Cardiology VI Flashcards
Describe the treatment
for:
TIA due to AF: [1]
TIA not due to AF [2]
Stroke due to AF: [2]
Stroke not due to AF: [2]
TIA due to AF: DOAC immediately and continue for life
TIA not due to AF: Aspirin 300mg immediately for 2 weeks and then clopidogrel lifelong
Stroke due to AF: Aspirin 300mg for 2 weeks and then DOAC lifelong
Stroke not due to AF: Aspirin 300mg for 2 weeks and then clopidogrel lifelong
A 47 year old woman presents to her GP with a history of breathlessness of 6 months duration. On examination she has a large a wave of her jugular venous pressure.
Which condition is likely to be the cause of the large a wave?
Heart failure
Mitral valve prolapse
Mitral regurgitation
Pulmonary hypertension
Tricuspid regurgitation
Pulmonary hypertension
A patient is on a PPI, ACEin and BB.
They are scheduled for sugery.
Which drugs should be continued / discontinued? [1]
ACEin:
- should be withheld before surgery as they can be associated with severe hypotension following induction of anaesthesia
BB:
- be continued before surgery as they are thought to lead to better perioperative haemodynamic stability
PPI:
- Continue
Which drugs should you stop prior to surgery? [4]
Give a timeline [4]
Cardiovascular drugs:
- Clopidogrel should be stopped 7 days before surgery
- warfarin should be (generally) stopped 5 days before surgery and instead patients should be on low molecular weight heparin until the night before
- ACE inhibitors should be stopped the day before surgery.
Combined oral contraceptive pill should be stopped 4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile). This reduces the risk of DVT.
What questions do you need to ask about pre-syncope events? [3]
Was there a trigger?
- Establish whether there was a trigger to the event. Syncope often includes an immediately preceding trigger such as emotion, pain or exercise.
Was there a prodrome?
- Syncope often involves an immediate warning (called ‘pre-syncope’), consisting of symptoms such as feeling faint, dizzy, sick, visual disturbances and ringing in the ears (tinnitus).
- The presence of palpitations or other cardiac symptoms suggests a cardiac cause of syncope.
Did the patient change colour?
- Pallor occurs from systemic hypotension, thus indicating syncope.
- A blue colour (cyanosis) occurs from transient loss of respiratory muscle action in any seizure beginning with a tonic phase (e.g. generalised tonic-clonic seizure).
What questions do you need to ask about events during syncope [4]
How long did the unconsciousness last?
- Typically, patients are unconscious for seconds in syncope. The duration of unconsciousness is often longer in seizures.
Was there a convulsion?
- Convulsions may occur in both epilepsy and syncope and thus do not distinguish between the two. However specific patterns (e.g. tonic-clonic) may be recognisable if the eyewitness provides a detailed, reliable account.
Was there tongue biting?
- Although tongue biting can rarely happen in syncope, this is more strongly associated with seizures.
Was there urinary incontinence?
- Urinary and faecal incontinence are more strongly associated with seizures and not a typical feature of syncope (although not impossible).
What question should you ask about post-syncope? [1]
How long did it take for full recovery?
- Seizures are followed by a post-ictal fatigue lasting several hours. In contrast, syncope is usually followed by near-immediate complete recovery with no lasting effects.
What are the three types of neurally mediated syncope? [3]
Neurally mediated syncope is due to an inappropriate autonomic reflex in response to a trigger and hence this is also known as reflex syncope.
Vasovagal syncope:
- Vasovagal syncope. also known as a ‘simple faint’, is by far the most common type of syncope overall.
Situational syncope
- Situational syncope occurs when syncope occurs consistently after a specific trigger:
Post-micturition (the most common)
Post-cough
Post-swallow
Post-defecation
Post-prandial
Post-exercise
Carotid sinus hypersensitivity
- mechanical manipulation of the carotid sinus, which can happen accidentally whilst shaving, wearing a tight shirt collar or even head movement (e.g. looking over shoulder).
Describe different causes of postural (orthostatic hypotension) syncope [4]
Autonomic nervous failure secondary to drugs:
- this is the commonest cause of orthostatic hypotension.
- Common drugs include antihypertensives, diuretics, tricyclic antidepressants, antipsychotics and alcohol.
Hypovolaemia:
- hypovolaemia may be a key contributing factor in syncope.
- There may be a sinister underlying cause such as a gastrointestinal bleed.
Primary autonomic nervous failure:
- this is usually present to some degree in the spectrum of disorders which includes Parkinson’s disease, Lewy body dementia and multi-system atrophy.
Secondary autonomic nervous failure:
- occurs secondary to other conditions such as diabetes, uraemia and spinal cord lesions
What are the investigations should do for orthostatic syncope? [2]
Lying and standing blood pressure
Tilt table testing:this will distinguish between postural and vasovagal syncope
- Tilt table testing: recreates trigger/situation while measuring BP and other signs to confirm the diagnosis
Which is more likely to cause syncope:
Tachyarrhythmias
Bradyarrhythmias
Which is more likely to cause syncope:
Tachyarrhythmias
Bradyarrhythmias
Describe how bradyarrhythmia syncopes occur [3]
Usually there is either failure of impulse initiation by the sinus node (sick sinus syndrome) or impulse conduction to the ventricles.
When this occurs sporadically, there is usually an ectopic site further down the pathway which will take over and continue to beat at its own slower rate.
The reduction in blood pressure responsible for the syncope occurs when there is a long pause (usually >3 secs) between the impulse conduction failure and the ectopic escape mechanism.
Name three causes of bradyarrhythmias causing syncope [3]
Sick sinus syndrome
Second-degree atrioventricular block
Third-degree (complete) atrioventricular block
Name 4 causes of tachyarrhythmias that can cause syncope
atrial fibrillation, atrial flutter, atrioventricular nodal re-entry tachycardia) or ventricular tachycardia
Structural causes of syncope are usually due to mechanical obstruction in the [] [] inflow or [] tract.
Structural causes of syncope are usually due to mechanical obstruction in the left ventricular inflow or outflow tract.
Describe how structural syncope occurs
Structural causes of syncope are usually due to mechanical obstruction in the left ventricular inflow or outflow tract.
Normally during exertion, systemic vasodilatation occurs in order to increase perfusion to skeletal muscle and the reduction in blood pressure is compensated for by an increased stroke volume and heart rate.
However, when there is an obstruction to outflow, this compensation does not happen and exertional syncope can occur due to a reduction in blood pressure during exercise.
State 5 causes of structural syncope [5]
Causes of structural syncope include:
- Valvular disease (e.g. aortic stenosis)
- Cardiac masses (e.g. atrial myxoma)
- Cardiomyopathy (e.g. hypertrophic cardiomyopathy)
- Pericardial disease (e.g. constrictive pericarditis)
- Non-cardiac causes (e.g. pulmonary embolism, aortic dissection)
What are the two types of arrhythmogenic syncopes? [2]
Tachyarrhythmias
Bradyarrhythmias
What is the first line treatment if someone is exhibiting bradycardia with sympptoms / evidence of life threatening signs? [1]
IV atropine 500 mcg
A patient is exhibiting bradycardia with signs of MI. You give 500mg of IV atropine.
There is no satisfactory response. What is the next step in management? [4]
- IV Atropine 500 mcg, repeat to maximum of 3mg
- Isoprenaline 5mcg IV
- Adrenaline 2-10mcg IV
OR
- Transcutaneous pacing
A patient has bradycardia and has no signs of shock / syncope / MI / HF but is at risk of asytole.
What are 4 conditions that means person is at risk of asytole? [4]
- Recent asytole
- Mobitz II AV block
- Complete Heart Block with broad QRS
- Ventricular pause > 3secs
A patient has bradycardia and has no signs of shock / syncope / MI / HF but is at risk of asytole.
What is the next appropriate managemet steps? [4]
Describe the treatment algorithm for ALS
- CPR 30:2
- Attach defibrillator
- Assess rhythm:
- If shockable (VF / Pulseless VT): one shock, then resume CPR for 2 min then assess rhythm again and repeat
- If non-shockable: immediately resume CPR for 2 mins and assess rhythm again
Adrenaline:
- 1 mg as soon as possible for non-shockable rhythms
- during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
- repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
amiodarone:
* 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered.
* a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
thrombolytic drugs:
* should be considered if a pulmonary embolus is suspected
* if given, CPR should be continued for an extended period of 60-90 minutes
When performing ALS, under which conditions do you give three successive shocks? [1]
if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend ‘up to three quick successive (stacked) shocks’, rather than 1 shock followed by CPR
&
if in ventricular fibrillation or pulseless VT
When performing ALS, under which conditions do you give adrenaline? [1]
Non-shockable rhythms:
- adrenaline 1 mg as soon as possible
Shockable rhythms:
- adrenaline 1 mg is given once chest compressions have restarted after the third shock
repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
Describe how the Standford [2] and Debakey Systems [4] are used to classifiy aortic dissections
The Stanford system:
Type A – affects the ascending aorta, before the brachiocephalic artery
Type B – affects the descending aorta, after the left subclavian artery
Debakey system:
Type I – begins in the ascending aorta and involves at least the aortic arch, if not the whole aorta
Type II – isolated to the ascending aorta
Type IIIa – begins in the descending aorta and involves only the section above the diaphragm
Type IIIb – begins in the descending aorta and involves the aorta below the diaphragm
Aortic dissection can lead to:
- Mitral stenosis
- Mitral regurgitation
- Aortic stenosis
- Aortic regurgitation
Aortic regurgitation
Aortic dissection can lead to which other cardiac complication? [1]
Cardiac tamponade
Describe the treatment of acute Stanford Type A AD [1]
What is the blood pressure systolic target prior to this? [1]
Emergency surgery is indicated in suitable patients
(It carries a mortality of 50% in the first 48 hours in those not undergoing surgical intervention)
blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Type A dissection is defined as a dissection proximal to the [] artery.
Type A dissection is defined as a dissection proximal to the brachiocephalic artery.
How do you manage a type A aortic dissection? [1]
IV BB and surgery
The patient’s blood pressure must be controlled within 100 -120 mmHg (systolic) whilst awaiting surgical intervention, therefore IV labetalol must be given.
How do you treat Dresslers? [1]
Post infarction pericarditis or Dressler’s syndrome can occur in 5-10% of patients after an acute MI
Treat with high dose aspirin
Concurrent use of clopidogrel and [] can make clopidogrel less effective
Concurrent use of clopidogrel and omeprazole/esomeprazole can make clopidogrel less effective
How do you adminiter TXA in an emergency haemorrhage? [1]
IV bolus followed by titration
A patient has neutropenic sepsis. What Abx should you give? [1]
IV tazocin
Which antiplatelets alongside aspirin do you give a STEMI patient depending on their current anticoagulation? [2]
NO medication - pragusel
Anticoagulation: Clopidogrel
Which antiplatelets alongside aspirin do you give an NSTEMI patient depending on their risk of bleeding? [2]
Low risk of bleeding:
- Aspirin; Ticagrelor; Fondaparinoux
High risk of bleeding:
- Aspirin; Clopidogrel; Fondaparinoux
You perform an ECHO and see that it is ‘shimmery.’ What is the likely diagnosis? [1]
Amyloidosis
What is Carvallo’s sign? [1]
Tricuspid regurgitationm murmur being louder on inspiration
What is psoas sign and what does it indicate? [1]
Extend right hip
If positive: feel pain in RIF
Indicates appendicitis
Caused by appendix in the retrocaecal position moving agaisnt iliopsoas muscle and causing irritation
