Cards Flashcards
Complications of pulmonary vein ablation for AF
1-2 percent Aorto-oesophageal fistula Valve damage Femoral vascular complications Thromboembolic events Tamponade Phrenic or gastric nerve injury Pulmonary vein stenosis
What is actually abated in AF? In flutter?
Complete electrical isolation of the pulmonary veins in AF
In flutter need to ablate the cavotricuspid isthmus also
What is the best indication for AF ablation? Other indications accepted?
Symptomatic AF that is resistant to at least one class 1 or 3 antiarrhythmic
Best patients are young with paroxysmal AF, small atria and no underlying heart disease
Discontinuation of warfarin is not a good sole indicator
After procedure, anticoaguate for 1-3 months. Don’t discontinue if CHADS2 is 2 or more
12 causes of pericarditis
Idiopathic Infective- coxsackie, hep, adeno/ histoplasma, aspergillus, candida/tb/ strep, staph, pneumo,haemoph Uraemia Autoimmune- rheumatic (sle sarcoid ra) and non rheum (uc, pan, gca) Traumatic Aortic disease related MI related Radio frequency AF ablation Neoplastic Radiation Recovery phase takotsubo Medications- amiodarone, penicillin, hydralazine
If effusion - all of the above plus hypothyroidism plus cirrhosis
4 Hs
Hypo/hyperthermia
Hypo/hyperkalaemia
Hypovolaemia
Hypoxia
4Ts
Toxins
Tamponade
Thrombosis
Tension pneumothorax
Causes of short QT
digoxin and hypercalcaemia
Causes of long QT
hypokalaemia hypomagnesaemia hypocalcaemia hypothermia myocarditis myocardial ischaemia Drugs including class one and three antiarrhythmics
SURGERIES where dual antiplatelet risk of bleeding is unacceptable- even aspiring alone might be bad
Intracranial Spinal TURP extra-ocular Plastic reconstructive
Asthmatic person with SVT?
Give verapamil
Not adenosine
Most common cardiac issue in Turners syndrome
Bicuspid AV
Also coarctation of aorta
Name three indications for temporary pacemaker insertion
- symptomatic/haemodynamically unstable bradycardia, not responding to atropine
- post-ANTERIOR MI: type 2 or complete heart block*
- trifascicular block prior to surgery
*post-INFERIOR MI complete heart block is common and can be managed conservatively if asymptomatic and haemodynamically stable
Poor prognostic markers in HOCM (6)
Syncope FH sudden cardiac death Young age at presentation NSVT on holter Fall in SBP on exercise Increase in septal thickness
Five groups of pulmonary hypertension
Group 1: Pulmonary arterial hypertension (PAH)
- idiopathic*
- familial
- associated conditions: collagen vascular disease, congenital heart disease with systemic to pulmonary shunts, HIV**, drugs and toxins, sickle cell disease
- persistent pulmonary hypertension of the newborn
Group 2: Pulmonary hypertension with left heart disease
- left-sided atrial, ventricular or valvular disease such as left ventricular systolic and diastolic dysfunction, mitral stenosis and mitral regurgitation
Group 3: Pulmonary hypertension secondary to lung disease/hypoxia
- COPD
- interstitial lung disease
- sleep apnoea
- high altitude
Group 4: Pulmonary hypertension due to thromboembolic disease
Group 5: Miscellaneous conditions
- lymphangiomatosis e.g. secondary to carcinomatosis or sarcoidosis
Components of TIMI risk score
Each of the following criteria constitutes one point for TIMI scoring :
Age ≥65 years Three or more risk factors for coronary artery disease (CAD) (family history of CAD, hypertension, hypercholesterolemia, diabetes mellitus, tobacco use) Known CAD (stenosis >50%) Aspirin use in the past 7 days Severe angina (≥2 episodes in 24 hours) ST deviation ≥0.5 mm Elevated cardiac marker level
Score Risk of Death/MI/Urgent revascularization by Day 14
0-1 5% 2 8% 3 13% 4 20% 5 26% 6-7 41%
TIMI risk score- what is the use?
The Thrombolysis in Myocardial Infarction (TIMI) Score is used to determine the likelihood of ischemic events or mortality in patients with unstable angina or non–ST-segment elevation myocardial infarction (NSTEMI)
Causes of hypertriglyceridaemia? (You can think of at least 10!)
Obesity (often with increase cholesterol too)
Diabetes mellitus with poor glycaemic control
Alcohol excess
Nephrotic syndrome
Hypothyroidism
High oestrogen states (except transdermal HRT)
Beta blockers except carvedilol
Thiazides and frusemide
Immunosupressives (steroid, cyclosp, sirolimus)
HIV antiretrov
Retinoids
Bile acid sequestrants
Second gen antipsychotics
How does BNP break down?
ventricle releases pro-BNP which is cleaved to BNP and NT-proBNP
In normal people, fractions will be about the same.
In heart failure, proBNP goes up more than BNP
900 of NT-pro is about the same as the 100 for BNP
What increases and decreases your BNP?
old women renal failure PE cor pulmonale
Reduce in obese, duretics, ACE
Cut offs for BNP in normal renal function and in AF
over 100 in normal PPV 83%
If AF use 200 as cutoff as lower specificity
NTproBNP under 300 has NPV 98%
What do you do about SVT in asthmatics?
DONT give adenosine
Give verapamil
Tako stubo want to diagnose?
GREAT! But need a normal angio
Also GET OFF INOTROPES- makes worse
What is the earliest sign of anthracycline induced cardiac dysfunction?
Lack of significant increase in EF during stress echo
Diastolic dysfunction
before systolic dysfunction
Which chemo gives you heart failure>
Anthracyclines (doxorubicin, danorubicin, epirubicin)
Mitoxantrone
Alkylating agents (cyclophosphamide, cisplatin)
5-FU can give you MI during treatment
Trastuzumab
IL-2 or IFN gamma- HF during treatment
What are the time cut offs for PCI vs thrombolysis?
Less than an hour of chest pain
PCI within 60 mins–>do that
Not –>thrombolyse
pain 1-3 hours duration
PCI within 90 mins–> do that
Not–>thrombolyse
Pain 3-12 hours
PCI within 90 mins or 2 hours including transport if off site–>PCI
If not–>thrombolyse
Contraindications absolute to thrombolysis
ICH ever known AVM ie in brain ischemic stroke three months bleeding signif head trauma three months suspect dissection cancer in brain
Relative: major surgery last three weeks INR high non compressible vascular puncture CPR more than 10 mins or traumatic bad hypertension dementia pregnancy
Components of TIMI risk?
Estimates mortality for pts with unstable angina and NSTEMI
Age over 65 ***** strongest risk of death
Known CAD with stenosis over half
Aspirin last 7 days
severe angina with more than 2 eps last 24 hours
3 or more RF CAD
biomarkers up
ST seg changes over 0.5mm
Most common myocarditis symptom?
Chest pan
Strongest RF for CVD?
Age
What is in MACCE?
Cardiovascular event
Non fatal MI
stroke
Need for revascularisation
Most effective after AF cardioversion to maintain sinus
Amiodarone
better than sotalol and flecanide (probably almost as good)
SPRINT trial and BP targets?
Aim under 120 in non diabetics reduces cardiac events
If put in a stent and then later present with ACS… where is the lesion?
Half restenosis half new position
Mangement bradycardia post inferior MI
Fluids then atropine then Isoprenaline
Indications for BMS over DES?
unlikely compliant
technical eg large vessel
scheduled surgery next year and need to come off
high bleeding risk including on anticoag
Most common event? errosion or rupture of plaque
rupture- associated with hypercholesterolaemia
errosion associated with smoking, not cholesterol, and is the primary mechanism in premenopausal women
Most common valve lesion over age 75?
AS
What do you see in HOCM with the Brockenbrough-Braunwald sign?
After a PVC, the LV pressure increases but because of dynamic outflow obstruction, the aortic pressure decreases.
This is in contrast to in AS where the outflow obstruction is fixed, so following beat post PVC is all high (both LV and aortic trace)
Worst symtom in AS for mortality?
failure (worse than syncope)
Ischaemic CM what is worst prgnostic factor
age
worse than EF significantly
Does it make a difference is ACE or beta blockers is started first in heart failure?
no
CBIS 3 study
Poor neuro prognosis post arrest?
Myoclonus generalised and repeditive motor response under 3 at day 3 day 3 pupil and corneal not reactive absent bilat SSEP - somatosens evoked potentials Neuron specific enolase
Should you do a rhythm check post shock?
No. continue CPR
AFter airway is in during CPR, ventilate at …
6-10 breaths per min
After resus what should be avoided?
Hyperoxaemia - aim 94-96%
