Cardiovascular medicine Flashcards
What is type 1 heart block?
- The PR interval is more than 0.2 s/ 200ms/ 3-5 small boxes
- P to QRS is 1:1
- Prolonged AV conduction
What is mobitz I Wenckebach heart block?
- P to QRS complex gets longer
- until a QRS is dropped
What is second degree heart block?Mobitz 2
P waves equally apart/
Many QRS dropped
What are the causes of aortic stenosis? How does this differ in the older and younger patient?
Degenerative valve disease is the most common aetiology in older patients (the commonest group) with aortic stenosis.
In younger patients a bicuspid valve is the commonest underlying cause
Valve replacement is the treatment of choice in patients fit enough to undergo the procedure. If the patient is unfit for open heart surgery a valvuloplasty or transcatheter aortic valve implantation (TAVI) may be attempted.
Exercise testing is contraindicated in aortic stenosis.
Name three signs of aortic stenosis?
Many cardinal features of aortic stenosis are present in this patient with a slow rising pulse, narrow pulse pressure and ejection systolic murmur radiating to the neck.
- Slow rising pulse
- Ejection systolic murmur
- Narrow pulse pressure
Mitral regurgitation typically produces a pansystolic murmur, which does not radiate to the neck.
What are the signs of an anteroseptal myocardial infarction on an ECG?
There is ST elevation in the anterolateral leads V1-V4. To confirm that this is an acute STEMI there should be reciprocal changes on the opposite wall: there is T wave inversion in the inferior leads 3 and AVF.
Left Ventricular aneurysms can present with ST elevation together with Q waves alone but without the reciprocal changes.
What are the signs of MI?
This clinical history with chest discomfort, nausea and pain in the jaw should suggest a diagnosis of myocardial infarction. Clammy and sweating as well are signs.
What can be used to study valvular and septal changes to the heart?
Echocardiogram
Suggest some features of Wolf Parkinson White Syndrome seen on an ECG?
The combination of preexcitation on the ECG and paroxysmal narrow complex tachycardia (AVRT) is known as the Wolff-Parkinson-White Syndrome. It is due to the presence of an accessory pathway that links the atria and the ventricles electrically. It is more common for this to be left sided (i.e. between the left atrium and left ventricle) than right sided. It is important not only because it causes symptoms from the AVRT but also because if the patient develops atrial fibrillation, this can be conducted very rapidly down the accessory pathway which may lead to ventricular fibrillation and sudden death (as was the case with patient’s younger brother).
Suggest two drugs that could help with WPW syndrome?
Drugs that are safe to use with less AV node blocking ability are flecainide and amiodarone.
What should be initial management for a heart attack?
The immediate management from those choices should be ECG, Aspirin 300mg, and oxygen saturation monitoring. Mnemonic MONA= morphine, oxygen, nitrates and asprin.
Subsequently, a portable CXR is indicated (the patient should be kept in the resuscitation area and mobile film performed), oxygen saturations can be quickly performed with observations, the patient should be sat up and given oxygen via a face mask if oxygen saturation are less than 90%. Diamorphine is correct but should be titrated to pain (20mg is too high initial dose).
How should heart attack be treated?
Intravenous opiates (morphine or diamorphine), high flow oxygen only if saturations are below the expected range, oral Aspirin 300mg and sublingual GTN are the immediate management of the patient. Intravenous Metoclopramide 10mg is also given to counteract the emetic effects of the opiates.
The mnemonic: MONA can be used to help remember the immediate management of patients:
M – morphine
O – oxygen
N – nitrogycerin
A – aspirin
What are the medications for secondary prevention of heart attack?
Clopidogrel 75mg OD (could also be ticagrelor 90 mg bd or prasugrel 10 mg od which are stronger antiplatelets), Bisoprolol up to 10 mg OD, Ramipril up to 10mg OD, Aspirin 75mg OD, Atorvastatin 80mg OD are correct. The NICE guidelines for the secondary prevention of MI recommend that all patients should be offered an ACEi, dual antiplatelet therapy, a beta-blocker and a statin.
Use Braca
Bisoprolol, Ramipril, Atorvastatin, Clopidogrel, Apirin
What is aortic dissection?
It is a result of the inner layer of the aortic wall tearing, leading to blood flowing through thereby dissecting the inner from middle layer. Aortic dissection is three times more common in males compared to females. There is also an increased prevalence amongst Afro-Caribbeans. Most aortic dissections occur due to arterial wall deterioration. This is commonly associated with high blood pressure, which is present in over half of people who have an aortic dissection. Aortic dissection may be caused by hereditary connective-tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome. It may also be caused by birth defects of the heart and blood vessels, such as coarctation of the aorta, patent ductus arteriosus, and defects of the aortic valve. Other causes include arteriosclerosis and trauma.
What is the most common classification for aortic dissection?
The most common classification of aortic dissections is the Stanford classification. They are split into type A when the ascending aorta is involved and type B when the descending aorta is involved. This also has a relevance on treatment with virtually all type A dissections requiring surgery.
How is aortic dissection treated?
Anti-hypertensives, usually sodium nitroprusside plus a beta-blocker, are given intravenously to reduce the heart rate and blood pressure.
Oxygen and analgesia would also be of benefit for symptom control.
What are some other features of aortic dissection?
Primarily higher blood pressure and shearing pain
How is a type A aortic dissection treated?
In this patient the most important initial treatment should be analgesia, oxygen and IV antihypertensive agents to reduce blood pressure to a safe and narrow range around 110/70 mmHg.
What is a side effect of amiodarone?
Blue-grey syndrome may occur in patients taking amiodarone for several years. The blue-grey discolouration of the skin appears mainly (but not only) on places that are exposed to direct sunlight (this means it affects mainly the face and hands). It is caused by accumulation of amiodarone and its metabolites in the skin.
What is HOCM?
hypertrophic cardiomyopathy (HCM) which is also called hypertrophic obstructive cardiomyopathy (HOCM).
What cause HOCM?
HCM is an autosomal dominant condition and each child (regardless of sex) has, therefore, a 50% chance of the abnormal gene being passed on to them. Many people with the abnormal gene will not however show any symptoms or die from cardiac problems but may only show evidence of HCM on detailed investigation i.e. the expressivity of the gene varies from individual to individual.
What anti-hypertensives are best for diabetes?
JNC VI recommends angiotensin-converting enzyme (ACE) inhibitors as preferred agents, with calcium channel blockers (CCBs) and low-dose diuretics as alternatives. 6 [Evidence level C, consensus/expert guidelines] Angiotensin II receptor blockers also show promise in the treatment of hypertension in diabetes.
What is Wellens syndrome?
Wellens’ syndrome is an electrocardiographic manifestation of critical proximal left anterior descending (LAD) coronary artery stenosis in people with unstable angina. Originally thought of as two separate types, A and B, it is now considered an evolving wave form,
What are pathological Q waves?
What effect does digoxin have on the ECG?
It causes ST depression known as salvador dali mark or reverse tick
What is a useful marker for re-infarction or second heart attack?
CK-MB and tropinin rises over 4-8 hours. CK-MB lasts for 3-4 days, whereas troponin lasts for 7 days.
What is the difference between acute and subacute endocarditis?
Acute = fast onset, normal valve, 50% mortality and necrotising
Subacute = insidious in onset, faulty valve, low mortality
What is the effect of hypocalcemia?
Longer QT
What is the most common form of valvular disease?
Floppy mitral valve
Carlow syndrome, click systolic
What is fish mouth mitral stenosis?
Valvulitis linked with rheumaric fever
What does this show?
Pathological Q waves
What are the different types of infective effusion
If pH is above 7.2 its empyema but below is parapneumonia
