Cardiovascular (1) Flashcards
List three important investigations to carry out in the acute setting when a patient presents with chest pain.
ECG
Troponins (Can do high sensitivity assays at 6hr, most sensitive at 12)
Echocardiogram
NB: can do troponin at 3 hr and monitor incrementally
What is the next step in the management of a patient whose troponins are i) negative ii) positive
i) -ve: Exercise tolerance test
ii) +ve: coronary angiography (with dye)
List possible causes of chest pain of cardiac origin (3)
Ischaemic heart disease
Pericarditis
Aortic dissection
List possible causes of chest pain of respiratory origin (3)
PE
Pneumonia
Pneumothorax
List possible causes of chest pain of GI origin (3)
Oesophageal spasm
Oesophagitis/Gastritis
Candida
List one cause of chest pain of musculoskeletal origin
Costochondritis
List the symptoms, associated symptoms and risk factors of ischaemic heart disease.
Symptoms:
• Central, crushing chest pain
Associated Symptoms:
• Nausea
• Sweating
Risk Factors:
• Smoking
• Diabetes mellitus
• Hypertension
List the symptoms and associated symptoms of pericarditis
Symptoms:
• Pleuritic pain (worse on inspiration), which is better when leaning forward
Associated Symptoms:
• Preceding flu-like symptoms
List the symptoms, associated symptoms and risk factors of aortic dissection.
List 2 signs of AD
Symptoms:
• Tearing pain between the shoulder blades
Associated Symptoms:
• Based on where blood supply is being lost (e.g. if dissection spread up the carotid arteries it can cause stroke)
Risk Factors:
• Hypertension
• Marfan’s Syndrome
• Ehlers-Danlos Syndrome
O/E: Difference in BP in 2 arms, Early DM: AR
List some specific respiratory symptoms that you should ask a patient about when taking a history. (5)
Wheeze Breathlessness Haemoptysis Cough Weight loss
What is a common and major risk factor for gastritis?
Excessive alcohol
Which upper GI infection are immunocompromised patients at risk of developing?
Oral candidiasis
Following ECG, describe the management of a patient with a:
a. STEMI
b. NSTEMI
a. STEMI
Go to cathlab immediately for percutaneous coronary intervention + Angiogram/Angioplasty
Give aspirin + clopidogrel
b. NSTEMI
Go to cathlab within 24 hours
Give aspirin + clopidogrel + fondaprinux/LMWH
State the artery affected and the ECG leads showing ST elevation in myocardial infarction affecting the following parts of the heart:
a) Anterior
b Inferior
c) Lateral
a. Anterior Left Anterior Descending V1-V4 b. Inferior Right Coronary Artery II, III, aVF c. Lateral Left Circumflex I, aVL, V5/V6
Which common artery do the left circumflex and left anterior descending coronary arteries originate from?
Left Main Stem
How long after an MI does the troponin level peak?
24-48 hours
How long after an MI does the troponin level return to normal?
5-14 days
Describe how collapse caused by a cardiac condition is different from collapse caused by a neurological condition.
The sequence of events before, during and after the collapse is important
Before: No warning vs Aura
During: Tongue biting
After: Confusion
What are the three main cardiac causes of collapse?
Give another one
Arrhythmia
Outflow Obstruction
Postural Hypotension
Vasovagal syncope (increased vagal discharge leads to bradycardia and collapse – it can be precipitated by certain conditions)
List the main causes of collapse.
Hypoglycaemia
Cardiac reasons - 4
Neurological - seizure
List some features of seizures.
Tongue biting
Aura
Wetting themselves
Being confused after the seizure
Define syncope.
Collapse caused by hypoperfusion of the brain
List some investigations for arrhythmias.
ECG
24 hr tape
Cardiac monitor
State two causes of left-ventricular outflow obstruction.
Aortic stenosis
Hypertrophic obstructive cardiomyopathy (HOCM)
List two signs of aortic stenosis
Slow-rising pulse (+ low volume if severe)
Ejection-systolic murmur
What is the main investigation for outflow obstruction
Echocardiogram
What is the main investigation for postural hypotension?
Lying/standing blood pressure (20mmHg significant)
List some causes of Long QT Syndrome; how do you tell?
Congenital (mutations of K+ channels) - FHx of sudden death Hypomagnesaemia Hypokalaemia Drugs Longer than half of RR interval
List three causes of pan-systolic murmur
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
How do you differentiate between left-sided murmurs and right-sided murmurs?
Left-sided murmurs are louder on EXPIRATION (Aortic, mitral valves)
Right-sided murmurs are louder on INSIPRATION (Tricuspid, pulmonary)
State an important non-cardiac feature of tricuspid regurgitation
Hepatomegaly – due to backpressure causing hepatic congestion –> Increased JVP, pulsatile liver
List three causes of a raised JVP
Tricuspid regurgitation
Right heart failure
Constrictive pericarditis
List two causes of tricuspid regurgitation
Damage to valve leaflets (e.g. by bacteria); IVDU infective endocarditis
Right ventricular dilation of valve ring (valve root enlarges)
List two causes of right heart failure.
Left heart failure
Pulmonary hypertension
(E.g. COPD: Chronic hypoxia –> chronic vasoconstriction –>pulmHTN)
List some causes of constrictive pericarditis and define it
Infection (e.g. TB)
Inflammation (e.g. connective tissue disease - lupus, sarcoid)
Malignancy
Thickening/calcification of pericardium
List four causes of a systolic murmur.
Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Where are Systolic murmurs loudest and its radiation
Aortic stenosis – loudest in aortic area and radiates to the carotids
Mitral regurgitation – loudest in mitral area and radiates to the axilla
Tricuspid regurgitation: L sternal border
VSD: L sternal border, parasternal thrill
Describe how you would differentiate aortic stenosis and mitral regurgitation by associated signs
Aortic stenosis – slow-rising pulse (thrill under thumb), ejection systolic murmur, soft S2
Mitral regurgitation – displaced apex beat (hyperdynamic)
State four broad causes of palpitations.
Sinus tachycardia
Supraventricular tachycardia
Atrial fibrillation
Ventricular tachycardia
State three causes of sinus tachycardia.
- Physiological:
Shock (Sepsis)
Hypovolaemia - Endocrine (e.g. hyperthyroidism, phaeochromocytoma)
What is supraventricular tachycardia?
Regular narrow complex tachycardia with no p waves (depol. from AVN, not SAN
SVT refers to AVRT and AVNRT
Explain the difference between AVNRT and AVRT.
AVNRT – a local circuit forms around the AV node (Slow and fast pathways, one with shorter refractory period)
AVRT – a circuit forms between the atria and ventricles via an accessory pathway
What key feature can be spotted on the ECG of a patient with AVRT who has been restored to sinus rhythm?
Delta wave (slurred upstroke on the QRS complex)
What is the name of the accessory pathway in AVRT?
Bundle of Kent
How is AVRT definitively treated?
Radiofrequency ablation of the accessory pathway
Describe the ECG morphology of atrial fibrillation.
Irregularly irregular with no p waves
State two important causes of atrial fibrillation that must be considered in young people.
Thyrotoxicosis
Alcohol
List some causes of atrial fibrillation.
Myocardium (Heart Muscle): ischaemic heart disease, rheumatic heart disease, hypertensive heart disease
Endocardium: Valvular heart disease
Pericardium: Pericarditis
Lung: pneumonia, PE, cancer
Why do respiratory conditions cause AF?
AF originates in the part of the right atrium that is close to the pulmonary vasculature – so changes in the levels of oxygen, carbon dioxide and pressure can impact on the myogenic cells within the right atrium
Describe the ECG morphology of ventricular tachycardia.
Regular broad complex tachycardia (assume VT until proven)
State three causes of VT.
Ischaemia
Electrolyte abnormalities (Hypomagnesaemia
Hypokalaemia)
Long QT syndrome (look at old ECGs) - congen mutation?
Under what circumstance would you DC cardiovert a patient with SVT?
If they are haemodynamically unstable
What is the difference between cardioversion and defibrillation?
Cardioversion is synchronized with the cardiac cycle – the electrical impulse is delivered at a certain point during the cardiac cycle
Defibrillation is not synchronized
Describe the management of a patient with SVT who is not haemodynamically compromised. (AIM: restore to sinus rhythm)
- Start with manoeuvres (e.g. valsalva, immerse face in cold water, blow into a syringe)
- If unsuccessful give ADENOSINE, and put the patient on a cardiac monitor (rhythm strip)
6 mg rapid IV bolus -> doesn’t work -> give 12 mg -> if that doesn’t work, give another 12 mg
Adenosine slows the AVN
Warn pt. they may feel like they’re going to die
In which patients is adenosine contraindicated?
Asthmatics
What are the two main aims of management of AF?
Rate control
Reduce risk of stroke
Describe the criteria for cardioversion of patients with acute fast AF (rhythm control)
Cardioversion should only occur if the patient has presented within 48 hours of onset of symptoms or if they have presented after 48 hours and have been anticoagulated for 3-4 weeks
If the onset is > 48 hours then you will need to anticoagulate them for 3-4 weeks before cardioversion is possible (Warfarin, Rivaroxaban, Apixiban)
Which two drugs are regularly used for rate control in AF?
Beta-blockers
Digoxin
Under what conditions would digoxin not be particularly effective as a drug for rate control?
If the patient is acutely unwell (e.g. pneumonia)
Which drug is used to treat ventricular tachycardia without haemodynamic compromise?
IV Amiodarone
Treat underlying cause
What is the treatment of choice for patients who experience recurrent VTs?
Implantable cardioverter defibrillator (ICD)
Which variant of VT requires defibrillation?
Pulseless VT
Describe the appearance of left ventricular hypertrophy on ECG.
Deep S wave in V1/V2
Tall R wave in V5/V6
If S wave + R wave = > 7 large squares then it is left ventricular hypertrophy by voltage criteria
What is the definitive diagnostic test for left ventricular hypertrophy?
Echocardiography
Describe the ECG morphology of first-degree heart block.
Fixed prolonged PR interval
Describe the ECG morphology of Mobitz type 2 heart block.
Fixed prolonged PR interval with a dropped QRS every few beats
Describe the ECG morphology of complete heart block.
Complete dissociation between the atria (p waves) and ventricles (QRS complexes)
QRS complexes will be broad
Bradycardia
State three ECG signs of ischaemia.
ST depression
Pathological Q waves
T wave inversion
What features of an ECG would suggest ventricular strain or hypertrophy?
S waves and R waves
Axis deviation
What is responsible for these heart sounds:
S1, S2, Fixed wide splitting of S2, S3, S4?
S1: Closure of the mitral valve
S2: Closure of the aortic valve
Fixed wide splitting of S2: Atrial septal defect
S3: Rapid ventricular filling (sign of heart failure)
S4: Ventricular hypertrophy (caused by atria contracting against stiff ventricles)
Describe how you would distinguish between fixed wide splitting of S2 and S3.
Fixed wide splitting of S2 is heard better with the diaphragm
S3 – better with the bell and light pressure (low pitched)
Click b/t S1 and S2 is a sign of?
Mitral Valve Prolapse
Describe the steps in the management of acute heart failure.
Sit up Oxygen 60-100% GTN infusion (VD, less preload) Furosemide (IV) - gut oedema = wont absorb CPAP later if not oxygenating well
Why are the three drugs mentioned above used in acute heart failure?
GTN, diamorphine and furosemide are all venodilators – they reduce venous return to the heart, hence reducing preload
Describe the ALS protocol for VT and pulseless VF.
Shock CPR (2 mins) Assess rhythm Adrenaline every 3-5 mins Correct reversible causes
What are the two non-shockable rhythms?
Pulseless electrical activity (PEA)
Asystole
(Just do CPR + Adrenaline and correct causes)
State the 4Hs and 4Ts – reversible causes of cardiac arrest.
Hypoxia Hypothermia Hypovolaemia Hypokalaemia Toxic Thromboembolic Tamponade Tension pneumothorax
Describe the appearance of pericarditis on ECG.
Diffuse ST elevation (in all leads)
ST elevation is saddle-shaped
List causes of pleuritic chest pain.
PE Pneumothorax Pneumonia Pericarditis Pleural pathology NOTE: and subphrenic pathology (e.g. hepatic abscess)
Atrial Flutter: what does it look like?
Chaotic atrial activity
No p waves, narrow QRS
Saw-tooth baseline
Variable block (if 2:1 block = 150bpm)
What to check for if you think there is an Arrythmia/Conductive defectis?
Rate, rhythm
PR - prolonged?
QRS: Narrow, Broad, L/RBBB?
QT interval (long QT –> VT)
What to do if hypothermic pt is in VT?
Hypothermia affects metabolism of drugs –> cardiotoxic, and shock will not work. warm patient and give CPR
In HF what crackles do you hear?
Fine, end inspiratory crackles
