Cardiovascular Medicine Flashcards
What is the most common cause of death worldwide?
Ischaemic heart disease
What can you do to improve cardiovascular health?
- Excercise - Reduce weigh through diet - Moderate alcohol - Stop smoking
What are risk factors for cardiovascular mortality?
- Hypertension -Smoking - Fatty food
Methods of reducing smoking
- Smoking in consultations
- Patient chooses a date to stop
- Throw away accessories such as cigarettes, pipes, lighters, ash trays. Nicotine gum - >ten 2mg stick may be needed/day.
Transdermal(easier) - dose increase at 1 wk can help. offer follow up(written not so helpful
Vareniciline - Oral nicotine receptor partial agonist - start 1 wk before stop date Bupropion (=amfebutamone) - better than patches - second line
Mechanism of action + side effect of varenciline
oral selective nicotine receptor partial agonist. SES: appetite change; dry mouth; taste disturbance; headache; drowsiness; dizziness; sleep disorders; abnormal dreams; depression; suicidal thoughts; panic; dysarthria.
Bupropion moa and side effects
stops reuptake of norepinephrine-dopamine reuptake inhibitor. Warn of SES: seizures (risk <1:1000), insomnia, headache.
What is the QRISK3 score?
predict future cardiovascular health looking at their risk factor. Looks at: age, sex, ethnicity, location, smoking, diabetes, angina(u or fam), ckd(>stg3),atrial fib, hypertension med, migrains, rheumatoid arthritis, SLE, severe mental illness(schizo, bi, depress), atypical antipsychotic, steroids, erectile dysfunction, chol/hdl ratio, BP and BMI
What does constricting pain suggest?
angina, oesophageal spasm, or anxiety
Sharp pain suggest
pain may be from the pleura, pericardium, or chest wall. A prolonged (>½h), dull, central crushing pain or pressure suggests MI
Radiation to jaw or arms suggests
Cardiac ischaemia
instantaneous, tearing, and interscapular, but may be retrosternal pain suggests
aortic dissection
Pain association with cold, exercise, palpitations, or emotion suggests
cardiac pain or anxiety
pain brought on by food, lying fl at, hot drinks, or alcohol, consider
oesophageal spasm/disease (but meals can also cause angina)
If pain relieved within minutes by rest or GTN suspect what?
angina
if GTN relieves pain slowly then it is more likely to be?
oesophageal spasm
Leaning forwards help with what cardiac problem?
Pericarditic
Dyspnoea(hard to breath) occurs due to?
cardiac pain(LVF), pulmonary emboli, pleurisy, or anxiety, respiratory problems
MI might show what syptoms?
nausea, vomiting, or sweating
Causes of angina
Angina is caused by coronary artery disease—and also by aortic stenosis, hypertrophic cardiomy opathy (HCM), paroxysmal supraventricular tachycardia (SVT)—and can be exacerbated by anaemia
Chest pain with tenderness suggests
self-limiting Tietze’s syndrome(swelling of cartilage) - rare - <40(age) seen costochronditis - > 40(age) more commonly seen Other causes:idiopathic, microtrauma, infection, psoriatic/rheumatoid, fibrositis, lymphoma, chondrosarcoma, myeloma, metastases, rib TB
Odd neurological symptoms and atypical chest pain think of?
aortic dissection
Pleuritic pain (pain worsened by inspiration) suggests
inflammation of the pleura from pulmonary infection, infl ammation, or infarction. musculoskeletal pain; fractured rib (pain on respiration, exacerbated by gentle pressure on the sternum); subdiaphragmatic pathology (eg gallstones)
Chest pain and acutely unwell what should you do?
• Admit • Check pulse, BP in both arms (unequal in aortic dissection p654), JVP, heart sounds; examine legs for DVT • Give O2• IV line • Relieve pain (eg 5–10mg IV morphine) • Cardiac monitor • 12-lead ECG • CXR • Arterial blood gas (ABG) Famous traps: Aortic dissection; zoster (p404); ruptured oesophagus; cardiac tamponade (p154); opiate addiction.
heart failure specific syptoms
orthopnoea (ask about number of pillows used at night), paroxysmal nocturnal dyspnoea (waking up at night gasping for breath, p49), and peripheral oedema
What should you look at when looking at an ECG
- Confirm patient name and age
- Rate - speed(25mm/s). big sq =0.2s. small sq =0.4s. Rate = 300/R-R big square. Normal - 60 - 100bpm
- Rhythm - is it regular or irregular.
- Axis - left or right axis deviation - look at lead 1 and 2. Away = left axis. towards = right
- P wave - inverted in avR. absence = af or hidden to junctional rhtym. p mitrale - left atrial hypertrophy. p pulomonale - peaked p wave - right atrial hypertrophy. psueo - p - pulmonale(sharp p wave) - K+ high
- PR interval - normal is 0.12 - 0.2s (3-5 small squares). Delay - AV conduction (1st degree heart block). short might be wpw
- QRS complex - normal <0.12s(3ss) - >0.12 = ventricular conduction issue = bundle branch block. High amplitude = Suggest ventricular hypertrophy. Deep wide q wave seen after a few hours of acute mi
- QT interval - QT corrected = QT/sqrt(R-R interval) = 0.38 - 042s. Long qt - VT or death
- ST segment - elevation or depression - infarction or ischaemia
- T wave - normally inverted in AVR. Abnormal invertion in I, II, V4-V6. Peaked in hyperkalaemia and flattened in hypokalaemia.
- J wave - s wave finish and st segment starts - seen in hypothermia, Subarachnoid haemorrhage, hypercalcaemia
atrial fibrillation on ecg looks like what?
AF has no discernible P waves and QRS complexes are irregularly irregular
atrial flutter ecg
‘sawtooth’ baseline of atrial depolarization (~300/min) and regular QRS complexes
1st degree heart block ecg shows and is caused by
The PR interval is prolonged and unchanging; no missed beats.
Caused by
Increased vagal tone
Athletic training
Inferior MI
Mitral valve surgery
Myocarditis (e.g. Lyme disease)
Electrolyte disturbances (e.g. Hyperkalaemia)
AV nodal blocking drugs (beta-blockers, calcium channel blockers, digoxin, amiodarone)
May be a normal variant
2nd degree(Mobitz I) heart block on ECG shows
The PR interval becomes longer and longer until a QRS is missed, the pattern then resets. This is Wenckebach phenomenon.
2nd-degree HB: Mobitz II ecg shows and causes
QRSs are regularly missed. eg P - QRS - P - - P - QRS - P - - this would be Mobitz II with 2:1 block (2P:1QRS). This is a dangerous rhythm as it may progress to complete heart block.
1st and 2nd-degree HB may be caused by: normal variant, athletes, sick sinus syndrome, IHD (esp inferior MI), acute myocarditis, drugs (digoxin, -blockers).
3rd degree heart block causes and ecg changes
No impulses are passed from atria to ventricles so P waves and QRSS appear independently of each other. As tissue distal to the AVN paces slowly, the patient becomes very bradycardic, and may develop haemodynamic compromise. Urgent treatment is required.
Causes: IHD (esp inferior MI), idiopathic (fi brosis), congenital, aortic valve calcifi c ation, cardiac surgery/trauma, digoxin toxicity, infi ltration (abscesses, granulomas, tumours, parasites).
ST depression
Normal variant (upward sloping), digoxin toxicity (downward sloping), ischaemic (horizontal): angina, NSTEMI, acute posterior MI (ST depression in V1–V3).
Myocardial infarction ECG signs
Within hours, the T wave may become peaked and ST segments may begin to rise.
- Within 24h, the T wave inverts. ST elevation rarely persists, unless a left ventricular aneurysm develops. T-wave inversion may or may not persist.
- Within a few days, pathological Q waves begin to form. Q waves usually persist, but may resolve in 10% of patients.
Pulmonary embolism
ECG fi ndings may include: sinus tachycardia (commonest),
RBBB (p100),
right ventricular strain pattern (R-axis deviation,
dominant R wave and T-wave inversion/ST depression in V1 and V2,).
Rarely, the ‘SIQIIITIII’ pattern occurs: deep S waves in I, pathological Q waves in III, inverted T waves in III
Digoxin effect on ECG
Down-sloping ST depression and inverted T wave in V5–V6 (‘reversed tick’, see fi g 3.19). In digoxin toxicity, any arrhythmia may occur (ventricular ectopics and nodal bradycardia are common).
What ECG signs are seen in hyperkalemia
Tall, tented T wave, widened QRS, absent P waves, ‘sine wave’ appearance
Hypokalemia ecg sign
Small T waves, prominent U waves, peaked P waves.
Hypercalcaemia ECG shows
Short QT interval
Hypocalcaemia ECG change
Long QT interval, small T waves
ECG territories
Where do you put the chest lead for ECG?
V1 : Right sternal edge, 4th intercostal space.
V2 : Left sternal edge, 4th intercostal space.
V3 : Half-way between V2 and V4.
V4 : 5th intercostal space, mid-clavicular line; all
subsequent leads are in the same horizontal
plane as V4.
V5 : Anterior axillary line.
V6 : Mid-axillary line (V7: posterior axillary line).
Right bundle branch block looks like what on ECG
QRS >0.12s, ‘RSR’ pattern in V1; dominant R in
V1; inverted T waves in V1–V3 or V4; wide, slurred S wave in V6. Causes: normal variant
(isolated RBBB), pulmonary embolism, cor pulmonale.
MaRRow and WiLLiam
Left bundle branch block ECG signs
QRS >0.12s,
‘M’ pattern in V5, dominant S in V1, inverted T waves in I, aVL, V5–V6.
Causes: IHD, hypertension, cardiomyopathy, idi-opathic fibrosis. NB: if there is LBBB, no comment can be made on the ST segment or
T wave. >>New LBBB may represent a STEMI.
Acute infero-lateral myocardial infarction ECG
marked ST elevation in the inferior leads (II, III, aVF), but also in
V5 and V6, indicating lateral involvement. There is a ‘reciprocal change’ of ST-segment depression in leads I and aVL; this is often seen with a large inferior myocardial infarction.
What does this ECG show?
Ventricular tachycardia—regular broad complex tachycardiac indicating a likely ventricular origin for the rhythm.
