Cardiovascular 1 Flashcards
ACS risk factors
Age Male Family history Smoking DM HTN Hypercholesterolaemia Obesity
ACS initial management
ABCDE + MONA + DAPT Morphine O2 if sats < 94% Nitrates (GTN) - Useless in MI Antiemetic - Metoclopramide?
DAPT - Clopidogrel/Ticagrelor + Aspirin 300mg
ACS investigations
ECG
Cardiac enzymes
- Serial troponins (6 hours apart)
- Cardiac myosin-binding protein C
Glucose
FBC, U&E, LFT
TFT!!!!
Lipid profile
Rule out differentials - CXR, D-dimer, etc.
STEMI - ECG findings
> 2mm ST elevation
New onset LBBB
Reciprocal ST depression
Secondary
- T-wave inversion
- Pathological Q waves
ACS - ECG regions
V1-V4 - Anterior - LAD
I, V5, V6, aVL - Lateral - Circumflex
II, III, aVF - Inferior - Right coronary
V7-V9, ST depression V3-V4 - Posterior - Right coronary
STEMI management
DAPT + Morphine
Heparin - Pre-PCI
PCI if…
< 12 hours since onset and PCI available within 2 hours
> 12 hours since onset, with evidence of ongoing ischaemia
PCI not available within 2 hours - Fibrinolysis - Alteplase
+ CABG
NSTEMI management
DAPT
+ Fondaparinux
Grace score risk > 3
- Angiography within 4 days
+ CABG
ACS secondary management
ACE-I
Statin - 1 year
BB - 1 year
DAPT - 1 year
Cardiac rehab
Smoking cessation
Diet/exercise
Education
ACS complications
Pro-Heart ADVERTS
Papillary muscle rupture - MR HF - Chronic Aneurysm - LV wall - Stroke risk Dressler's - Pericarditis 2-5 weeks post-MI VSD Electrical - VF/VT/AF Rupture - LV wall Tamponade Shock - Pulmonary oedema
Angina criteria
- Sharp
- On exertion
- Relieved by GTN
3 = Angina 2 = Atypical angina 1 = Not angina
Angina referral rules
CP < 12 hours + Abnormal ECG = Urgent
CP > 24 hours = Same day admission
CP > 72 hours = Check ECG and troponin
Silent MI
Common exam question!
Patient is female or diabetic!
Atypical history
ECG shows obvious ischaemic changes
Angina management
Aspirin
Nitrates
Statin
BB or CCB (Amlodipine)
Long-acting nitrate - Isosorbide mononitrate
+ CABG
Infective endocarditis risk factors
CHIPS
CHD History of IE IVDU Prosthetic valve Structural heart defect
Infective endocarditis aetiology
Staph Aureus
Staph Epidermidis - Recent surgery
Strep Bovis - Colorectal
Strep Viridans
Predisposing factors in paeds
- ASD
- VSD
- PDA
Infective endocarditis symptoms
FROM JANE
Fever
Roth spots
Osler nodes - Painful - Hours/days
Murmur - MR - Pansystolic
Janeway lesions - Not painful - Days/weeks
Anaemia and anorexia
Nail haemorrhages
Emboli
Infective endocarditis investigations
Blood cultures
TTE
Duke’s criteria!
Infective endocarditis criteria
Duke’s criteria - BE TV MICE
2 major / 1 major + 3 minor / 5 minor
Major
- Blood culture +ve
- TTE - Evidence of endocardial involvement
Minor
- Temp > 38
- Vascular phenomenon
- Microbiological evidence
- Immunological phenomenon
- Cardiac condition or IVDU
- Echo findings
Infective endocarditis management
Unknown bacterial cause - Amoxicillin
Known Staph Aureus - Flucloxacillin
(Known prosthetic valve) + Rifampicin + Gentamicin
Strep Viridans - Benzylpenicillin
Rheumatic fever aetiology
Strep Pyogenes
Paeds
- Scarlet fever
- Strep pharyngitis
Rheumatic fever presentation
History of strep throat!
JONES FACE P
Joints - Arthralgia O - Heart - Murmur - Late diastolic MS Nodules Erythema marginatum Sydenham's chorea Fever Anaemia / Anorexia CRP ^ ECG - Prolonged PR Previous rheumatic fever
Rheumatic fever criteria
JONES (FACE P) criteria
JONES = Major
FACE P = Minor
2 major
1 major + 2 minor
Rheumatic fever investigations
Blood cultures
Throat swab
ASO titre
ECG - Prolonged PR
Rheumatic fever management
Penicillin
IM Benzylpenicillin
Rheumatic fever complications
Mitral stenosis!
HTN aetiology
Primary - Essential HTN
Secondary
Renal
- RAS
- PKD
- Glomerular disease
Endocrine
- Conn’s
- Cushing’s
- Acromegaly
- Phaeochromocytoma
Other
- Pregnancy
- COCP
- NSAIDs
HTN thresholds
> 140/90 - Perform ABPM
150/95 - Start anti-HTN medication
Age < 80 + Systolic > 135 + One of the following... - QRISK2 > 10 - End organ damage - Renal failure - HF - Diabetes = Start anti-HTN medication
HTN management
< 55 or DM2
- ACE-I or ARB
- A + Diuretic / CCB
- A + D + C
- K < 4.5 = Add spironolactone
K > 4.5 = Add AB or BB - Specialist review
HTN management
> 55 or Afro-Caribbean
- CCB
- C + ACE-I or ARB
- C + A + Diuretic
- K < 4.5 = Add spironolactone
K > 4.5 = Add AB or BB - Specialist review
Heart failure aetiology
CHAVS
CHD HTN Age Valvular disease Structural heart defect
Heart failure pathophysiology
Decreased renal perfusion
= RAAS activated
= Fluid retention
= Systemic oedema
HF presentation
Orthopnoea Dyspnoea Paroxysmal noctural dyspnoea Cough - Pink frothy sputum Lethargy Ankle oedema
HF signs
S3 + S4 Displaced apex beat Crackles / Wheeze Raised JVP Hepatosplenomegaly
Breathlessness in HF - Pathophysiology
Poor cardiac output from LV Left side of the heart becomes congested Poor blood flow in pulmonary vessels Increased hydrostatic pressure Fluid moves from vascular to tissue compartment Poor gaseous exchange = Breathlessness
HF investigations
BNP TTE CXR - ABCDE ECG - LVH Baseline bloods
Depression screen
HF - CXR findings
ABCDE
Alveolar oedema B - Kerly B lines - Interstitial oedema Cardiomegaly Dilated upper lobe vessels Effusions
HF management - Pharmacological
ACE
BB
One of…
- Spironolactone
- ARB
- Hydralazine nitrate
Digoxin
Diuretic - Symptomatic relief only
HF management - Non-pharmacological
Cardiac rehab Lifestyle modification Fluid restriction - If overloaded Pneumococcal vaccine Flu vaccine
HF complications
Arrhythmias - AF Sudden cardiac death Depression Cachexia Death - 5-year survival is 5% Impotence CKD
HF classification
New York Heart Association
- Functional capacity (1-4)
- Objective assessment (A-D)
Acute HF - Clinical features
Acute pulmonary oedema
Cardiogenic shock
Right-sided HF
Acute HF - Management
Diuresis - Furosemide
O2 / CPAP
Clinical evaluation of systolic BP
> 100 - GTN
85-100 - Inotrope - Milrinone / Dobutamine
< 85 - Volume loading - NaCl
Pericarditis aetiology
MUMPs ITCH
Mumps/Coxsackie’s
Uraemia
Malignancy
Post-MI - Dressler’s
Infiltrative - TB
Trauma
Connective tissue disorder
Hypothyroid
Pericarditis clinical features
Chest pain - Relieved sitting forwards
Pericardial rub - Scratchy sound on auscultation
Pericarditis investigations
ECG - Global changes
- PR depression
- Concave ST elevation - Saddle deformity
CRP ^
CXR - Rule out alternative diagnoses
Troponins - Rule out MI
Pericarditis management
NSAIDs
Colchicine
Steroids - If severe
Treat cause
Constrictive pericarditis
Most often caused by TB
Pericardial knock - Loud S3
CXR - Pericardial calcification
Cardiac tamponade aetiology
Pericardial effusion
Usually due to trauma
Cardiac tamponade presentation
Beck’s triad!
- Fixed raised JVP
- Hypotension
- Muffled heart sounds
Dyspnoea
Tachycardia
Cardiac tamponade investigations and examination findings
ECG - Electrical alternans - QRS complexes alternate in amplitude
On examination…
- Pulsus paradoxus - BP drop > 10 during inspiration
- Kussmaul sign - JVP unchanged throughout inspiration
- Absent Y descent in JVP
Cardiac tamponade management
Pericardiocentesis
Aortic stenosis aetiology
Calcification
Bicuspid valve
Rheumatic heart disease
Aortic stenosis presentation
SADD
Syncope
Angina
Dyspnoea
Death
Aortic stenosis examination findings
Ejection systolic murmur - Radiating to the carotids
- 2nd intercostal space
Ejection click Narrow PP Slow rising pulse S4 Thrill
Aortic stenosis investigations
TTE
ECG
- LVH
- Downward T wave in V6
Aortic stenosis management
Symptomatic or valvular gradient > 40
TAVI - Transcatheter aortic valve replacement
+ Angiography
Aortic regurgitation aetiology
Acute
- Aortic dissection - Dilatation effect
- IE
- Rheumatic fever
Chronic
- Ehlers-Danlos / Marfan’s
- Ankylosing spondylitis
- RA
Aortic regurgitation presentation
Orthopnoea
Fatigue
Aortic regurgitation clinical findings
Diastolic murmur - On held expiration
- Left 3rd intercostal space
Austin-Flint murmur - Mid-late
- Low pitched rumbling
- Best heard at cardiac apex
Wide PP
Slow rising pulse
Quincke’s sign - Systolic pulsations on light compression of nailbed
DeMusset’s sign - Rhythmic head nodding in line with heartbeat
Aortic regurgitation investigations
TTE
Aortic regurgitation management
Diuretics - Furosemide
Valve replacement
Treat cause
Mitral regurgitation aetiology
Post-MI - Papillary muscle rupture
Rheumatic fever
IE
Ehlers-Danlos
Mitral regurgitation clinical findings
Pansystolic murmur
Best heard at cardiac apex
Left lateral position
Mitral regurgitation investigations and management
TTE
ECG
Valve replacement
Mitral stenosis aetiology
Rheumatic fever
Mitral stenosis examination findings
Mid-late diastolic murmur - Radiating to axilla
Opening snap
Malar flush
AF
Mitral stenosis investigations
TTE
ECG - AF
CXR - Left atrial enlargement
Mitral stenosis management
Vasodilators - GTN
Diuretics - Furosemide
Replacement
Bradycardia aetiology
Sinus bradycardia
- Athletes
- Hypothyroid
- Hypothermia
- Sick sinus syndrome
- Infarction
Extrinsic factors
- BBs
- Alcohol
AV block
BBB
Sinus bradycardia management
When symptomatic or < 40bpm
IV atropine
Temporary pacing wire
IV adrenaline
AV node block aetiology
PR > 0.2
Coronary artery disease
Cardiomyopathy
Fibrosis - Elderly patients
Abscess
AV node block symptoms
Syncope
Heart failure
AV node block management
If symptomatic or broad QRS
Pacemaker
IV atropine
AV node block types
1st degree - Prolonged PR
2nd degree
- Mobitz 1 - Increasingly long PR + Dropped QRS
- Mobitz 2 - Prolonged PR + Dropped QRS (specific ratio)
3rd degree - P waves have no relationship to QRS
LBBB
Aetiology - Post MI / Aortic stenosis
WiLLiaM
W in V1
M in V6
RBBB
Aetiology
- Physiological
- PE
- RVH
- CAD
- ASD
MaRRoW
M in V1
W in V6
Bifascicular block
Trifascicular block
Bifascicular = RBBB + LAD Trifascicular = RBBB + LAD + 1st degree block
Sinus tachycardia aetiology
Alcohol Stress Hyperthyroid HF PE Anaemia Caffeine Infection
SVT aetiology
AAAAAAAAAAAAAAAAAAA
AF
Atrial flutter
Atrioventricular re-entry tachycardia - AVRT
Atrioventricular nodal re-entry tachycardia - AVNRT
AF aetiology
Paroxysmal
- PE
- Infection
- Alcohol - Holiday heart syndrome
Prolonged / permanent
- HF
- Age
- Post-MI
- Cardiomyopathy
- Mitral stenosis
- Hyperthyroid
AF investigations
ECG
- Irregularly irregular
- Absent P waves
TFTs
AF management
Onset < 48 hours - Rate or rhythm control
Onset > 48 hours - Rate control
Rate control
- BB
- CCB - Rate limiting - Verapamil
- Digoxin
Rhythm control
- Flecainide - No structural heart abnormality
- Amiodarone
- DC cardioversion - If acutely unwell and < 48 hours since onset
- Ablation
CHADSVASC - Anticoagulate - Warfarin
CHA2DS2-VaSc
Female = 2 Male = 1
CHF - 1 HTN - 1 Age 65-75 - 1 Age > 75 - 2 DM - 1 Stroke/TIA/VTE - 2 Vascular disease - 1 Sex - Female - 1
HASBLED
HTN - 1 Abnormal renal and/or liver function - 1 or 2 Stroke - 1 Bleeding disorder - 1 Labile INRs - 1 Elderly > 65 - 1 Drugs - NSAIDs and/or alcohol - 1 or 2
AVNRT
Atrioventricular nodal re-entry tachycardia
Teens / 20s
ECG - Absent P waves + Narrow QRS
WPW pathophysiology
Congenital accessory pathway between atria and ventricles
Atrioventricular re-entry tachycardia
Accessory pathway does not slow conduction
AF can lead to VF
WPW ECG findings
Short PR Wide QRS - Slurred upstroke - Delta wave Left or right axis deviation Type A - Dominant R wave in V1 Type B - No dominant R wave in V1
WPW associated conditions
Hypertrophic cardiomyopathy Mitral valve prolapse Ebstein's anomaly Thyrotoxicosis Secundum ASD
WPW management
Radiofrequency ablation of accessory pathway
Sotalol
Amiodarone
Flecainide
SVT management
Vasovagal manoeuvres
IV adenosine
DC cardioversion
Long-term
- Radiofrequency ablation
- BB
