Cardiovascular Flashcards
1
Q
How should arrhythmias be investigated?
A
- bloods: (TFTs, U&Es, glucose, FBC)
- baseline ECG without symptoms
- Echo (not diagnostic)
- 24 hr ECG
- implantable loop recorders
2
Q
When do you worry about ectopic beats on a 24hr ecg?
A
when they occur >20% of the time, it may lead to heart failure
3
Q
Describe how regular narrow complex (SVT) regular tacharrhythmias are treated if the pt is haemodynamicaly stable? (4 steps)
A
1st: Valsalver maneouvre
2nd: carotid sinus massage
3rd: adenosine 6mg IV then 12mg x2
4th: IV verapamil or betablockers(last resort// in asthma)
5th: electrocardioversion (do this 1st if haemodynamically unstable)
4
Q
How should narrow complex irregular tachycardias be treated initially?
(if haemodynamically unstable, if new onset within 48hrs, if been present for >48hrs and if infrequent episodes)
A
Treat as AF- by far most likely diagnosis
DC if haemodynamically unstable
If presents acutely (within 48hrs)-> chemical rhythm control with amiodarone or 300mg PO flecainide then DC and if urgent rate control needed use CSM, VSM, bisoprolol then verapamil
If old: anticoagulate and offer bisoprolol for rate control/ digoxin in HF. Then bring back in two weeks for cardioversion. Flecainide PRN can be used in infrequent symptomatic AF.
5
Q
What are the criteria on the CHA2DS2 VASc score?
A
Congestive heart failure/ LVSD Hypertension Age >75 Diabetes Stroke/ TIA/ VTE Vascular disease Age 65-75 Sex -female
6
Q
What are the criteria on the HAS BLED score?
A
Hypertension Abnormal liver or renal function Stroke Bleeding Labile INR Elderly (>65) Drugs or alcohol abuse
7
Q
Name 3 anticoagulants
A
warfarin, apixaban, dabigatran, rivaroxaban
8
Q
What can be done in AF if anticoagulants are not tolerated or contraindicated?
A
left atrial appendage occlusion
9
Q
Give 5 causes of AF
A
- hypertension
- valvular disease
- heart failure
- IHD
- chest infection
- PE
- lung cancer
- alcohol
- hyperthyroid
- electrolyte disturbance
- infections
- diabetes
- age
10
Q
How are unstable bradycardia treated?
A
- 500micrograms atropine IV every 3-5 mins (upto 6 times)
- Then give Iv adrenaline 2-20 micrograms/ min IVI while you try to get someone todo transcutaneous pacing
- find and treat cause (eg electrolyte disturbance)
11
Q
How should pulseless VT and V fib be treated?
A
defibrillation +/- lidocaine
adrenaline every 3-5 mins and amiodarone after 3 shocks
12
Q
How should unstable and stable sustained VT with a pulse be treated?
A
unstable: sedate and do DC cardioversion x 3 then amiodarone 300mg over 20 mins whilst doing more DC shocks, check and correct electrolytes
stable: amiodarone, then flecainide then lidocaine then cardioverision or pacing
13
Q
How can non sustained VT be treated?
A
beta blockers- may also need implantable defibrillator
14
Q
What is torsade de pointes
A
A very regular broad complex tachy with pointed QRS complexes.
Associated with long QT.
15
Q
How is torsade de pointes treated?
A
IV magnesium sulphate 2mg- if unsucessful then sedate for DC cardioversion
Look for cause of long QT (drugs, hypokalaemia, bradycardia, genetics)
Other anti arrhythmics cant be used as they prolong QT
16
Q
What investigations are needed for angina
A
- ECG: pathological q waves, LBBB, ST segment changes, T flattening or inversion
- Bloods: (FBC (anaemia), U&E (renal function), glucose and cholesterol (RFs), LFTs (statins), Troponin if ECG changes or unstable
- Echo to asses function or if HCM or valve disease is suspected
17
Q
How should stable angina be treated
A
- all need referral to cardio via rapid access chest pain clinic
- GTN spray for symptom relief
- aspirin (75-300mg) or clopidogrel for anticoagulant taking into account bleeding risk
- statins and other CVS risk reduction (HTN treatment, stop smoking etc)
- BB or CCB for hypertension to reduce risk factors
- ACEi if also got diabetes
- cardiac rehab (exercise)
- coronary revascularisation if high risk or medical therapy fails
18
Q
How is an MI investigated?
A
- ECG
- Bloods: FBC, U&E, glucose, lipids, crp, troponin T and I and cardiac enzymes
- CXR
- pulse oxymetry
- cardiac catheterisation and angiography
- Echo
- MI perfusion scan / CTCA
19
Q
How should a STEMI be treated? short and long term (inc drug doses)
A
- Aspirin (300mg) and ticagrelor (180mg) (or clopidogrel)
- Morphine (5-10mg)
- metaclopamide (anti emetic) 10mg
- GTN sublingual or IV (50mg in 50 ml NS at 2-10ml/hr)
- Oxygen if sats are low
- call cathlab for primary PCI or CABG if multi vessel disease, if no PCI available then thrombolysis
- long term continue dual antiplatelet for 12 months (add PPI for stomach protection)
- B blockers or CCB
- ACEi
- high dose statin
- Echo also needed to asses for HF
- long term treatment is for NSTEMI
20
Q
What do you need to think about when assessing NSTEMI risk and need for angiography/ PCI?
A
- rise in troponin
- dynamic st or t wave changes
- diabetes
- CKD
- LVF
- recent PCI or prior CABG
21
Q
What causes mitral regurg and mitral stenosis?
A
Regurg: MI, LV dilation, calcification, CT disorders, rheumatic fever, endocarditis, cardiomyopathy
Stenosis: rheumatic fever or congenital
22
Q
What causes aortic stenosis and regurg?
A
Stenosis: calcification, sometimes rheumatic fever or congenital
Regurg: congenital, CT disorders, rheumatic fever, RA, SLE, hypertension
23
Q
Describe the clinical features of mitral regurg?
A
Dyspnoea, fatigue, palpitations, AF, systolic murmer best on expiration at apex with soft s1, displaced apex.
24
Q
Describe the clincial features ofmitral stenosis?
A
pulmonary hypertension–> dyspnoea, haemoptysis, chronic bronchitis like picture, RA pressure increase can impinge recurrent laryngeal so hoarseness of voice, dysphagia. Fatigue, palpitations, chest pain, systemic emboli, rarely infective endocarditis. Malar flush on cheeks, AF, diastolic murmer best on exp with loud s1.
25
Describe the clinical features if Aortic stenosis
chest pain, exertional dyspnoea or syncope, heart failure, heaving, displaced apex, aortic thrill, ejection systolic murmer radiating to carotids.
26
Describe the clinical features of aortic regug
exertional dyspnoea, PND, Orthopneoa, palpitations, angina, syncope, collapsing pulse, displaced apex, high pitched early diastolic murmer, quinckes signs.
27
How are valvular diseases investigated?
ECG, Echo, FBC, CXR, cardiac catheterisation
28
how do you treat valvular diseases?
balloon valvuloplasty or open valvulotomy for stenosis or valve replacements for both
29
Describe the clinical features of left sided heart failure
- Breathlessness (PND &orthopnoea v specific to it) +/- nocturnal cough and wheeze,
- fatigue
- pink throthy sputum
- increased HR and RR
- exertional dyspnoea
- bibasal crackles
- murmers associated with cause
- cardiomegaly
Can present acutely with acute onset breathlessness
30
What investigations are needed for heart failure?
ECG and BNP, if either abnormal do echo. If had MI before do echo in 2 weeks.
Bloods: FBC, U&E, LFT, glucose, fasting lipids, TFT, cardiac enzymes
CXR (cardiomegaly, alveolar shadowing, fluid in fissues, pleural effusions)
Urinalysis (? Nephrotic syndrome). Cardiac MRI (rarely), Ct angiography if CHD suspected as cause
31
Describe 5 levels of the NYHA heart failure severity classification
Class1: no symptoms on ordinary physical activity
Class2: slight limitation of physical activity by symptoms
Class3: Less than ordinary activity leads to symptoms
Class4: inability to carry out any activity without symptoms
32
How can heart failure be managed pharmacologically?
Diuretics: furosemide 40mg to relieve symptoms, add thiazide if no improvement but monitor k+ (systolic and diastolic)
ACEi: in those with LV systolic dysfunction, ARB if get a cough
B Blockers: decreases mortality, ‘start low and go slow’ (systolic)
Spironolactone: use in those still symptomatic despite optimal therapy and in those post MI with LVSD (systolic)
Digoxin: Use in those with LVSD who are still symptomatic despite optimal treatment
Vasodilators: hydralazine and isosorbide dinitrate should be used if intolerant to ARB or ACEi
Ivrabradine used in NYHA class 2-4 with sinus rhythm >75bpm and conventional therapy not working/ tolerated and ejection fraction <35%
33
How is heart failure managed non pharmacologically?
```
Optimise risk factors.
Treat cause
Flu vaccines should be given
Salt and fluid restriction.
Cardiac rehabilitation
LV assist devices can be used in end stage
```
34
When should urgent and 6 week referrals be used when heart failure is suspected?
Urgent referral if: previous MI, very high BNP, severe symptoms, pregnant
6 week referral: no Mi history but reasonably high BNP, ECG abnormal, ECG normal but strong suspicion of heart failure.
35
How is flash pulmonary odema managed? (inc drug doses)
- Furosemide 40-80 mg IV slowly to remove fluid
- High flow O2
- Sit up
- Morphine 5mg IV to help with feeling of breathlessness
- GTN spray 2 puffs for veno dilation
- Do BNP, ECG, CXR, echo, troponin, U&E, daily weights, obs QDS
- be aware of copd, asthma attack and pneumonia as differentials
- If these fail, CPAP and IV nitrates
- If BP drops <100mmHg treat as cardiogenic shock
36
Give 3 renal causes of secondary hypertension
glomerularnephritis, systemic sclerosis, pyelonephritis, APCKD, renovascular disease
37
Give 3 endocrine causes of secondary hypertension
cushings, conns, thyroid, phaeochromocytoma, acromegaly, hyperparathyroidism
38
Give 3 non endocrine or renal causes of secondary hypertension
pre eclampsia
coarcation of aorta
obstructive sleep apnoea
pharmacological (alcohol, cocaine, amphetamines, antidepressants, COCP, ciclosporin, EPO, steroids)
39
What are the risk factors for primary hypertension
High BMI, high salt diet, lack of activity, excess alcohol, stress, old age, FHx, ethnicity, gender (F>M)
40
How would unexplained hypertension be investigated? (10)
- Ambulatory blood pressure monitoring
- Urine dip for protein and blood (renal disease)
- Serum creatinine, U&E, eGFR
- Renal USS
- 12 lead ECG
- Echo
- Fasting blood glucose and lipid profile
- Urinary free cortisol/ dexamethasone surpression test
- Renin/ aldosterone levels
- Plasma calcium
- MRI of renal arteries
41
How is emergency hypertension (>200mmHg systolic) managed?
- IV nitroprusside or nicarpidine
- phentolaminde for phaeochromocytoma crisis
- Find cause
42
What lifestyle advice can be given to reduce blood pressure
weight reduction, whole grain starchy foods, increase activity, low sat fat, fruit and veg, low caffine, low alcohol, stop smoking, low salt
43
When should drugs be used for treatment of hypertension
- everyone in stage 2 (>160 clinic and >150 ABPM) and stage 1 (<140 clinc and <135 ABPM) if <80 yo, plus signs of end organ damage or DM or QRISK2 >20%.
- Refer is step 4 not bringin it down to <140
44
Describe secondary causes of hyperlipidaemia (5)
- hypothyroid
- liver disease
- nephrotic syndrome
- cushings
- drugs (thazides, steroids, ciclosporin, beta blockers, COCP, antipsychotics)
45
What criteria are used to diagnose someone with a familial hyperlipidaemia?
```
Simon broom diagnostic criteria:
- TChol> 7.5 mmol/l
plus
- tendon xanthoma or evidence of in a 1st or 2nd degree relative
- DNA evidence
```
46
How is hyperlipidaemia investigated?
- lipid profile (fasting test)
- fasting blood glucose and hba1c
- renal function
- LFTs
- TFTs
- DNA test if familial mutation suspected
- creatine kinase (baseline for statin therapy)
47
What dose of atorvastatin is used for primary and second prevention?
primary: 20mg
secondary: 80mg
48
What are the main side effects of statins?
Myalgia (no raised CK) and rhabdomyalysis (usually starts within 6 months, stop drug if muscle pain not tolerable or CK >10x the upper limit of normal) and hepatotoxicity (reversible, monitor LFTs)
49
Give 4 alternatives to statins
ezetimibe (cholesterol lipase inhibitors) , fibrates (PPAR agonists) , nicotinic acids (inhibit lipoprotein synthesis), evolocumab (destroy LDL receptors)
50
What can cause infective endocarditis? (5)
- valve trauma (catheters, pacing wires)
- dental procedures
- valve replacement
- valve pathology
- thrombus formation
- CKD
- SLE
- neoplasia
- malnutrition
- cuts
- IV drug use (tricuspid)
- nothing at all
51
Which valves are most commonly affected by infective endocarditis?
Mitral> aortic > both mitral and aortic > tricuspid> pulmonary
52
Which organisms most commonly cause infective endocarditis? (3)
staph a, strep viridans, enterococcus
53
What are the major dukes criteria for diagnosing infective endocarditis? (3)
- two positive blood cultures
- positive echo
- new regurgitant murmer
54
What are the minor dukes criteria for diagnosing infective endocarditis? (5)
- predisposing condition
- fever
- immunologic or vascular signs
- one positive blood culture
- positive echo not meeting major criteria
55
What signs are associated with infective endocarditis?
- roth spots on retina
- splinter haemorrhages
- janeway lesions (lesions on palms)
- oslers notes (nodes on fingers)
56
How is infective endocarditis treated?
- IV abx (amoxicillin or gentamicin) start treating empirically while you wait for cultures to return
- If prosthetic valve is cause, it will need replacing if abx dont work or they develop heart failure
- gent + vanc + rifampicin if prosthetic valve
57
How may hypertrophic obstructive cardiomyopathy (HOCM) present?
- asymptomatic
- palpitations
- chest pain
- syncope
- breathlessness
- tiredness
- sudden cardiac death
58
What ECG findings may be present in HOCM?
tall sharp q waves in anterior leads
59
What is heard on auscultation of HOCM?
systolic creshendo- decreshendo murmer heard best on left sternal edge and when performing the valsalva manouver
60
How is HOCM treated medically?
B Blockers, CCBs, anticoagulants and diuretics if in heart failure
61
What surgical treatment is available for HOCM? (2)
- implantable cardioverter defibrillators are used in high risk pts (age, thickness, fhx sudden cardiac death, syncope, VT)
- septal alcohol ablation and surgical myectomy also available but carry risks such as BBB, arrhythmias, death
62
What does QRISK2 take account for? (13)
age, gender, diabetes, familly history, blood pressure, postcode, BMI, cholesterol, ethnicity, rheumatoid, CKD, AF
63
What dietary recommendations would you make to reduce someones cardiovascular risk?
- total fat is <30% energy intake
- saturated fats <7% of energy intake
- wholegrain diet (brown bread rice etc) w/ starchy foods
- reduce sugar intake
- increase fruit veg, fish, nuts/ seeds/ legumes intake
64
Other than dietary changes, give 6 recommendations you'd advise to reduce someones cardiovascular risk
- get 150 mins moderate
intensity aerobic or 75 mins vigorous exercise a week
- get to health BMI by reducing calories
- reduce alcohol intake to 2-3 units per day
- stop smoking
- statins
- blood pressure control
65
How do you report on an ECG in an osce?
PRAIRS
P: pt- check name, time and date of ECG
R: rate and rhythm
A: axis deviation
I: intervals: PR 3-5 small squares, QRS 2-3 small squares, QTc 400-450 ms, check the P, QRS and T waves morphology
R: R wave progression from V1-6
S: ST segment (T wave present? tall and tended? ST elevation or depression? T wave inversion?)
66
Describe normal and right and left axis deviation?
Normal: I, II or AvF should be most +ve
Left axis: AvL is most positive
Right axis: III is most positive
67
What could cause poor R wave progression?
- prior anteriorseptal MI
- LVH
- RVH
- dilated cardiomyopathy
- incorrect lead placement
68
Describe the appearance of left bundle branch block?
| WILLIAM
- wide QRS
- wide negative in V1 sometimes with W shape
- wide positive in V6 with M shape
- Left axis deviation and poor R wave progression also associated
69
Describe the appearance of right bundle branch block?
| MARROW
- wide QRS
- M shape and wide QRS in V1
- W shape and wide in V6
70
Describe how you approach tachycardias?
1st: wide or narrow QRS?
2nd: Regular or irregular rhythm?
3rd: if narrow QRS-> P waves?
4th: if broad QRS-> delta waves? (indicate abnormal atrial- septal connection)
71
What is the cause of a tachycardia with narrow complex QRS, regular rhythm but no P waves?
AV node reentry tachycardia or AV reentry tachycardia
| also usually see inverted P in II, as atria depolarising from AV node not SAN
72
What features do you look for when you suspect VT?
```
Wide QRS
tachycardia
irregular or regular
capture beats
fusion beats
Ventricular- Atrial dissociation
```
73
Describe the method for assessing an ECG with bradycardia? (4)
- Look at QRS width to asses where escape rhythm arises
- Are there P waves? (is SAN or AVN causing contraction)
- Is there a relationship between P and QRS
- Any pacing spikes suggesting a pace maker
74
What is bi and triphasicular block on an ECG?
Biphasicular block: RBBB + Left axis deviation
| Triphasicular block: RBBB+ left axis + prolonged PR interval
75
What would an ECG look like if the escape rhythm is arising from high in the bundle of his in 3rd degree heartblock?
Narrow but shallow QRS
| No P- QRS association
76
What should an ECG look like is the escape rhythm is arising from the right or left ventricle?
QRS is wide for both and negative if arising from right ventricle and positive if arising from left ventricle.
No P- QRS association
77
What does an ECG look like if there is only one pacing lead?
Pacing spike before QRS, QRS is wide and negative as lead is placed in RV
78
Describe how a STEMI ECG may change over time
- ST elevation over mins- hrs
- T wave inversion, Q wave development and ST elevation persisting over hrs to days
- Q wave and T wave inversion can persist for a week as ST elevation goes down
- Q wave can persist for months, T wave inversion reverses
79
What leads would be affected by an inferior MI and which vessel is affected
II, III, AVF
| RCA and/or LCx depending on which one is dominant in that area
80
What leads are affected in a lateral MI and which vessel is affected?
I, aVL, V5-6
| Lateral circumflex or diagonal of LAD
81
What leads are affected in a anterior MI and which vessel is affected?
V1-4
| left anterior descending
82
What reciprocal changes are seen on ECG of anterior MI
ST depression in II, III and aVF
83
Where is the occlusion of V3-6, II, III and AvF are affected by ST elevation?
Left main stem (takes out circumflex and LAD)
84
ST elevation is often seen normally in LBBB, what criteria are used to determine if it is truly an MI?
sgarbossa criteria
85
How do posterior STEMIs present?
ST depression in V1-6--> may need todo a V7-9 to see ST elevation
86
Describe the types of heart block
```
1st- prolonged PR
2nd:
mobitz1/ wenkebach: increasing PR interval with each beat until a QRS is dropped (regularly irregular)
Mobitz2: random non conduction of a QRS
3rd: complete dissociation
```
87
how is 1st degree heartblock managed?
Its usually benign. Check meds for cause: CCB, betablockers, cholinergics.
if slow can give atropine
88
How is 2nd degree heartblock managed?
Mobitz1: usually benign
| Mobitz 2: needs implantable pacemaker insertion, usually temporary wire first, then permanent one fitted later
89
How is 3rd degree heartblock managed?
- if very slow can give atropine
| - also needs transvenous temporary pacing followed by permenant pacemaker insertion
90
What causes LBBB?
Usually systemic things causing LVH eg high blood pressure, aeortic stenosis. Can also get primary conduction problems
91
What causes RBBB?
Things causing right ventricle strain, eg PE, corpulmonale, MI, pulmonary hypertension
92
What causes long QT?
HYPOs: hypokalaemia/ calcaemia/ magnesia
idiopathic
drugs: amiodarone, erythromycin
LVH, MI, heart failure
93
What causes short QT syndrome?
digitalis toxicity
hyperkalaemia/ magnesia/ calcaemia
idiopathic
94
Give 4 complications of MI
```
ALARMS
Aneurysm
LV dysfunction
arrhythmias
rupture
Mitral regurg
septal defect
ALSO: tamponade, death, embolism, Dresslers syndrome,
```
95
What may cause heart block?
- CCBs
- amiodarone
- sick sinus syndome
- inferior MI
- myocarditis
- digoxin
- B blockers
96
What is sick sinus syndrome? What is the management?
SAN fibrosis in elderly, leads to a range of arrhythmias inc AF, tachy- brady, sinus pauses. most of which need permanent pacemakers
97
How should AF be investigated?
- Echo- may find cause eg mitral valve disease, LA enlargement etc and for assessment of LV function
- U&E
- TFTs
- ECG
98
Describe the clinical features of right sided heart failure
- peripheral odema and associated weight gain
- ascites
- increased JVP
- anoerxia and GI complaints
- most have PND, orthopnoea, dyspnoea etc as most right sided heart failure is caused by left sided heart failure
99
What causes right sided heart failure?
- most commonly its caused by left sided heart failure
- some due to increase pulmonary pressure
- this can be idiopathic or secondary to diseases like COPD (if this is cause of pulmonary HTN its called cor pulmonale)
- some is due to valvular disease
100
What causes left sided heart failure? (give 3 systolic and 3 diastolic)
```
Systolic:
- HTN
- Coronary artery disease
- idiopathic dilated cardiomyopathy
- mitral or aortic regurg
Diastolic:
- HTN
- HOCM
- aortic stenosis
- tamponade
- obesity
```
101
Describe the clinical features of pericarditis?
- central chest pain worse on lying flat, relieved by sitting forward
- percardial rub
- fever
- signs of tamponade due to effusion
- raised cardiac enzymes
- ECG- saddle shaped ST segment in all leads
102
What may cause pericarditis?
- autoimmune- SLE, RA, vasculitis, dresslers syndrome, sarcoidosis
- malignancy
- virus (EBV, CMV)
- bacteria (lyme, TB, pneumonia)
- trauma
- uraemia
- MI
103
How should pericarditis be managed?
- NSAIDS or aspirin for 2 weeks
+ colchine for 3 months
- treat the cause (usually needs steroids)
