Cardiovascular Flashcards
Angina Pectoris
investigations
management
Investigations:
12 lead ECG - ST depression, T wave flattening
Blood tests
Coronary CT angiogram
Stress echo
Invasive angiography if inconclusive
Pharm mx: GTN, aspirin, B blocker, CCB, third agent (ivabradine, nicorandil or ranolazine)
Surgical mx: coronary revascularisation via PCI or coronary artery bypass graft
Long-term mx of ACS
Dual anti platelet (aspirin + clopidogrel/ticagrelor) for 12mo then aspirin indefinitely
Start B-blocker or CCB
Start short-acting nitrate for Sx relief
Start ACEi or angiotensin II receptor antagonist
Statin (atorvastatin 80mg)
AV block:
Causes
Types
Investigations
Management
Causes - cardiac (IHD), autoimmune (SLE), endocrine (hypothyroid), infective (endocarditis), drugs (BBs, CCB, amiodarone, digoxin)
Types
1st degree: PR > 200s (5 small boxes)
2nd degree Mobitz type 1 (Wenckebach): progressive PR prolongation resulting in missed QRS complexes
3nd degree Mobitz type 2: consistent PR interval with intermittently dropped QRS complexes, may present with dizziness syncope or sudden cardiac death
3rd degree (complete): no association between QRS and P waves. Pt has low cardiac output (dizzy, syncope, breathless, Stokes-Adams attacks)
Investigations
12 lead EC G
Bloods - FBC, U&Es, creatinine, Mg, thyroid, glucose, troponin
CXR
Echo
Mx
Discontinue AVN block drugs (BBs, CCBs, digoxin)
Permanent pacemaker even if asymptomatic.
Narrow complex tachycardia:
ECG
Investigations
Mx
SVT shows narrow QRS and absent/abnormal P-waves
Investigations:
Serial ECGs & continuous cardiac monitoring
U&Es (hypokalaemia and hypomagnesia)
FBC for anaemia and infection
Thyroid
Drug levels e.g. digoxin levels
Echo (once rate controlled) to assess LV function and asses for structural heart disease
Non-pharm Mx:
Unstable = DC cardioversion
Stable = carotid sinus massage (young patients due to embolic stroke risk) or valsalva
Radiofreq catheter ablation
Pharm Mx:
IV adenosine (except asthmatics)
IV verapamil
Consider digoxin, BB or amiodarone
Risk factors for broad complex tachycardia
IHD
Structural heart disease (e.g. cardiomyopathy, congenital heart disease)
Congenital conduction disorders e.g. Brugada syndrome, long QT
Electrolyte deficiency e.g. hypokalaemia/calcaemia/magnesaemia
QT-interval prolonging meds
Sympathomimetic agents e.g. cocaine
Torsades de Pointes
ECG
Investigations
Mx
ECG: polymorphic VT with cyclical sinusoidal chances in QRS
Investigations: ECGs, U&Es, drugs (digoxin), troponin, echo when rate controlled to assess structural abnormalities
Pharm Mx (if stable):
IV amiodarone
IV magnesium
Non-pharm: DC cardioversion if unstable
Implantable cardioverter defibrillator if cardiac arrest due to VT (unless reversible cause found)
Atrial fibrillation
Investigations
Management
Complications
Investigations:
12 lead ECG, 24h monitor if paroxysmal
Bloods - thyroid, fbc, U&Es, renal, coagulation (prior to anticoagulation)
CXR
Echo to assess LV function, left atria size and structural/valve disease
Complications: embolic events, MI (increase myocardial demand), tachycardia-induced cardiomyopathy, congestive cardiac failure
Mx: rate control (1st line) or rhythm (reversible, HF caused by AF or failed rate control)
ABCD Mx for AF: Anticoagulate, Beta blockers, Cardiovert/calcium channel blocker, Digoxin (if refractory)
Pharm Mx:
Rate control
1st line: bisoprolol or rate-limiting CCB (diatiazem)
2nd line: digoxin or alternative BB or CCB if not tried
Consider digoxin monotherapy if sedentary
Rhythm control
Trial BB
Consider flecainide if no SHD
Consider amiodarone if left ventricular impairment
Non-pharm Mx:
DC cardioversion if <48h duration, requires >3 weeks anticoagulation or transoesophageal echo prior (rule out atrial clot)
Radiofreq ablation if above is unsuccessful
CHA2DS2-VASc score
Congestive HF 1
HTN 1
Age >75 2
DM 1
Stroke/TIA 2
Vasc disease 1
Age 65-74 1
Sex (female) 1
Anticoagulation advised if score =>2 (men scoring >1)
Use ORBIT and HASBLED to predict bleeding risks
HTN
Stages
Mx
Treatment targets
Stage 1 - CBP 140/90 x 2 or home ave >135/85
Stage 2 - CBP 160/100 HBP 150/95
Severe - CBP 180/110
Mx:
<55 and not afro: ACEi (ramipril) or ARB (candesartan)
>55/afro: CCB (amlodipine) if not tolerated give thiazide like diuretic (inapamide)
2nd line: dual therapy A+C or D; C+A or D
3rd line: A + C + D
4th: alpha/BB of K+ >4.5 or spironolactone if <4.5
Targets
<80 = <140/90
>80 = <150/90
diabetic = <130/80
Heart failure
Subtypes
NYHA
Investigations
Mx
Preserved EF >40%: present as hypertrophic and restrictive cardiomyopathy
Reduced EF <40%: dilated cardiomyopathy, IHD or MI
NYHA
I - no limit
II - slight limit
III - marked Sx on minimal activity
IV - Sx at rest (bed bound)
Investigations
ECG for arrhythmia
CXR for cardiomegaly or pul oedema
NT-proBNP
Echo for ventricular function
Pharm Mx:
ACEi (ramipril) or BB (bisoprolol) improve outcome in reduced EF
Loop diuretic (furosemide)
Spirinolactone
Vasodilator (isorbide) reduces mortality
Rate control or anticoagulate if arrhythmia
Non-pharm Mx:
Treat underlying cause (valve replacement)
Cardiac resynchronisation if EF<35% and LBBB with QRS >120ms
ICD if EF <35% or sudden cardiac death
LVAD if patient unresponsive to pharm
Heart transplant
Cardiomyopathy
Subtypes
Investigations
Management
Dilated CM (most common) - ventricles become dilated and reduce LVEF.
Hypertrophic CM - leading cause of sudden cardiac death. Autosomal dominant. Ejection systolic murmur.
Restrictive CM - reduced diastolic filling with normal systolic function.
AVRC - fatty replacement of myocardium. presents as cardiac syncope or sudden cardiac death in the young.
Investigations
ECG (normal)
CXR for cardiomegaly and HF
Echo is gold standard
Pharm Mx:
rhythm control - BB, amiodarone
anticoagulants for emboli
mx of HF
Non-pharm:
ICD if sudden death
Surgical myomectomy
Heart transplant
Screen relatives.
Mitral regurgitation
Aetiology
Pathophysiology
Clinical signs
Investigations
Mx
Complications
Primary - degeneration of valve
Secondary - distortion or subvalvular apparatus
MR reduced cardiac output, causes volume overload in the left atrium and ventricle.
Signs
Irregularly irregular pulse (AF associated)
Pansystolic murmur
Right ventricular heave
Displaced hyperdynamic apex beat
Soft S1 and split S2 and S3 in severe MR
Investigations
ECG: AF, p mitrale or left ventricular hypertrophy
ECHO IS GOLD STANDARD
CXR for cardiomegaly/HF
Consider angiography if coronary artery disease
Mx: manage risk factors, AF and diuretics if HF.
Mitral valve replacement if acute/severe
Complications: AF, LVD, pul HTN
Aortic stenosis
Clinical signs
Investigations
Management
Signs:
Ejection systolic murmur
Slow rising pulse
Narrow pulse pressure
No S2
Heaving, non-displaced apex beat
Investigations
ECG - p mitrale, left-axis dev, LBBB, left ventricular hypertrophy
ECHO IS GOLD STANDARD
CXR for cardiomegaly/HF
Consider angiography if coronary artery disease
Mx:
medical - reduce HTN (ACEi)
surgical - aortic valve replacement or trans catheter valve implantation
Aortic regurgitation
Clinical signs
Associations
Investigation
Mx
Signs:
collapsing pulse
wide pulse pressure
hyper dynamic displaced apex beat
high pitch early diastolic murmur
Austin flint murmur if severe
quinickes sign (capillary pulsation on nail bed)
Associations - Marfans syndrome
Investigation
ECG - left-axis dev
ECHO IS GOLD STANDARD
CXR for HF
Consider angiography
Management
Medical: reduce systolic HTN (ACEi) and repeat echo every 6-12mo
Surgical: replace valve if severe or acute
Rheumatic fever
Diagnosis
Investigation
Management
Diagnosis - complication of group A streptococcus pharyngitis which can lead to chronic rheumatic HD
Signs - erythema marginatum
Investigation
Antistrep antibodies
ECG - tachycardia common
CXR if HF suspected
Echo for valvular pathology
Mx
Reduce pain and cardiac workload
ABX - benzylpenicillin, erythromycin
Anti-inflammatory - aspirin, naproxen, ibuprofen for joint pain
