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Passmed > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

What three conditions come under Acute Coronary Syndrome?

A

STEMI
NSTEMI
Unstable angina

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2
Q

How does an STEMI present on an ECG?

A

St elevation
New left bundle branch block

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3
Q

What are the symptoms of ACS?

A

Chest pain: central, crushing
Pain radiating down left arm
Dyspnoea
Nausea
Dizziness
Vomiting
Palpitations
Epigastric pain
Syncope
Confusion

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4
Q

What are the modifiable risk factors for ACS?

A

Smoking
Obesity
Diet
Hyperlipidemia
Sedentary Lifestyle

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5
Q

Is MI more common in males or females?

A

Males
60-70

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6
Q

How do you differentiate between NSTEMI and unstable angina?

A

Both show inverted t waves and st depression
NSTEMI: will have raised Troponin due to myocardial infarction

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7
Q

How do you diagnose ACS, and differentiate between the types?

A

ECG
CxR
Troponin
Echocardiagram
lipid profile
U&E
Glucose
FBC

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8
Q

What is the initials management for suspected ACS?

A

Aspirin: 300mg orally
Morphine: 5mg IV
Nitrates: GTN
Oxygen: If says below 94%

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9
Q

What is the criteria for PCI treatment in STEMI? What drugs are used?

A

Criteria:
- within 12 hrs of symptom onset
- can be given within 120minutes of thrombolysis
- >12 hrs if ongoing ischaemia

Drugs:
- prasegral once PCI confirmed: no anticoagulant
- clopidogrel if on anticoagulant.

Radial access: unfractioned heparin + GPI
Femoral access: bivalirudin + GPI

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10
Q

If PCI cannot be given within 120 minutes what treatment is given for a STEMI?

A

Thrombolysis + antithrombin
Then ticagrelor

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11
Q

How is NSTEMI/ unstable angina treated?

A

Initial management + fondaparinux (2.5mg)
Use Grace scoring:
- >3% angiography + PCI (prasegral)
-<3% offer ticagrelor

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12
Q

What is the secondary management for ACS?

A

ACE inhibitor: Indefinitely
Dual Antiplatelet therapy: for 12 months
Then single Aspirin: indefinitely
Beta blocker: up to 12 months
Statin: indefinitely

Lifestyle:
Diet
Exercise
Smoking cessation
Alcohol consumption

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13
Q

Is infective endocarditis more common in males or females?

A

Males

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14
Q

What are the risk factors for infective endocarditis?

A

Cardiac:
- Structural heart disease
- valvular disease
- hypertrophic cardiomyopathy
- prosthetic valve and cardiac devise

General,
- Male
- IV drug use
- immunocompromised
- Previous IE
- dental procedure/ surgery
- Haemodialysis

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15
Q

What are the most common bacteria causing IE?

A
  • staph aureus
  • streptococcus Viridian
  • Enterococci
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16
Q

What are the symptoms of IE?

A

Fever
Fatigue
Weight loss
Anaemia
Night sweats
Malaise
Breathlessness
Haematuria
Abdominal pain

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17
Q

What are the clinical signs of IE?

A

Heart murmur
Splinter haemorrhages
Jane way lesions
Osler nodes
Roth spots
Clubbing
Petechiae
Bibasal lung Crepitations
Glomerular nephritis

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18
Q

What investigations are done for IE?

A

Blood cultures
FBC
CRP/ESR
Urea + Electrolytes
Transthoracic echocardiogram
Transoesophageal echocardiogram
CxR
CT

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19
Q

Which type of echocardiogram is performed first line for IE?

A

Transthoracic
Transoesophageal performed if trans thoracic is negative but clinical signs point towards IE

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20
Q

Describe the bacterial culture process for IE?

A

3 cultures must be taken within 30 mins of each other, from 3 different sites, before commencing antibiotics at the peak of fever

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21
Q

What is the dukes criteria?

A

Dukes criteria is used for diagnosis of Infective endocarditis
IE definite if :
- positive pathological criteria
- 2 major criteria
- 1 major + 3 minor
- 5 minor criteria

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22
Q

What are the major criteria for IE?

A

Positive blood cultures:
- 2 separate cultures positive for microorganisms causing IE
- persistent positive cultures of microorganism typical of aiE
- single positive culture for coxiella Burnetti
- High IgG antibody titre 1:800

Endocardial damage:
- new dehiscence (breakdown of sutures attaching valve)
- new valvular regurgitation
-abscess

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23
Q

What are the minor criteria for IE?

A
  • fever >38c
  • present risk factors for IE
  • vascular phenomena: Jane way lesions, septic emboli (PE)
  • immunological phenomena: glomerulonephritis, Osler nodes, roth spots
  • positive microorganisms/ blood culture
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24
Q

What is the empirical treatment for suspected IE?

A

Native: Amoxicillin + gentamicin
PA allergy: vancomycin + gentamicin
prosthetic: vancomycin + rifampicin + gentamicin

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25
Q

What is the antibiotic of choice for Staph aureus causing IE in both native and prosthetic IE?

A

Native:
- fluoxacillin
Penicillin allergy: vancomycin + rifampicin

Prosthetic:
- fluoxacillin + rifampicin + low dose gentamicin
PA: vancomycin + rifampicin + low dose gentamicin

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26
Q

What are the indications for surgery in IE?

A
  • heart failure
  • persistent/ uncontrolled infection
  • abscess
  • recurrent systemic emboli
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27
Q

What is acute heart failure?

A

New onset of or worsening of signs and symptoms of heart failure

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28
Q

What is decompensated acute heart failure?

A

Decompensated heart failure is worsening of symptoms in a patient with a background of heart failure

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29
Q

What is the leading cause of acute heart failure?

A

Myocardial infarction

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30
Q

What are the symptoms of acute hearts failure?

A

Dyspnoea
Ankle oedema
Fatigue
Pink frothy sputum
Orthoptera
Reduced exercise tolerance
Paroxysmal nocturnal dyspnoea
Wheezing
Weight gain

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31
Q

What are the signs of heart failure?

A

Bibasal crackles
Hypoxia
Tachypnoea
Raised JVP
Cyanosis
Dull lung bases

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32
Q

How is heart failure diagnosed?

A

BNP
NT-ProBNP
CxR
Echocardiogram
Troponin
fBC
ABG
ECG

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33
Q

When do you urgently refer a patient with suspected Acute heart failure for an echo?

A

If the NT-proBNP is greater than 2000ng/L

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34
Q

If a patient has a pro BNP between 400-2000ng/L what should you do?

A

Refer them for specialist assessment and transthoracic echocardiogram within 6 weeks

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35
Q

What can a chest x ray show in acute heart failure?

A

Alveolar oedema (batwing opacification, perihilar)
Kerley b line (IO)
Cardiomegaly
Dilated upper lobe vessels
Effusion

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36
Q

How is acute heart failure initially managed?

A

Oxygen if patient is hypoxic
Loop diuretic: furosemide 40mg
Nitrates: In patients with myocardial Ischemia and hypertension, not in patients with systolic below 90mmHg

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37
Q

What can reduce cardiac output?

A

Reduced heart rate
Reduced preload
Reduced contractility
Increased preload

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38
Q

When patient is on an ACE inhibitor what routine checks need to be done?

A

Serum sodium
Serum potassium
Renal function

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39
Q

What specialist treatment is available for chronic heart failure?

A

Ivabradine
Digoxin
Sacubitril Valsartan

40
Q

What lifestyle changes are recommended in heart failure patients?

A

Smoking cessation
Reduced alcohol consumption
Exercise
Diet
Vaccinations
Cardiac rehabilitation

41
Q

What is the order of treatment in chronic heart failure?

A

1: ACE/ARB
2: Beta blocker
3: aldosterone antagonist (MRA)
4: SGLT2 inhibitor

42
Q

What is the most common cause of right sided heart failure?

A

Left sided heart failure

43
Q

What is the most commonly involved artery in an MI?

A

Left anterior descending artery

44
Q

Which leads show st elevation in inferior MI? Which artery is affected?

A

Lead 2
Lead 3
avF
Right coronary artery

45
Q

Which leads show st elevation in anteroseptal MI? Which artery is affected?

A

V1-V4
Left anterior descending artery

46
Q

Which leads show st elevation in lateral MI? Which artery is affected?

A

Lead 1
AVL
V5-V6
Left circumflex artery

47
Q

What is required to make a diagnosis of postural hypotension?

A

Standing/ lying blood pressure.
Get patient to lie on the bed for 5 minutes, then take blood pressure.
Get patient to then stand for a minute then take blood pressure again.
Make diagnosis if:
Systolic Bp falls by 20mmHg or more
Diastolic BP falls by 10mmHg or more

48
Q

What is the difference between primary and secondary hypertension?

A

Primary hypertension makes up around 90% of cases and is hypertension with no underlying cause. Secondary hypertension is high blood pressure caused secondary to another condition.

49
Q

What is classed as stage 1 hypertension?

A

Clinic BP of 140/80 mmHg or more
ABPM/HBPM 135/85mmHg or more

50
Q

Describe step 1 management of hypertension in stage 2 and 3 hypertension?

A

Offer ACE/ARB in:
- patients who are type 2 diabetic
- patients who are <55 and are not of black African/ African-Caribbean origin

Offer calcium channel blocker in:
- patients >= 55 and don’t have type 2 diabetes
- are of black African or African- Caribbean descent and don’t have diabetes

51
Q

What is step 2 management of hypertension?

A

If step 1 not successful, first check adherence and review

Add:
- thiazide like diuretic (indapamide)
- calcium channel blocker

Those already on CCB:
- offer ACE or ARB
- offer thiazide like diuretic

ARB preferred in black Africans and African- caribbeans

52
Q

What treatment is offered in step 3 for hypertension?

A

Check doses at optimal and adherence

Offer all 3:
- ACE/ARB
- thiazide like diuretic
- CCBn

53
Q

What is the mechanism of action of rivaroxaban? Side effects?

A

It is a factor Xa antagonist
It competitively inhibits factor Xa which prevents activation of prothrombin (factor 2) to thrombin (factor 2a). This then prevents activation of fibrinogen to fibrin.

Side effects: menorrhagia, dizziness, GI discomfort, headache, oedema, diarrhoea

54
Q

What is the reversal agent for factor Xa antagonists?

A

Adexanet alfa

55
Q

Which murmurs are systolic?

A

Aortic stenosis
Pulmonary stenosis
Mitral regurgitation
Tricuspid regurgitation

56
Q

What produces an ejection systolic murmur?

A

Aortic stenosis
Pulmonary stenosis
Atrial septal defect
HOCM

57
Q

What murmur produces a diastolic murmur?

A

Mitral stenosis
Tricuspid stenosis
Aortic regurgitation
Pulmonary regurgitation

58
Q

When in diastole does the s4 and s3 sounds occur?

A

S4: End diastole
S3: Early diastole

59
Q

What produces a mid to late systolic murmur?

A

Mitral valve prolapse

60
Q

Why is the S4 sound produced?

A

Pressure overload
Thickened left ventricle resulting in increased pressure which the atrium has to pump blood against ( non compliant ventricle)

61
Q

What causes a S4 heart sound?

A

Left ventricular hypertrophy
Hypertrophic cardiomyopathy
Systemic hypertension

62
Q

Do you listen for s3 and s4 with the bell or diaphragm?

A

Bell: low pitched sounds

63
Q

What type of murmur is produced by aortic regurgitation?

A

Early diastolic murmur

64
Q

What is aortic stenosis?

A

Narrowing of the aortic valve

65
Q

What are the main symptoms of aortic stenosis?

A

Exertional dyspnoea
Exertional angina
Exertional syncope

66
Q

What are the clinical signs found in aortic stenosis?

A

Ejection systolic murmur
Radiation to carotids
Slow rising pulse
Split s2 on expiration
S4 heart sound

67
Q

What are the causes of aortic stenosis?

A

Idiopathic age related calcification
Bicuspid valve
Unicuspid valve
Rheumatic fever
Familial hyper cholesterolemia
Chest radiation therapy

68
Q

What is galvardins phenomenon?

A

It is when a pansystolic murmur is heard at the apex due to aortic stenosis mimicking mitral regurgitation

69
Q

What are other symptoms of aortic stenosis?

A

Heyde syndrome
Heart failure symptoms: oedema, Orthopnoea
AF

70
Q

How do you determine the severity of aortic stenosis?

A

Jet velocity
Mean transvulvular pressure gradient
Aortic valve area

71
Q

Which symptom most often presents first in aortic stenosis?

A

Dyspnoea

72
Q

What is Heyde syndrome?

A

It is a triad of aortic stenosis, GI bleeding and acquired Von Willebrand syndrome
It is GI bleeding from Angiodysplasia in the presence of aortic stenosis due to increased shear stress on the blood flowing through the aortic valve

73
Q

How do you distinguish between gallavardin phenomenon and mitral regurgitation?

A

Hand grip exercise and transient arterial occlusion

74
Q

Describe the mechanism behind syncope in aortic stenosis?

A

During exercise the peripheral blood vessels dilate to increase blood flow to muscles, this results in reduced total peripheral resistance. In aortic stenosis the valve is narrowed and therefore the cardiac output cannot increase enough to meet this demand as a result the mean arterial blood pressure drops and blood flow to the brain is reduced. Resulting in syncope.

75
Q

Describe the mechanism behind angina in aortic stenosis?

A

In aortic stenosis, the left ventricle needs to pumps against a greater pressure in order to pump blood around the body. In order to overcome this, the left ventricle becomes thicker (hypertrophies) overtime as aortic stenosis worsens. However, the ventricle at one point is unable to hypertrophic anymore but the aortic stenosis continues to worsen. The left ventricle requires more blood as it needs to work harder, the blood supply to the heart is unable to meet this demand resulting in myocardial ischaemia. During exercise there is a mismatch in supply and demand.

76
Q

Why is the intensity of an aortic stenosis murmur not a good indicator of severity?

A

Initially as aortic stenosis becomes worse the murmur gets loader. However, once the patient develops heart failure the cardiac output reduces and the murmur becomes softer

77
Q

How is symptomatic AS treated?

A

SAVR or TAVI

78
Q

When do you offer surgical treatment for AS if patient is asymptomatic?

A
  • left ventricular ejection fraction below 50%
  • undergoing other cardiac surgery
  • rapid progression
79
Q

What is the most common cause of aortic stenosis in those aged under 70?

A

Bicuspid aortic valve

80
Q

What investigation is done for aortic stenosis with reduced ejection fraction?

A

Dobutamine stress echocardiogram

81
Q

What 2 things can cause an irregularly irregular pulse?

A

AF
Ventricular ectopics

82
Q

What is Atrial Fibrillation?

A

AF is when the electrical activity of the atria become disorganised. Each individual myocyte of the heart has the ability to contract independently resulting in unsynchronised contraction of the atria.

83
Q

What symptoms are seen in AF?

A

Asymptomatic
Palpitations
Dizziness
Fatigue
Dyspnoea
Stroke
Tachycardia
Tachypnoea
HF

84
Q

What are the risk factors/ causes for AF?

A

Cardiac: IHD, structural heart disease, HTN, DM, obesity
Respiratory: pneumonia, PE
Thyrotoxicosis
Chronic kidney disease
Caffeine
Alcohol excess
Age
Male

85
Q

What investigations are done for suspected AF?

A

ECG
Radial pulse examination
24hr ECG

Underlying cause:
FBC
U&Es
TFTs
Blood glucose
Echo radiogram

86
Q

What are the 2 types of AF?

A

Paroxysmal: recurrent episodes of AF terminating within 7 days
Persistent: AF lasting more than 7 days

87
Q

What is the first line treatment for AF? What are the contraindications?

A

Rate control
Contraindications include:
Reversible cause of AF
Haemodynamically unstable
New onset AF
HF caused by AF

88
Q

What are the indications for immediate cardioversion?

A

New onset AF within 48hrs of onset
Haemodynamically unstable

89
Q

What medication is used for pharmacological cardioversion?

A

Flecainide
Amiodarone: if IHD or SHD

90
Q

When should delayed cardioversion be done? Procedure?

A

Patient presents after 48 hrs with symptoms/ unsure of onset. Anticoagulant must be started 3 weeks before cardioversion. Cardioversion must be electrical guided by trans oesophageal echocardiography.

91
Q

What medications are used for long term rhythm control after successful cardioversion?

A

First line: beta blocker
Second line: dronedarone
Third line: amiodarone

92
Q

W(at are the requirement# for dronedarone use?

A

No HF or left ventricular systolic function plus one of the following:
Hypertension
Diabetes
Age 70 or above
Previous stroke/ TIA

93
Q

What is the “pill in pocket” approach?

A

This is used for patients with paroxysmal AF, who meet the following criteria:
Infrequent episodes
No IHD, SHD
Systolic Bp above 100
HR above 70

Flecainide is given to be taken when experiencing an episode of AF

94
Q

What anticoagulation medication is given for patients with new onset AF? When can it be discontinued?

A

Heparin
Discontinue if patient is successfully returned to sinus rhythm after cardioversion
Low risk of reacurrence

95
Q

If rate is not controlled in Afib my mono therapy what can be done?

A

Dual therapy with 2 of the following:
Beta blocker
Diltiazem
Digoxin

96
Q

Which calcium channel blockers are rate limiting?

A

Diltiazem
Verapamil

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