Cardiovascular Flashcards
Anteroseptal, inferior, lateral leads and which coronary artery they cover?
Anteroseptal = V1-V4 (LAD)
Inferior = II, III and aVF (RCA)
Lateral = I, aVL, V5, V6 (LCx)
Normal P, PR and QRS duration?
P = 0.08-0.1 secs
PR = 0.12-0.2 secs
QRS = < 0.1 secs
What does a small vs large box on a standard ECG represent?
Small = 0.04 seconds
Large = 0.2 seconds
Calculating heart rate using the rhythm strip?
Regular = 300 ÷ large squares between QRS complexes
Irregular = QRS complexes in 6 seconds (30 large squares) x 10
ECG feature of right vs left axis deviation and causes?
Right = lead I + III point to each other
→ RVH, RBB, cor pulmonale, anterolateral MI, left posterior hemiblock
Left axis = lead I + II point away from each other
→ LVH, LBBB, inferior MI, left anterior hemiblock
ECG features of RBBB vs LBBB?
WiLLiaM MaRRoW:
→ RBBB = M in V1, W in V6
→ LBBB = W in V1, M in V6
Bifascicular vs trifascicular block?
Bifascicular = RBBB + left hemiblock
Trifascicular = above + 1st degree heart block
Outline the sinoatrial (SA) node action potential.
- Slow Na influx (HCN “pacemaker” channel)
- Rapid Ca influx
- K efflux
Outline the atrial/ventricular myocyte action potential.
- Rapid Na influx
- K efflux vs Ca influx (plateau phase)
- K efflux exceeds Ca influx
Virchow’s triad?
Stasis of blood
Endothelial damage
Hyper-coagulability
Heart attack vs cardiac arrest?
Heart attack = vascular occlusion or ischaemia leads to tissue death
Cardiac arrest = electrical disturbance stops heart beat
Acute coronary syndromes and ECG/troponin findings?
Unstable angina = abnormal/normal ECG + normal troponin
NSTEMI = abnormal/normal ECG + raised troponin
STEMI = ST-elevation/new LBBB + raised troponin (not required)
Patient groups more likely to have an atypical ACS presentation?
Elderly
Diabetics
Women
ECG features of ischaemia?
ST elevation or depression
T wave elevation or inversion or flattening
New LBBB
Pathological Q waves
ECG criteria for STEMI diagnosis?
≥ 1mm ST elevation in any 2 contiguous leads except V2 and V3 where these criteria apply:
→ ≥ 2.5mm in men < 40
→ ≥ 2mm in men > 40
→ ≥ 1.5mm in women
ECG feature of posterior MI?
Reciprocal changes in leads V1-V3 (e.g. ST depression)
Which coronary artery supplies the atrioventricular (AV) node and significance?
Right coronary artery
RCA infarcts (e.g. inferior MI) can cause arrhythmias
Management of a STEMI?
Morphine (severe pain)
Oxygen (SaO2 < 94%)
GTN (not if hypotensive)
Aspirin 300mg
Ticagrelor or prasugrel or clopidogrel
PCI < 120 mins = PCI + UFH and GPI (radial access) or bivalirudin and GPI (femoral access)
PCI > 120 mins = thrombolysis + fondaparinux
Preferred antiplatelet for patient getting PCI vs high bleeding risk?
PCI = prasugrel
High bleeding risk = clopidogrel
ECG monitoring post-thrombolysis?
ECG after 60-90 mins
Consider PCI if ongoing ischaemia
List some contrindications to thrombolysis?
Bleeding/coagulation disorder
Active internal bleeding
Recent bleed, trauma or surgery
Stroke < 3 months ago
Severe hypertension
Intracranial neoplasm
First enzyme to be released in MI and enzyme used to assess re-infarction?
First to be released = myoglobin
Assessing for re-infarction = CK-MB
Most sensitive enzyme in MI, time of elevation, peak levels and when it return to normal?
Troponin
→ elevates in 4-6 hours
→ peaks at 12-24 hours
→ returns to normal at 7-10 days
Post-MI persistent ST-elevation and ventricular failure?
Left ventricular aneurysm
Post-MI cardiac tamponade?
Left ventricular free wall rupture
Features and management of cardiac tamponade?
Beck’s triad:
→ hypotension
→ raised JVP
→ muffled heart sounds
Management = pericardiocentesis
Post-MI pericarditis classification and management?
< 48 hours = acute pericarditis
2-6 weeks = Dressler’s syndrome
Management = NSAID + colchicine
Most common cause of death post-MI?
Ventricular fibrillation (VF)
Post-MI DVLA guidance?
4 weeks off driving
→ 1 week if successful angioplasty
Management of NSTEMI and unstable angina?
Morphine (severe pain)
Oxygen (SaO2 < 94%)
GTN (not if hypotensive)
Aspirin 300mg
Fondaparinux (if urgent PCI not planned)
Unstable = angiography +/- PCI (urgent)
GRACE score > 3% = angiography +/- PCI (within 72 hours)
GRACE score ≤ 3% = ticagrelor or clopidogrel
Secondary drug prevention of ACS?
Block an ACS:
→ beta-blocker
→ aspirin (lifelong)
→ ACEi
→ ticagrelor or prasugrel or clopidogrel (12 months)
→ statin
Statin examples, mechanism of action and side effects?
Examples = atorvastatin, simvastatin
Mechanism of action = inhibits HMG-CoA reductase
Side effects = myalgia, myositis, rhabdomyolysis, deranged LFTs
Statin monitoring requirements?
Baseline LFTs
→ LFTs at 3 months
→ LFTs at 12 months
Investigation for stable angina?
CT coronary angiogram
Management of stable angina?
GTN for all then:
1st line = beta-blocker or non-dihydropyridine CCB
2nd line = beta-blocker + dihydropyridine CCB
3rd line = beta-blocker + isosorbide mononitrate or ivabradine or nicorandil or ranazoline
4th line = PCI or CABG
Technique for preventing tolerance to standard-release isosorbide mononitrate?
Asymmetric dosing intervals e.g. 7 hours apart
Examples of antiplatelets vs anticoagulants?
Antiplatelets = aspirin, clopidogrel, prasugrel, ticagrelor
Anticoagulants = warfarin, heparin, rivaroxaban, edoxaban, dabigatran, fondaparinux, apixaban, bivalirudin
Mechanism of action of aspirin, clopidogrel, prasugrel and ticagrelor?
Aspirin = COX-1 and COX-2 inhibitor
Clopidogrel/prasugrel/ticagrelor = P2Y12 ADP receptor inhibitor
Mechanism of action of warfarin, heparin, rivaroxaban, apixaban, edoxaban, dabigatran, fondaparinux and bivalirudin?
Warfarin = vitamin K antagonist
Heparin/fondaparinux = activates antithrombin III
Rivaroxaban/apixaban/edoxaban = direct factor Xa inhibitor
Dabigatran/bivalirudin = direct thrombin inhibitor
Reversal agent for dabigatran vs apixaban vs rivaroxaban?
Dabigatran = idarucizamab
Apixaban/rivaroxaban = andexanet alfa
How is INR calculated?
INR = (patient PT ÷ normal PT) x ISI
Key factors which may potentiate warfarin?
Liver disease
P450 enzyme inhibitors
List some P450 inducers vs inhibitors?
Inducers = phenytoin, carbamazepine, rifampicin, St John’s wort, phenobarbitone, chronic alcohol use
Inhibitors = ciprofloxacin, erythromycin, isoniazid, amiodarone, ketoconazole, acute alcohol use
Management of INR 5.0-8.0 (no bleed vs bleed), INR > 8 (no bleed vs bleed) and major haemorrhage?
INR 5.0-8.0 (no bleed) = withhold 1 or 2 doses, reduce maintenance dose
INR 5.0-8.0 (bleed) = stop warfarin, IV vitamin K, restart warfarin when INR < 5.0
INR > 8 (no bleed) = stop warfarin, oral vitamin K, restart warfarin when INR < 5.0
INR > 8 (bleed) = stop warfarin, IV vitamin K, restart warfarin when INR < 5.0
Major haemorrhage = stop warfarin, IV vitamin K, prothrombin complex (1st line) or FFP (2nd line)
Examples of tachycardia?
Sinus tachycardia
Atrial fibrillation
Atril flutter
Re-entrant pathways
Ectopic beats
Classification of tachycardias?
Narrow, regular
Narrow, irregular
Wide, regular
Wide, irregular
Management of REGULAR narrow complex tachycardia?
Unstable = synchronised DC cardioversion!
Stable = vagal manoeuvres e.g. carotid sinus massage or Valsalva manoeuvre (1st line), adenosine 6mg → 12mg → 18mg (2nd line)
Management of REGULAR broad complex tachycardia?
Unstable = synchronised DC cardioversion!
Stable = amiodarone or lidocaine
Management of torsades de pointes?
Unstable = synchronised DC cardioversion!
Stable = IV magnesium sulphate
Outline the types of AF?
Acute (< 48 hours)
Paroxysmal AF (< 7 days, episodic)
Persistent AF (> 7 days, responds to cardioversion)
Permanent AF (> 7 days, no response to cardioversion)
Overview of acute AF management?
< 48 hours = rate OR rhythm control
> 48 hours or uncertain = rate control
Rate control management of AF?
1st line = beta-blocker or non-dihydropyridine CCB
2nd line = dual therapy of beta-blocker, diltiazem or digoxin
Rhythm control management of AF?
DC cardioversion
Pharmacological cardioversion
→ structural heart disease = amiodarone
→ no structural heart disease = flecainide
Advice for cardioversion management of AF?
< 48 hours = DC or pharmacological cardioversion
> 48 hours or uncertain = 3 weeks anticoagulation then DC cardioversion or TOE to exclude thrombus in the left atrial appendage then immediate DC cardioversion
Score to assess stroke vs bleeding risk of AF patients?
Stroke = CHA2DS2VASC
Bleeding risk = ORBIT
CHA2DS2VASC criteria and recommendation based on score?
CHF, HTN, > 75, DM, stroke/TIA/VTE, vascular disease, 65-74, female
0 = no treatment
1 = consider anticoagulation (male), no treatment (female)
≥ 2 = anticoagulation
Drug options for AF anticoagulation?
Non-valvular AF = DOAC
Valvular AF/prosthetic valve = warfarin
Management of atrial flutter?
Initially the same as AF e.g. rate/rhythm control
Radiofrequency ablation is curative
Examples of bradycardia?
Sinus bradycardia
Sick sinus syndrome
Heart block
Outline the types of heart block?
1st degree = PR > 0.2, regular
2nd degree (Mobitz I) = PR prolongs until dropped beat
2nd degree (Mobitz II) = PR interval constant but beat sometimes dropped
3rd degree = no association between P wave and QRS
Management of bradycardia?
1st line = atropine 500mcg (repeat up to 3mg)
2nd line = transcutaneous pacing
3rd line = transvenous pacing or permanent pacemaker
Which types of heart block require a permanent pacemaker?
Mobitz type II
3rd degree (complete) heart block