Cardiology quickfire 3 Flashcards
LV thrombus - best imaging
ECHO (TTE) with IV transpulmonary contrast agent - demonstrates any filling defect
CRT and ICDs in heart failure
a) Indications for CRT
b) Indications for ICDs
c) What is it CRT?
a) CRT indications:
- NYHA class 3 or 4
- EF <35%
- Broad QRS complex
- On full medical treatment
b) ICD indications:
- Sustained VT with an EF <35% (or with history of collapse/arrest/heart condition like Brugada)
c) Biventricular pacing:
- Synchronous pacing of LV and RV to restore contractility
AF
a) Paroxysmal vs persistent AF
b) Rate vs rhythm control
a) - Paroxysmal - recurrent episodes lasting < 7 days
- Persistent - recurrent episodes lasting > 7 days
b) - Rhythm control preferred in paroxysmal AF, younger patients (< 65), obvious precipitant (e.g. alcohol, infection), symptomatic (e.g. palpitations, heart failure)
- Rate control as effective as rhythm control in over 65s in terms of mortality
Mid-systolic click followed by late systolic murmur
MVP
- displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole
- there is usually a small amount of mitral regurgitation*
*Different to proper MR which is the result of chordae/papillae rupture that causes a much larger amount of regurgitation
STEMI
a) Mortality in PCI-treated vs non-treated patients
b) Time frames for PCI
a) 4% vs 40%
b) - Presentation is within 12 hours of onset of symptoms and
- Primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
Atrial flutter
a) Initial management
b) Definitive management
a) - Stabilise with rate control
- Initiate anticoagulation
- Once anticoagulated effectively, proceed with DC cardioversion
b) Ablation
Vasovagal syncope
a) Warning signs vs arrhythmia
b) Diagnostic tests
a) Common in vasovagal (dizziness, etc.) vs arrhythmia where patients are walking down the street and next thing they know they’re on the floor
b) Tilt table test
- May inject GTN and perform carotid sinus massage during test
NYHA classification and MRC dyspnoea scale
NYHA:
I No limitation of physical activity
II Slight limitation of physical activity - Ordinary physical activity results in fatigue, palpitations, dyspnoea
III Marked limitation of physical activity - Less than ordinary activity causes fatigue, palpitations, or dyspnoea
IV Symptoms at rest. If any activity is undertaken, discomfort increases
Modified MRC dyspnoea scale*:
0 - no breathlessness except on very strenuous exercise
1 - breathless while hurrying or on slight incline
2 - walks slower than contemporaries on the flat
3 - breathless after walking for 100m or a few minutes on the flat
4 - too breathless to leave the house. Breathless on activities like dressing/undressing
*Original scale was 1-5 as opposed to 0-4
MRC dyspnoea scale
1 Not troubled by breathless except on strenuous exercise
2 Short of breath when hurrying on a level or when walking up a slight hill
3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
4 Stops for breath after walking 100 yards, or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing/undressing
LV aneurysm
a) Suspect in who?
b) ECG findings vs. recurrent acute STEMI
c) Complications
a) ST elevation persisting >2 weeks most MI
b) - ECG identical to previous (acute STEMI) ECG
- Absence of dynamic ST segment changes
- Absence of reciprocal ST depression
c) Ventricular arrhythmias
Heart failure
Mural thrombus and embolisation
Cardiac pharmacology.
a) Clopidogrel/ticagrelor
b) Nitrates
a) Antagonise the P2Y12 receptor on platelet surface, which prevents ADP attaching, therefore reducing platelet aggregation
b) Nitric oxide (NO) donors, leading to stimulation of guanylate cyclase to produce cyclic guanosine monophosphate (GMP), which mediates the vasodilatory effect of nitrates
Classic ischaemic ECG patterns
a) Left main coronary artery stenosis
b) Wellens sign (and Wellens syndrome)
c) De Winter T waves
a) Left main coronary artery stenosis:
widespread ST depression (especially lateral leads) with ST elevation in aVR*
*aVR correlates to the basal septum, which is supplied by the septal perforator artery, a branch of the proximal LAD. ST elevation in aVR could be reciprocal to lateral ischaemia or indicate basal septum infarction (from LAD/LMCA stenosis)
b) Wellens sign:
- Deep precordial T wave inversions or biphasic T waves in V2-3, indicating critical proximal LAD stenosis (a warning sign of imminent anterior infarction)
Wellens syndrome:
Wellen sign on ECG while pain-free, but usually with history of recent chest pain that is now resolved
c) De Winter T waves:
- Upsloping ST depression with symmetrically peaked T waves in the precordial leads; a “STEMI equivalent” indicating acute LAD occlusion.
Chronic heart failure (reduced EF) management
a) First line
b) If still symptomatic, offer..?
c) Indications for Entresto (sacubitril/valsartan)
d) Indications for ivabradine
e) Indications for digoxin
a) Beta-blocker, and ACE
b) Spiro/eplerenone
c) NYHA 2-4, EF <35%, symptomatic despite the above
d) NYHA 2-4, EF <35%, HR >70, symptomatic
e) Symptomatic despite the above
Proximal vs distal RCA occlusion
Proximal - ST elevation in V1-V3 and inferior leads
Distal - inferior ST elevation only
ACE inhibitors
a) Management of creatinine rise on initiation
b) Cause of rise in K but no rise in Cr
a) <20% acceptable
20-50% prompt review of fluid status and monitoring
>50% should be discontinued
b) Aldosterone antagonism
Type 4 RTA
