Cardiovasular Disease Flashcards
What is the site and quality of pain in an ACS?
Location: central in the chest
Radiation: into jaw and arms
Quality: heavy
What factors may lead to aggravation or relief of chest pain due to myocardial ischemia?
Aggravated: physical exertion, stress, emotion
Relieved: rest, sublingual nitrates
What position typically relieves the pain of pericarditis?
Pericarditis pain is typically relieved by sitting up and learning forwards.
What other symptoms may be associated with chest pain due to myocardial ischemia?
Diaphoresis Dyspnoea Nausea and vomiting Fatigue Pre-syncope
What type of pain suggests aortic dissection?
Chest pain that radiates through to the back.
Tearing or ripping in sensation.
Reaches its peak intensity immediately.
On examination, what do you find in a patient with MI?
(1) general inspection?
(2) vital signs?
(3) respiratory signs?
(4) heart signs?
(1) appear anxious, uncomfortable, in pain, pale, cyanotic, diaphoretic
(2) tachycardia, hypotension or hypertension both possible
(3) possibly crackles due to acute pulmonary oedema with left ventricular dysfunction as a result of MI
(4) possibly a 3rd or 4th heart sound, possibly a new murmur (as a result of mitral valve regurgitation developing, papillary muscle rupture, VSD)
Give a differential diagnosis of chest pain. List 8 possible differentials.
Cardiac causes: myocardial ischemia - stable angina, unstable angina, NSTEMI, STEMI; pericarditis
Vascular causes: acute aortic syndrome
Pulmonary causes: PE, pneumonia, pneumothorax
GIT causes: oesophageal reflux, oesophageal spasm, peptic ulcer, cholecystitis, pancreatitis
Neuromuscular causes: costochondritis, trauma, herpes zoster
Psychological: anxiety
What are the risks of coronary angiography?
Death Stroke Contrast nephropathy & AKI Bleeding Bruising Infection
Define syncope.
Syncope is a transient loss of consciousness due to inadequate cerebral blood flow.
What are the causes of syncope (neural, cardiac, orthostatic hypotension)?
NEURALLY-MEDIATED: Vasovagal (common faint) Situational Syncope - especially micturition syncope, but also Cough/Sneeze/Defectation/Swallowing syncope Carotid sinus syncope Cardiac - OBSTRUCTIVE: Aortic stenosis/Pulmonary stenosis Cardiac tamponade Hypertrophic cardiomyopathy PE Pulmonary hypertension Atrial myxoma Defective prosthetic valve Cardiac - ARRHYTHMIAS: Rapid tachycardias Profound bradycardias Significant pauses Pacemaker failure ORTHOSTATIC HYPOTENSION: Volume depletion Autonomic dysfunction Drugs - e.g. B blockers
What other conditions may be mistaken for syncope? (give 3 conditions)
Seizures
Vertigo
Ataxia
What investigations might be useful in a patient with syncope? (Give 5)
12 lead ECG Holter monitor Loop recorder Echocardiogram Exercise stress testing Electrophysiological studies EEG (if you suspect it was really a seizure)
Give 6 causes of palpitations.
Cardiac arrhythmia Hyperthyroidism Pheochromocytoma Fever Dehydration Anaemia Hypoglycaemia Drugs - e.g. cocaine, caffeine Electrolyte disorders Panic attack
Give 3 causes of bilateral leg swelling.
Congestive heart failure
Liver cirrhosis
Nephrotic syndrome
Give 3 causes of unilateral leg swelling.
Venous insufficiency Thrombophlebitis Lymphoedema Ruptured Baker's cyst Ruptured gastrocnemius
Give 8 common causes of fatigue.
ACTIVITY/SLEEP RELATED Prolonged exercise Inadequate sleep Sleep apnoea PSYCHOLOGICAL Stress Depression HEMATOLOGICAL Anaemia ENDOCRINE Hypo/hyper-thyroidism Addison's disease Diabetes mellitus CANCER CHF URAEMIA DRUGS/MEDICATIONS VITAMIN DEFICIENCY
What investigations might be useful in investigating fatigue?
FBC Urinalysis EUC Fasting blood glucose Thyroid function tests ESR/CRP Chest x-ray Sleep study
On an ECG, which leads correlate with the lateral aspect of the heart?
Lead I
V5, V6
aVL
On an ECG, which leads correspond with the inferior aspect of the heart?
Lead II
Lead III
aVF
On an ECG, which leads correspond to the IV septum?
V1
V2
On an ECG, which leads correspond with the anterior aspect of the heart?
V3
V4
Explain how you would determine cardiac axis.
Look at the QRS in lead I and aVF.
If they are both positive = normal axis
If lead I is positive but aVF is negative –> look at lead II. If lead II is positive, then the axis is normal, but if lead II is negative there is left axis deviation.
If lead I is negative and aVF is positive = right axis deviation.
What is the PR interval? What is a normal PR interval?
PR interval is the time taken for a cardiac impulse to spread from the atria to the ventricles through the AV node and bundle of His.
It is measured from the BEGINNING of the P wave to the BEGINNING of the QRS complex.
A normal PR interval is 3-5 small squares.
What is the definition of a wide QRS complex?
Greater than 3 small squares
In what leads is it normal to see T wave inversion?
aVR
V1
Explain first degree heart block.
Delayed PR interval.
There is a delay in the conduction, but each P wave conducts to the ventricles without dropping a beat.
Explain second degree heart block. What are the types?
Some P waves do not conduct to the ventricles.
Mobitz type I (aka Wenckeback) = progressive lengthening or PR and then failure to conduct, with PR interval then returning to normal and the cycle repeating
Mobitz type II = constant PR with occasional drop of a beat so that a P is not followed by a QRS
Explain third degree heart block.
P waves and QRS complexes are dissociated. Atrial conduction is not passing through to the ventricles. Ventricular contraction is maintained by an escape rhythm.
What does a right bundle branch block look like on ECG?
MaRRoW
R = right BBB
M = wide QRS in V1 appears like an M
W = wide QRS in V6 appears like a W
What does a left bundle branch block look like on an ECG?
WiLLiaM
L = left BBB
W = wide QRS in V1 appears like a W
M = wide QRS in V6 appears like a M
What is a ‘hemiblock’?
The left bundle branch has two divisions - an anterior division and a posterior division. If one of these divisions is blocked it is called a hemiblock.
What does atrial fibrillation look like on ECG?
No P waves with an irregular baseline
Normal QRS
Irregularly irregular rhythm
What is Wolf-Parkinson-White Syndrome?
Normally, there is only one pathway between the atria and ventricles - i.e. through the AV node and the His bundles. In WPW syndrome, there is an accessory conducting bundle. In this situation, a re-entrant circuit can be established with the excitation passing down the His bundle and travelling back up the accessory pathway.
Give 3 causes of a wide QRS complex.
Ventricular extra-systole
Ventricular tachycardia
Wolf-Parkinson-White syndrome
Bundle branch block
What can cause a QRS complex of abnormal height?
Right or left ventricular hypertrophy
What is a pathological Q wave? What causes a pathological Q wave?
Q waves > 1 small square wide and > 2 mm deep are pathological.
These pathological q waves occur as the result of MI. Once developed, they are usually present permanently.
Give 4 causes of inverted T waves.
Normally, in aVR and V1. Acute coronary syndromes Ventricular hypertrophy Bundle branch block Digoxin treatment
Outline the changes on ECG that occur with a myocardial infarction. What is the timeline of these changes?
First, ST elevation.
Then there is: (1) T wave inversion and (2) Appearance of Q waves.
After this, within 24-48 hours: ST returns to baseline, but T wave inversion and Q waves are often permanently altered.
What ECG changes occur with hypokalaemia?
T wave flattening
U waves
What ECG changes occur with hyperkalaemia?
Peaked T waves
What changes occur with hypercalcemia?
Shortened QT interval
What changes occur with hypocalcemia?
Prolonged QT interval
What blood tests would you order in someone with cardiac disease (give 5 that would be useful). Justify your decision.
FBC - anemia increases myocardial ischemia and can be the cause of palpitations.
EUC - many cardiac investigations require IV contrast and it is important to know their renal function as the contrast is nephrotoxic. Also, cardiac arrhythmia can be induced and exacerbated by electrolyte disturbance.
TFTs - thyroid disease can cause arrhythmia, and heart failure
Troponins - elevated troponin I and T indicates myocardial damage and is important in diagnosis of MI.
BNP - is elevated in CHF
Give 5 contraindications for cardiac catheterisation and angiography.
Patient refusal Severe uncontrolled hypertension Ventricular arrhythmia Recent stroke Active GI bleeding Allergy to radiocontrast agents Active infection Acute kidney injury/acute renal failure Severe coagulopathy Uncompensated heart failure and the patient cannot lie flat
