilloedema.
The NICE guidelines recommend a same-day referral
What are the IV options for managing an hypertensive emergency [4]
Z2F:
- Sodium nitroprusside
- Labetalol
- Glyceryl trinitrate
- Nicardipine
Lecture:
- BB (bisoprolol)
- Alpha blocker (doxazocin)
- Alpha 2 agonist (moxonidine)
- Hydralazine vasodilator
Which drug would be given in a hypertensive emergency caused by pheochromocytoma? [1]
Phentolamine (alpha-adrenergic antagonist)
Which patient populations should ACE inhibitors be avoided in? [3]
Pregnant women - teratogenic
AKI
Renal artery stenosis
Diltiazem and verapamil are contra-indicated with which medical conditions? [2]
(why?)
- Impaired LV function (can worsen HF)
- AV nodal conduction delay (may provoke heart block)
Explain why amlodipine and nifedipine are contra-indicated with which medical conditions? [2]
Unstable angina: vasodilation causes increase in contractility and tachycardia, which increase myocardial oxygen demand
Severe aortic stenosis: can cause myocardial collapse
CCBs all cause which side effect? [1]
Gum hypertrophy!
Which anti-hypertensive drugs should be prescribed in pregnany? [3]
Labetalol (acts on alpha and beta)
Nifedipine
Methyl dopa
What is is the most common identifiable cause of hypertension? [1]
Chronic kidney disease.
Under which circumstances would you admit a patient to hospital if their BP was > 180/120 in the clinic [3]
Refer for same-day specialist review if:
* retinal haemorrhage or papilloedema
(accelerated hypertension) or
* life-threatening symptoms or
* suspected pheochromocytoma
a. What antihypertensive medication is contraindicated during pregnancy according to NICE guidelines?
- A. Methyldopa
- B. Labetalol
- C. Amlodipine
- D. Enalapril
a. What antihypertensive medication is contraindicated during pregnancy according to NICE guidelines?
- A. Methyldopa
- B. Labetalol
- C. Amlodipine
- D. Enalapril
Enalapril is not recommended in pregnancy. It can reduce the level of fluid around your baby, particularly if you take it in the second and third trimesters
a. Which of the following antihypertensive medications requires regular monitoring of serum potassium levels due to the risk of hyperkalemia?
- A. Thiazide diuretics
- B. ACE inhibitors
- C. Calcium channel blockers
- D. Beta-blockers
a. Which of the following antihypertensive medications requires regular monitoring of serum potassium levels due to the risk of hyperkalemia?
- A. Thiazide diuretics
- B. ACE inhibitors
- C. Calcium channel blockers
- D. Beta-blockers
What do you need to consider about anti-hypertensive treatment in patients with CKD? [1]
A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped)
An [investigation] may be required in patients with fever of unknown origin and back pain to exclude [].
This refers to infection/inflammation of an intervertebral disc. This may be a complication of a septic emboli from IE.
Acute pulmonary oedema is usually secondary to acute left ventricular dysfunction or renal artery stenosis.
Patients complain of sudden breathlessness and need to be managed quickly on the ward. The acute management can be remembered using the mnemonic []:
FOND
F- furosemide 40mg IV
O - high-flow Oxygen
N - nitrates (Sublingual / infusion)
D - diamorphine IV
If this immediate management fails then patients may be started on continuous positive airway pressure (CPAP).
Explain the different clinical features of atrial flutter [5]
Haemodynamic Manifestations:
- Loss of co-ordinated atrial contractions causes reduced ventricular filling and reduced CO
- Causes dyspnea; fatigue; lightheadedness; syncope
Palpitations
Chest pain
- Due to increased myocardial oxygen demand secondary to rapid ventricular rates or decreased diastolic filling time causing subendocardial ischaemia
Heart Failure Symptoms
- May get tachycardia induced cardiomyopathy
- Orthopnea; paroxysmal nocturnal dyspnea, and peripheral oedema
Thromboembolic Complications:
- predisposes patients to thrombus formation
Describe the first line treatment algorithm for a patient with acute atrial flutter who is haemodynamically stable? [3]
What is the long term anticoagulation used? [2]
Primary option: Use an atrioventricular nodal blocking drug for rate control:
Beta blocker:
- Bisoprolol or others
OR
Non-dihydropyridine calcium-channel blockers:
- Verapamil
- Diltiazem
Secondary options:
- Digoxin
may convert atrial flutter to atrial fibrillation, which can be easier to manage.
CONSIDER:
Initial anticoagulation:
- heparin
or
- enoxaparin
Long term anticoagulation:
- 1st: apixaban or ther DOAC
- 2nd: warfarin
BMJ BP
Wht are common causes of AF? [5]
SMITH
S – Sepsis
M – Mitral valve pathology (stenosis or regurgitation)
I – Ischaemic heart disease
T – Thyrotoxicosis
H – Hypertension
Alcohol and caffeine are lifestyle causes worth remembering.
Which endocrine pathologies are associated with AF? [2]
DM
Hyperthyroidism
Which cardiac conditions are associated with AF? [5]
HTN: most common factor
HF
CAD
Valve pathologies: In particular, mitral valve disease and rheumatic heart disease.
Atrial flutter & WPWs
Describe the different classifications of AF [3]
.1. Persistent AF:
- Experience AF at all times (sustained for more than 7 days)
.2. Paroxysmal AF:
- Experiences AF at certain times. At all other times their heart contracts in sinus rhythm
- ‘AF that terminates spontaneously within 7 days of onset’
.3. Valvular Atrial Fibrillation:
- AF with significant mitral stenosis or a mechanical heart valve.
- NB: Atrial fibrillation without valve pathology or with other valve pathologies, such as mitral regurgitation or aortic stenosis, is classed as non-valvular AF.
The Ssgns of haemodynamic compromise in AF according to NICE CKS (2020) are what? [5]
- Heart Rate >150 bpm
- Blood Pressure < 90 mmHg
- Syncope or severe dizziness
- Shortness of breath
- Chest Pain
An elderly patient with a history of atrial fibrillation presents with a sudden painless loss of vision in one eye. Fundoscopy reveals a ‘cherry red’ spot on a pale retina is a stereotypical history of:
occlusion of central retinal artery
What is the cause of the cherry red spot? [1]
It is most frequently caused by emboli obstructing the retinal artery (e.g. stroke). Occasionally, it can be caused by vasculitis (e.g. giant cell arteritis).
Classical appearance is of a “cherry-red spot”. This occurs due to the intact reflex of the fovea standing out against a pale, ischaemic retina.
No anticoagulation:
CHA2DS2-VASc of 1 (female)
CHA2DS2-VASc of 0
A patient has AF, but a CHADSVASC score of 0.
What is the next investigational step? [1] Why? [1]
Remember that if a CHA2DS2-VASc score suggests no need for anticoagulation it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which in combination with AF is an absolute indication for anticoagulation.
What is vasovagal syncope? [1]
What is it caused by? [4]
Vasovagal Syncope:
- emotional or environmental trigger (e.g. prolonged standing, fasting, dehydration) causes an activation of the PNS
- Activation of the PNS causes vasovagal reaction: bradycardia and vasodilation
- Causes a drop in BP and reduction in blood supply to brain
- Cerebral hypoperfusion and LOC
How can you differentate between cardiac and vaso-vagal syncope?
Cardiac syncope:
- preceded by exertional chest pain
- occurring during exercise or stress
- concerning cardiac history
- no prodrome
- event requiring CPR,
- abnormal physical
examination
Vasovagal syncope
- Prodromal symptoms:
- Hot or clammy
- Sweaty
- Heavy
- Dizzy or lightheaded
- Vision going blurry or dark
- Headache
What are important areas to cover in a history when someone says they’ve fainted? [4]
Precipitant/trigger:
- if situational, ask if the trigger consistently causes syncope
Warning symptoms:
- classic pre-syncopal symptoms of nausea, sweating, feeling faint
Position:
- vasovagal syncope usually happens when standing
Underlying cardiac disease?
What are key history areas for arrhythmic and structural syncope? [8]
- Palpitations
- Other cardiac symptoms (e.g. chest pain, breathlessness, oedema)
- No prodromal warning (unlike in reflex and orthostatic syncope, where there are clear pre-syncopal symptoms)
- Onset when sitting or lying down
- Onset with exercise (clarify if it is after or during exercise)
- Presence of any previous heart disease including myocardial infarctions, surgeries, and any cardiac device details (pacemakers and ICDs)
- Drug history
- Family history of sudden cardiac death
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started [] weeks after the event
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started two weeks after the event
Describe the four possible rhythms in a cardiac arrest patient [4]
Shockable rhythms:
* Ventricular tachycardia
* Ventricular fibrillation
Non-shockable rhythms:
* Pulseless electrical activity (all electrical activity except VF/VT, including sinus rhythm without a pulse)
* Asystole (no significant electrical activity)
Describe how you would treat the following causes of broad complex tachycardia [4]
- Ventricular tachycardia or unclear cause
- Polymorphic ventricular tachycardia, such as torsades de pointes
- Atrial fibrillation with bundle branch block
- Supraventricular tachycardia with bundle branch block
Ventricular tachycardia or unclear cause:
- IV amiodarone
Polymorphic ventricular tachycardia, such as torsades de pointes:
- IV magnesium
Atrial fibrillation with bundle branch block
- AF tx
Supraventricular tachycardia with bundle branch block
- SVT tx
Give four differential diagnoses to VT for a broad complex tachycardia [4]
SVT with abberancy:
- SVT but the QRS becomes broad because of bundle branch block
Paced rhythm:
- An electrocardiographic finding in which the cardiac rhythm is controlled by an electrical impulse from an artificial cardiac pacemaker
Anti-dromic AVRT
Pre-excitation tachycardias (WPW)
Describe what is meant by sick sinus syndrome [1]
What can cause sick sinus syndrome? [1]
Sick sinus syndrome encompasses many conditions that cause dysfunction in the sinoatrial node.
It is often caused by idiopathic degenerative fibrosis of the sinoatrial node. It can result in sinus bradycardia, sinus arrhythmias and prolonged pauses.
What does asytole mean? [1]
State 4 cardiac pathologies that increase risk of asytole [4]
Asytole: cessation of electrical and mechanical activity of the heart.
- Mobitz type 2
- Third-degree heart block (complete heart block)
- Previous asystole
- Ventricular pauses longer than 3 seconds
Describe the MoA of atropine [1]
Atropine is an antimuscarinic medication and works by inhibiting the parasympathetic nervous system.
Inhibiting the parasympathetic nervous system leads to side effects of pupil dilation, dry mouth, urinary retention and constipation.
What is corrected QT interval (QTc)? [1]
What is prolonged QTc in men [1] and women [1]?
Corrected QT interval (QTc): estimates the QT interval if the heart rate were 60 beats per minute
Prolonged:
* More than 440 milliseconds in men
* More than 460 milliseconds in women
What does a prolonged QT interval mean physiologically? [1]
What are the physiologically consequences of a prolonged QT interval? [1]
What is the name for this phenomenom? [1]
A prolonged QT interval represents prolonged repolarisation of the heart muscle cells (myocytes) after a contraction.
Waiting a long time for repolarisation can result in spontaneous depolarisation in some muscle cells
These abnormal spontaneous depolarisations before repolarisation are known as afterdepolarisations.
Describe what is meant torsades de pointes from a physiological perspective? [1]
What type of tachycardia is torsades de pointes? [1]
Recurrent contractions without a normal repolarisation due to afterdepolarisations spreading throughout the ventricles, causing contraction before proper repolarisation
Type of polymorphic ventricular tachycardia
Describe the prognosis of untreatead torsades de pointes [2]
Torsades de pointes will terminate spontaneously and revert to sinus rhythm
OR
Progress to ventricular tachycardia. Ventricular tachycardia can lead to cardiac arrest.
Which medications can cause prolonged QT intervals? [6]
Methotrexate,** e**rythromycin, terfenadine, haloperidol, citalopram/chloroquine, amiodarone, TCA, sotalol
Which electrolyte imbalances can cause QT elongation [3]
- hypokalaemia
- hypomagnesaemia
- hypocalcaemia
Describe the resuscitation council treatment algorithm for adult tachycardias (with pulse) if the there are adverse features (e.g. shock, syncope, MI, HF) [5]
Assess using the ABCDE approach
Monitor SpO2 and give oxygen if hypoxic
Monitor ECG and BP, and record 12-lead ECG
Obtain IV access
Identify and treat reversible causes (e.g. electrolyte abnormalities)
Adverse features? Shock; MI; HF: Syncope - IF YES:
Synchronised DC shock x3
Amiodarone 300 mg IV over 10 - 20 mins
Repeat shock
Amiodarone 900 mg over 24hrs
What is the treatment algorithm for adult tachycardias (with pulse) once you have have assessed that there are no adverse features present and the QRS complex is < 0.12 secs and the rhythm is regular but sinus rhythm is NOT achieved? [1]
Assess using the ABCDE approach
Monitor SpO2 and give oxygen if hypoxic
Monitor ECG and BP, and record 12-lead ECG
Obtain IV access
Identify and treat reversible causes (e.g. electrolyte abnormalities)
Adverse features? Shock; MI; HF: Syncope - IF NO - Check QRS - If < 0.12s = narrow complex tachycardia
If rhythm is regular:
Perform vagal manoeuvres
Adenosine 6 mg rapid IV bolus
If no effect give 12 mg
If no effect give further 12 mg
Monitor/record ECG continuously
Diagnosis is probably atrial flutter: treat rate control - such as a beta blocker
What is the treatment algorithm for adult tachycardias (with pulse) once you have have assessed that there are no adverse features present and the QRS complex is < 0.12 secs and the rhythm is regular and sinus rhythm IS achieved? [1]
Assess using the ABCDE approach
Monitor SpO2 and give oxygen if hypoxic
Monitor ECG and BP, and record 12-lead ECG
Obtain IV access
Identify and treat reversible causes (e.g. electrolyte abnormalities)
Adverse features? Shock; MI; HF: Syncope - IF NO - Check QRS - If < 0.12s = narrow complex tachycardia
If rhythm is regular:
Perform vagal manoeuvres
Adenosine 6 mg rapid IV bolus
If no effect give 12 mg
If no effect give further 12 mg
Monitor/record ECG continuously
If sinus rhythm achieved, probably re-entry SVT (i.e. AVRT or AVNRT):
- Record 12 lead ECG in sinus rhythm
- If SVT recurs treat again and consider
anti-arrhythmic prophylaxis
Describe the treatment algorithm for adult tachycardias (with pulse) once you have have assessed that there are no adverse features present, the QRS complex is > 0.12 secs and there is a regular rhythm [2]
Assess using the ABCDE approach
Monitor SpO2 and give oxygen if hypoxic
Monitor ECG and BP, and record 12-lead ECG
Obtain IV access
Identify and treat reversible causes (e.g. electrolyte abnormalities)
Adverse features? Shock; MI; HF: Syncope - IF NO - Check QRS - If > 0.12s = broad complex tachycardia
If regular - could be:
VT (or uncertain rhythm):
Amiodarone 300 mg IV over 20-
60 min then 900 mg over 24hr
OR
If known to be SVT with bundle branch block:
Treat as for regular narrowcomplex tachycardia
The reversible causes of cardiac arrest are “4Hs and 4Ts”.
Name them [8[
Hypoxia
Hypokalaemia/hyperkalaemia
Hypothermia/hyperthermia
Hypovolaemia
Tension pneumothorax
Tamponade
Thrombosis
Toxins
