Cardiovascular Flashcards
how long do symptoms last in unstable angina vs stable angina?
20 minutes
when does troponin start to rise in ACS?
4-8 hours
when does troponin peak?
18-24 hours
Other than troponin, name 2 other indicators of ACS that can be measured in the blood?
myoglobin
CK-MB
Other than ACS what can cause a rise in troponin?
HF
Renal failure
sepsis
how does LBBB present on an ECG?
WILLIAM (V1+V6)
Abscence of Q waves and broad R in 1, V5 and V6
What is the definition of an MI?
- Rise in troponin +
2. either symptoms of ischaemia/ ECG changes
What is a pathological Q wave?
> 0.04seconds and >4mm deep
Where would ECG changes be seen in an anterior MI and what artery is occluded?
V1, V2, V3, V4
LAD
Where would ECG changes be seen in a septal MI and what artery is occluded?
V1, V2
LDA
Where would ECG changes be seen in an inferior MI and what artery is occluded?
2, 3, AVF
RCA
Where would ECG changes be seen in a lateral MI and what artery is occluded?
1, AVL, 5, 6
circumflex artery
Where would ECG changes be seen in a posterior MI and what artery is occluded?
dominant R wave in V1-3 and ST depression
V7-9
Right circumflex
what is the initial management of an MI?
MONA Morphine 2.5-10mg and metaclopromide 10mg IV O2 Nitrates aspirin 300mg and clopidogrel 300mg
what is the long-term management post-MI?
BASIC: BBs- propanalol Aspirin 75mg and clopidogrel/ ticagrelor statins inhibitor of ACE correction of RFs
which score can be used in ACS to assess mortality?
GRACE score
name 3 complications of ACS?
Death tacchyarrhythmia HF stroke Mitral regurg Dressler's syndrome
What is Dressler’s syndrome?
presents following an MI as pericarditis, treat with NSAIDs and colchicine
at what level does the aorta bifurcate?
L4
What does a third heart sound indicate?
congestive HF
what are 3 symptoms of left sided HF?
pulmonary oedema causing cough, shortness of breath and paroxysmal nocturnal dyspnoea
what are 3 symptoms of right sided HF?
raised JVP
peripheral oedema
ascites
what level of BNP/ pro-BNP would indicate HF and what level would require urgent referal?
> 100 BNP/ >400 pro-BNP = HF
>400 BNP/ >2000 pro-BNP = Urgent referal
what Xray changes may be seen in HF?
ABCDE Alveolar oedema (bat wings) kerley B lines cardiomegaly dilated upper lobe vessels effusion
NY heart association HF staging:
what stage is someone who is able to keep up with peers in normal physical activity?
Stage 1
NY heart association HF staging:
what stage is someone who is out of breath on mild exertion e.g. putting on the kettle?
Stage 3
NY heart association HF staging:
what stage is someone who is breathless on moderate exertion?
stage 2
NY heart association HF staging:
what stage is someone who is breathless on any activity?
stage 4
what is the management for an acute exacerbation of HF?
forusemide iv, aim to lose 0.5-1kg/ day
morphine
salbutamol nebs PRN
if not on ACEI/ BB do not start until not requiring IV forusemide
when would pharmacological interventions for heart failure be appropriate?
LVEF <40%
What are 3 complications of HF?
DVT/ stroke
arrhythmia
infections
what is the effect of ACEIs in HF?
reduce afterload and fluid retention therefore LV disease progression
What is the effect of BB in HF?
Reduce afterload and HR threfore reducing arrhythmias
What is the initial treatment of HF with reduced LVEF?
ACEI + BB
If a patient with HF who is on ACEI and BB is still symptomatic what is the next line of management?
mineralocorticoid receptor antagonist e.g. spironolactone
If a patient with HF who is on ACEI, BB and spironolactone is still symptomatic what is the next line of management?
if HR >70 ivabradine
if QRS> 130 consider ccardiac resynchronisation therapy
if still no response: hydralazine + nitrates/ transplant/ LV assist device
which drugs improve prognosis in HF?
ACEI
cardioselective BB
Spironolactone
loop diuretics, digoxin and nitrates purely to improve symptoms
name 3 causes of secondary hypertension?
renal disease e.g. RAS
endocrine (cushings/ phaeochromocytoma)
coarctation of the aorta
obstructive sleep apnoaea
how would a phaeochromocytoma present?
HTN
postural hypotension
headache
diaphoresis
define stage 1 HTN
clinic BP >140/90 or ABPM >135/85
define stage 2 HTN
clinic BP >160/100 or ABPM >150/95
define accelerated HTN
clinic BP >180/110 + end organ damage
when are pharmacological interventions for HTN appropriate?
stage 2
stage 1 + end organ damage/ DM/ QRISK2 >20%
What score in a 2 level Well’s score would make you suspect a DVT?
2+
name 3 causes of a raised D dimer
malignancy
inflammation
trauma- post-op
what difference in leg measurement is significant if suspecting a DVT?
> 3cm
measured 10cm below tibial tuberosity
what test is the gold standard if suspecting a DVT?
Venography, however compression USS usually used as cheap and easy- note only 50% sensitivity for DVT below knee, 90% above
Why are LMWH used when warfarin is started?
warfarin increases coagulability in first few days
takes few days to achieve target INR
How long is warfarin/ DOAC continued after first DVT?
6 months, unless post-op (3 months) or if continued risk e.g. cancer or genetic clotting disorder
what is Virchow’s triad?
stasis of blood
vessel wall injury
increased coagulation
how is heparin monitored?
APPT
How is warfarin monitored?
INR
how long before an operation should the COCP be stopped to prevent DVT?
4 weeks
ejection systolic murmur
aortic stenosis
pulmonary stenosis
ASD/ TOF
Pansystolic murmur
mitral/ tricuspid regurg
VSD “Harsh in character”
late systolic murmur
mitral valve prolapse
coarctation of aorta
early diastolic murmur
aortic/ pulmonary regurg “high pitched and blowing”
mid-late diastolic
mitral stenosis “rumbling”
continuous machine like murmur
PDA
what are the 6 Ps of acute limb ischaemia?
pallor pulseless painful parasthaesia perishingly cold paralysis
what does fixed mottling of skin indicate?
irreversible ischaemia
how would you roughly locate the location of a thrombus causing acute limb ischaemia?
the bifurcation distal to the last palpable pulse
what 2 treatment options are available for acute limb ischaemia?
- thrombolysis with tPA given over 8-24hrs
- open surgery/ angioplasty
give heparin after both
what device is used in acute limb ischaemia to locally deliver tPA?
Fogarty catheter
what is tPA?
tissue plasminogen activator
name 3 complications of acute limb ischaemia
reperfusion causing hyperkalaemia -> ECG changes/ AKI
chronic pain syndrome
compartment syndrome
name 3 drugs that can cause complete heart block
BB
CCB
digoxin
name 3 causes of complete heart block
congenital (aortic stenosis) CHD infective- rheumatic fever/ endocarditis autoimmune- SLE hyperkalaemia
what is the acute treatment of complete heart block in a haemodynamically unstable patient?
atropine- 0.5mg, repeat every 3-5 mins to 3mg
consider transcutaneous pacing/ dopamine infusion/ adrenaline infusion
what is a normal PR interval?
120-200ms (3-5 small squares)
what is mobitz 1 second degree heart block?
progressive lengthening of PR interval until beat dropped (Wenckebach)
What is mobitz 2 second degree heart block?
normal PR with occasional dropped beat e.g. 2:1
which type of second degree heart block may require prophylactic pacing to prevent progression to complete heart block?
mobitz 2
what is the definiton of postural hypotension?
drop in BP more than 20/10mmHg <3 minutes after standing
what lifestyle advice might you advise in postural hypotension
stand slowly
sleep with head of bed tilted up
may need compression socks
what medication can be used in postural hypotension when lifestyle interventions have failed?
fludrocortisone
what 3 symtpoms constitute typical angina?
chest pain
brought on by exertion/ emotional stress
relieved by GTN in <5 minutes
true or false: all cases of angina need urgent referral to cardiology
false: only if rapidly progressing or getting pain at rest. Although all cases should be referred to rapid access chest clinic to assess extent of damage
how many doses of GTN should you try before calling 999?
3 (5 minutes apart therefore 15 minutes total)
First line medication for stable angina?
BB (or CCB)
also RF control: aspirin 75mg, statin, ACEI (if DM)
what score on CHAD2S2VASc would you consider anticoagulation
2+
what are the rules on driving with AF?
if symptomatic no driving until symptom free for 4 weeks
if less than 48 hours of onset of AF, what treatment should be used?
if haemodynamically unstable cardioversion (electric/ amiodarone),
if over 48 hours 3 weeks of rate control and anticoagulation/ TTE first
treatment for recurrent AF?
BB
CCB
if no response catheter radiofrequency ablation/ rhythm control with butilide etc
what values would you expect HR to be in SVT?
140-250bpm
name 3 vagal manouvres
facial immersion in cold water
blow into syringe
carotid massage
if no response to vagal manouvres what is the next step of management in SVT?
adenosine 6mg-> 12mg-> 12mg
what size should the QRS be on an ECG?
<120ms
name 2 shockable rhythms
pulseless VT
VF
if unstable pulsed VT what would you give?
amiodarone
3 causes of mitral regurg?
rheumatic fever
infective endocarditis
CHD
which valve is most commonly affected by rheumatic fever?
mitral valve causing mitral stenosis or regurg (less common)
which organism causes rheumatic fever?
group A B-haemolytic strep pyogenes
what is a complication of mitral regurg?
LA dilatation leading to AF
what signs might you see in a patient with mitral stenosis?
signs of RV failure- raised JVP
peripheral oedema
hepatomegaly
what is a complication of mitral stenosis?
pulmonary hypertension leading to R-sided HF
With which murmur might you associate a widened pulse pressure?
aortic regurg
name 2 causes of aortic stenosis
calcification
congenital bicuspid aortic valve
With which murmur might you associate a slow rising pulse?
aortic stenosis
With which murmur might you associate a narrow pulse pressure?
aortic stenosis
With which murmur might you associate a thrusting and downward displaced apex beat?
aortic stenosis
which murmur most commonly radiates to the carotids?
aortic stenosis
name 3 signs you might find on a patient with infective endocarditis?
splinter haemorrhages
fever
osler’s nodes/ janeway lesions
what are osler’s nodes
red tender nodules on pulp of terminal phalanges fond in infective endocarditis, immunological cause, part of Duke’s criteria
what are janeway lesions?
erythematous macules on thenar/ hypothenar eminences in infective endocarditis. vascular cause, part of Duke’s criteria
what criteria can be used to determine the likelihood of infective endocarditis?
Duke’s criteria, differentiates into definite/ possible/ rejected
which other body system may be affected in infective endocarditis?
renal- glomerulonephritis/ AKI
what is trendelenberg’s test used for?
to identify the level of incompetent valves in varicose veins
what are some surgical options for treating varicose veins?
stripping
foam sclerotherapy
endothermal ablation
what are 3 complications of varicose veins?
thrombophlebitis
venous ulcers/ eczema
haemorrhage
what is the most common presentation of ischaemic rest pain?
increased pain at night, relieved by hanging foot off edge of bed
3 symptoms of PAD
hair loss on leg
ulcers
reduced pulses
poor wound healing
if a diabetic patient presents with a new food/ leg ulcer how soon should they be seen in MDT foot clinic?
24hours as high risk of infection and reduced wound healing so high risk for amputation
how would you calculate ankle-brachial pressure index?
SBP at ankle/ SBP in brachial artery
note higher reading from left/ right arm and ankle is used
what ABPI would indicate intermittent claudication?
0.5-0.9
what ABPI would indicate critical limb ischaemia?
<0.5, <0.3= high risk of gangrene
what are possible surgical interventions for PAD if lifestyle/ aspirin have failed?
percutaneous transluminal angioplasty (not surgery under GA? but high recurrence/ clotting of stent)
thromboendarterectomy (bypass if obvious occlusion and able to survive surgery)
limb compression several times a week if unsuitable for surgery
What are the monitoring options for AAA?
3-4.4cm annually
4.5-5.5cm 3 monthly
>5.5cm elective EVAR/ open repair
What should you cross match in AAA?
10 units RBCs
FFP
platelets
aim for SBP <90
according to DVLA when post-MI can patient drive?
4 weeks
name 3 causes of acute pericarditis
infetion (coxsachie B/ echovirus)
post MI pericarditis/ Dressler’s syndrome (AI)
HIV- staphylococcal
typical pericarditis pain is:
retrosternal
aggrevated by deep breathing
releived by leaning forward
associated pericardial friction rub on auscultation
Typical ECG changes in pericarditis
widespread saddle shaped ST elevation
pr depression
first line treatment for pericarditis?
NSAIDs (not in first few days post-MI)
bed rest
what are pulsus paradoxus(stron pulse on inspiration and very weak expiration) and Kussmaul’s sign (raised JVP and increased neck vain distention in inspiration) a sign of?
cardiac tamponade
what is pericardial effusion?
collection of fluid most commonly due to pericarditis, can result in tamponade. low voltage QRS on ECG, muffled heart sounds and enlarged heart on CXR
what are the 3 main types of cardiomyopathy?
dilated (CAD/ MI)
hypertrophic (congenital)
restrictive (idiopathic/ haemochromatosis)
how might aortic dissection present?
haemodynamic instability and syncope
tearing pain
in which layers does an aortic dissection occur?
separation in aortic wall intima leading to blood flow between inner and outer layers of media
define mesenteric ischaemia?
compromised blood supply to small intestine leading to severe pain, N+V, bloody stool, hx of AF/ CVD
how might SVCO/ thrombosis present?
breathlessness
facial swelling and redeness
visible swollen veins on chest/ neck
headaches- worse on bending forward
Raynauds cause
overreaction to cold by peripheral BVs, primary or due to working with drills etc/ atherosclerosis/ scleroderma/ carpal tunnel/ BB
whta is lymphoedema?
lymphatic obstruction due to malignancy, post-irradiation, surgery, recurrent infection, lymphatic hypoplasia
