Cardiovascular Flashcards
Give some differential diagnoses for chest pain. Which two of these are associated with pleuritic pain?
Acute Coronary Syndromes (presenting with crushing chest pain), Myocarditis (sharp but variable pain) Aortic dissection (tearing sudden onset chest pain radiating to the back) Pulmonary embolism (pleuritic chest pain worse on inspiration and movement)
Pneumothorax (pleuritic sudden onset pain)
Reflux (pain mimicking MI)
Both Pneumothorax and PE are associated with pleuritic pain
What can a Chest X-ray show for Aortic dissection?
Widened mediastinum
Briefly describe the utility of the D-dimer assay.
Useful in ruling out (when result is negative) PE in patients whose clinical history shows a low pre-test probability of PE. However, the test is has a low PPV D-diner can also be raised in sepsis and stroke
What is the first line investigation in Acute Coronary Syndromes?
ECG
If there is no ST elevation, what can be used to distinguish NSTEMI from Unstable Angina Pectoris?
Troponin, positive in NSTEMI and negative in Unstable Angina Pectoris
Give 3 indicators of high risk in NSTEMI patients
ST depression
Haemodynamic/rhythm instability
Diabetes mellitus
How is ST elevation defined?
> 0.1mV (2mm) in 2 adjacent limb leads
Give 5 risk factors for PE
Recent surgery Thrombophilia Long haul flight/immobility Previous PE Active cancer
What is the definitive treatment in ACS, and what are the two main methods?
Revascularisation (surgery)
- Coronary Angioplasty
- Coronary Artery Bypass Graft (CABG)
Rank the 3 common Achte Coronary Syndromes in terms of severity
STEMI>NSTEMI>UAP
How is Aortic dissection classified? What is the gold standard test?
Type A: dissection of ascending aorta
Type B: dissection of descending aorta.
Gold standard test is CT aortogram
Describe the pathophysiology of Aortic dissection and give 3 risk factors.
The tunica intima tears due to a pre-existing abnormality, causing blood to accumulate in the false lumen. In Type A, blood supply to the head and neck is compromised, increasing stroke risk. In Type B, kidney perfusion is impaired. Risk factors include Hypertension, trauma and Marfan’s syndrome
What heart sound is diagnostic of pericarditis?
Pericardial rub
What ECG change do you get in pericarditis?
ST segments are saddle shaped
Why is troponin elevated in myocarditis?
Inflammation (as well as infarction) can increase troponin.
State the main regular narrow complex tachycardias and irregular narrow complex tachycardias
Regular:
AVRT
AVNRT
Irregular:
AF
A patient has a broad complex tachycardia. Which part of the heart is likely affected? (Top/bottom)
Bottom
What is given in the short-term management of all regular narrow complex tachycardias?
Adenosine
A patient was found to be tachycardic and unstable. What is the immediate management? Soon after they present with an acute onset of AF. Under what two circumstances will the patient require the same treatment as above?
Electrical cardioversion.
First circumstance: acute onset <24 hours allows cardioversion
Second circumstance: If AF persists despite more than 3 weeks of pharmacological treatment including anticoagulation, cardioversion can also be used.
For Atrial flutter, what is the key ECG feature?
Saw-tooth pattern
Describe the rhythm control treatment in irregular narrow complex tachycardias in harmodynamically stable patients
If underlying structural heart disease -> Amiodarone.
If no structural heart disease -> Flecainide
Briefly describe the utility of the CHA2DS2-VASc score. What do the H, A and D stand for?
A score used to estimate the risk of someone in Atrial Fibrillation of having a stroke. Anyone with a score>1 should be anti-coagulated.
H - Hypertension
A - Age
D - Diabetes
A patient has 3rd degree complete heart block. What is the emergency treatment, and what is the definitive treatment?
Emergency: atropine and transcutaneous pacing
Definitive: pacemaker
What is the main cause of mortality in AF patients?
Stroke
In 10% of people, the ______________ artery is dominant in the inferior wall of the heart, but in most there is a dominant ___________ artery. The largest artery is the __________ artery which supplies the ___________.
Circumflex coronary artery
Right coronary artery
Left Anterior Descending (LAD)
Anterior wall
Summarise the criteria for diagnosis of STEMI
ST elevation by 0.1mV in 2 adjacent leads V1-3 and LBBB with QRS > 130ms absent W waves in I, V5 and V6
How can a posterior infarct be localised?
ST elevation in V7-9 (additional leads formed by pleading V4-6 on the back) and ST depression in V1-3 (mirroring V7-9)
Briefly describe the epidemiology of normal variant infarct mimics, in terms of age and ethnicity
Decrease in prevalence with age.
Found in Afro-Caribbeans
How does normal variant ST elevation differ from true infarct ST elevation?
Normal Variant ST elevation tends to be concave on ECG, whereas pathological ST elevation tends to be convex
In immediate management of acute MI, what intervention had replaced fibrinolysis?
PCI (Primary Coronary Intervention)
Give 3 situations when Coronary angiography is contraindicated
In patients with unexplained fever, severe anaemia or severe coagulopathy
Summarise the Ischaemic cascade, giving details of the ECG changes
Initially perfusion abnormality, then diastolic dysfunction, then systolic dysfunction, then ECG changes, then Angina.
ECG changes: Hyperacute T-waves, then ST elevation (convex) then Pathological Q-waves, then loss of R waves, then T-wave inversion
In which differential for chest pain is contrast MRI especially useful?
Myocarditis, because this can cause chest pain, ECG changes and troponin rise, but the coronary arteries will crucially be normal on MRI
In Type II MI the aim is to treat the underlying cause. What could cause a) decreased supply, or b) increased demand, in Type II MI?
a) Blood loss
b) Tachycardia due to sepsis
In severe Aortic stenosis, valve area is greater than _____ and peak velocity is greater than _____ .
1cm3
4m/s
Give 2 common causes of Aortic stenosis and regurgitation. Give 1 distinguishing cause for each.
Bicuspid and infective endocarditis can cause both stenosise and regurgitation.
Calcification causes stenosis, whereas Rheumatic Heart Disease causes regurgitation.
What is the definitive treatment for Aortic valve defects?
Percutaneous intervention with Transcatheter Aortic Valve Implantation (TAVI)
What scoring system is used to decide which patients will receive surgical intervention for TAVI?
The Euroscore
Mitral valve defects are more/less common than Aortic valve defects
Less
A patient has Aortic regurgitation. What do you expect to find on examination? What about if they had mitral regurgitation?
High volume pulse, diastolic murmur, signs of heart failure.
Mitral: pansystolic murmur, diastolic apex beat, atrial fibrillation.
What are the symptoms and signs of mitral stenosis? Give 3 of each.
Symptoms:
Breathlessness, palpitations, haemoptysis.
Signs:
Diastolic murmur, loud first heart sound, atrial fibrillation
Mitral stenosis and regurgitation share which sign? How do their murmurs differ?
Both share atrial fibrillation. Regurgitation murmurs are pansystolic whereas stenosis murmurs are diastolic
Briefly describe the epidemiology of heart failure
Prevalence and incidence increases with age, and there is a poor prognosis of 50% 5 year mortality
Which type of chronic heart failure has better outcomes with treatment?
Systolic HF (HFrEF)
What is the main cause of heart failure?
Ischaemic heart disease
What is the most specific a) sign, and b) symptom, of heart failure?
a) third heart sound
b) oedema
What is the most effective treatment for end-stage (IV) heart failure?
Heart transplant
A patient has heart failure. What 3 features would you expect to find on a chest X-ray?
Cardiothoracic ratio>50%
Pleural effusion
Upper love diversion (increased size of upper love vessels)
In heart failure patients, what do pathological W waves indicate?
That the cause of their heart failure is likely Ischaemic heart disease with previous MI
What is the stimulus for BNP release? What does BNP stand for?
Ventricular stretch
B-type Natriuretic Peptide
