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CP1 revision > Deck 1 > Flashcards

Deck 1 Flashcards

1
Q

Angina grading

A

Canadian cardiovascular society 1-4

1 is on strenuous, 2 is on mod exertion, 3 is on mild exertion and 4 is at rest

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2
Q

Angina causes

A

Reduced perfusion (atheroma, embolus, iflammation, hypotension, spasm, thrombosis), reduced oxygenation (anaemia, carboxyhaemoglobinaemia) or increased tissue demands (LVH)

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3
Q

CTCA

A

First choice in new onset angina pain. Looks at whole vessel, not just lumen (can adequately assess plaque burden)
Use in NICE probability 61-90%

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4
Q

CT-FFR

A

Computer modelling to assess functional impact (if <0.8 then haemodynamically significant)
Use in NICE probability 31-60%

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5
Q

Clinical diagnosis of angina

A

At NICE probability >90%

Looks at age and symptom type

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6
Q

Angina Tx

A

Address RF
GTN spray, BB (or rate limiting CCB)
Can add nicorandil for refractory disease (vasodilator)
Give statin and low dose aspirin
Surgery required if large area at risk (>10%) or left main stem, or 2-3 vessel disease.
CABG good for diffuse disease, reduced LV function, recurrent stent stenosis and in diabetes.
PCI good for 1 or 2 vessel, frailty, advanced age or varicose veins.

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7
Q

Acute MI

A

Can be regional (90%) or circumferential (10%)
See trop rise (if ECG change only then unstable angina)
If Trop rise + ST elevation/LBBB then STEMI (full thickness)
If trop rise and no ST elevation then NSTEMI (partial thickness)

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8
Q

RCA supplies
Type of MI
Which leads

A

RA, RV, posterior septum - often AVN and SAN
Gives posterior/inferior MI
Leads II, III, avF

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9
Q

LCA (main stem) MI

A

Massive anteriolateral MI

Seen on I, aVL, V1-V6

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10
Q

LAD supplies

Which leads

A

LV and anterior septum

V1-V4

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11
Q

Circumflex supplies?
Type of MI
Leads?

A

LA and LV
Lateral MI
I, aVL and V5/6

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12
Q

DDX for acute coronary syndrome

A

Coronary artery spasm, pericarditis/myocarditis, aortic dissection, PE, pneumothorax, oesophageal disease (worse on leaning forwards), mediastinitis, costochondritis, trauma

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13
Q

Troponin peak

A

24h

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14
Q

ECG MI progression

A 
Tall T waves at 5 mins
ST elevation at 30 minutes
T wave inversion, Q waves (2h)
ST segment normal (days)
T wave may return to normal, Q wave remains (WEEKS)
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15
Q

ACS management

A

Morphine (5mg + antiemetic), GTN/IV nitrates (unless hypotensive), 300mg aspirin, oxygen if <94%
PCI within 90 minutes if STEMI
If NSTEMI then GRACE score

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16
Q

AMI complications

A

Short term:
Arrythmias, Pulmonary oedema (LVF), cardiogenic shock, thromboembolism, ventriculoseptal defect (due to intracardiac rupture), ruptured cordae tendinae (mitral valve incompetence), ventricular wall rupture (leads to haemopericadium, cardiac tamponade and death)
Long term: HF, dressler (immune mediated pericarditis wit raised ESR and myocardial antibodies), ventricular aneurysm formation (distended scar)

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17
Q

IE risks

A

Damaged endocardium (valve disease, prostetic valves, congenital disease), sustained bacteraemias (IVDU, infected intravascular device, untreated abscess/collection)

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18
Q

Vascular IE phenomenom

A

Splinter haemorrahage, janeway lesion

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19
Q

Immunological IE phenomenon

A

Osler node, Roth spot, glomerulonephritis (microscopic haematuria)

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20
Q

Native valve IE causes

A

Streptococcus viridans, Streptococcus mitis

S. aureus in IVDU

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21
Q

Prosthetic valve IE causes

A

coagulase negative staphylococcus (e.g. s epidermidis for first 2 month)

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22
Q 
IE causes:
- Bowel malignany
-GI/GU disease
If culture negative
If non infectious
A

Streptococcus bovis in bowel malignancy
Enterococcus in GI/GU tract
Coxiella burnetii, bartonella, brucella, HACEK (haemophilus, actinobacilus, cardiobacterium, eikenella, kingella)
Non infectious cause is libman sacks lesions (SLE)

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23
Q

IE investigations

A

Echo (ideally TOE)

FBC, CRP, ESR, BCx3, Urinalysis, ECG, CXR

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24
Q

Dukes IE criteria

A

Major is: atypical organism on 2 separate BCs, echo findings or new valvular regurgitation (worsening of existing not enough)
Minor is predisposition, pyrexia, vascular phenomena, immunological phenomena, positive BC

Can diagnose if 2 major 1 minor, 1 major 3 minor or 5 minor

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25
IE complications and managment
HF (sudden onset valve disease), perivascular abscess (aotic root abscess), septic emboli (stroke, discitis, splenic/renal infatct), metastatic abscess (lung) and mycotic aneurysm. Manage with ABx, may need surgical involvement for valves or abscess. Prophylaxis is not routine.
26
``` Aortic stenosis Causes Features O/E O/I Management ```
Most common valvular disease. Bicuspid valve, rheumatic fever, age related calcification. Angina, arrythmias from remodelling, exertional syncope and LVF O/E: small volume, slow rising, narrow pulse, chest wall heave, crescendo/decrescendo EJ murmur (?carotid radiation). Accentuate by sitting forward on expiration. ECG shows LVH/arrythmia, cXR cardiomegaly, echo shows thickened valves/calcifications, cardiac catheterisation shows pressure gradient across valve Management: balloon valvuloplasty or valve replacement
27
``` Aortic regurgitation Causes Features O/E O/I Management ```
HTN, aortic dissection tracking back, CT disorder, IE, Rh fever, bicuspid valve SOB, fatigue, palpitations, angina O/E: wide pulse volume, collapsing pulse, displaced apex, early diastolic (decrescendo) murmur. Quinke's sign (nail bed pulse), De Musset's sign (nod with heart beat), Duroziez's sign (murmur on femoral with distal pressure) O/I: ECG (LV hypertrophy), Echo (regurgitation), cardiac catheter shows wide pressure Needs valve replacement as progresses to heart failure
28
Mitral stenosis causes Features O/E O/I
Rheumatic fever (mainly), but congenital, degenerative and SLE SOB, fatigue, AF, haemoptysis (pul. backflow) Malar flush, small volume pulse, left parasternal heave (RVH), mid diastolic murmur at apex (rad lat), JVP distension, AF ECG, CXR, Echo, cardiac catheter Haemodynamic support, diuretic, PBV
29
``` Mitral regurgitation Causes Features o/e O/I Management ```
left ventricular dilatation, cardiomyopathy, degeneration, infection Rh, IE, CT disoders, autoimmune SOB, fatigue, oedema, syncope, AF (less common than MS), parasternal heay, PS murmur, displaced apex ECG, CXR, echo, cardiac catheter Haemodynamic support, ACEi, BB, surgical valve replacement
30
Infected valves
Tend to be mitral, bu IVDU tricuspid
31
Tricuspid/pulmonary mutmur
TS: mid diastolic murmur with RHF signs TR: PS murmur and RHF signs (cor pulmonale) PS: ES murmur, RV heave, RHF PR: diastolic murmur, often asymptomatic
32
Valve replacement
Tissue replaced 10-15 years, but decreased clot risk (anticoag in weeks - months post surgery, but needs immunosuppression) Mechanical last longer, but need lifelong anticoag. If older, clot risk, or high bleed risk on warfarin/can't take warfarin/limited life expectancy then tissue
33
Warfarin INRs
2-3 in AF | 3-4 in mechanical heart valve
34
HF causes
IHD (most common), dilated cardiomyopathy, HTN, valvular, congenital, cor pulmonale, alcohol, drugs
35
EF HF classes
40-70% normal 40-50 is borderline <40 is systolic HF <35% is severe
36
HFrEF
Generally ischaemic heart disease, HTN, dilated cardiomyopathy, myocarditis. Systolic dysfunction, reduced EF
37
HEpEF
Insuffiicient filling of ventricle, reduced compliance. Generally age, HTN, left ventricular hypertophy, restrictive cardiomyopathy, hypertrophic cardiomyopathy, fibrosis, amyloidosis, sarcoidosis, constrictive pericarditis, haemochromatosis, aging
38
left sided HF
Fatigue, restlessness, confusion, orthopnoea, tachycardia, exertional dyspnoea, paroxysmal noctural dyspnoea, elevated pulmonary capillary wedge pressure - can track back to give pulmonary HTN (cough, crackles, wheeze, blood tinged sputum, tachypnoea) Can get crackles, gallop rhythm (3rd heart sound), displaced apex
39
RHF causes and signs
Can be via lung problem. Fatigue, increased peripheral venous pressure, ascites, hepatosplenomegaly, JVP distention, anorexia, GI distress, weight gain, oedema
40
HF class
NYHA | 1 is no limitations, 2 is slight, 3 is comfortable at rest but sig on activity, 4 is symptoms at rest
41
Pulmonary Oedema
Fluid in alveolar wall Most common cause is LVF with backpressure (red cell leaks digested by macrophages - heart failure cells) Generally increased capillary pressure (heart failure/fluid overload/pulmonary venous obstruction), can be increased capillary permeability (ARDS, infection, sepsis, DIC, inhaled toxin, protein loss, lymphatic obstruction (tumour) Causes dyspnoea, paroxysmal noctural dyspnoea, orthopnoea. May get cheyne stokes on acute CXR : batwing oedema, kerley B lines, upper vessel enlargement
42
HF management
In acute, sit patient up, give high flow oxygen and IV diuretics (consider IB nitrates, opiates, CPAP, ianotropic support, dervice therapy, assist device, transplant) Cardiac resynch can be useful In chronic: diuretic (symptom), ACEi (or ARB) + BB (not in acute decompensation or with asthma). Can add on others. Digoxin in refractory HF.
43
Atheroma
Fatty streak (due to initial insult allowing LDL deposits) Lipid plaque (damages media) Fibrolipid plauqe Complicated atheroma
44
Cardiac marker timeline
Initial rise is CK-MB, then myoglobin, then troponin. Peaks at 24h then has second peak at 4 days
45
ACS types1
Angina is demand ischaemia (no infarct) Unstable angina is rupture of unstable plaque (ischaemia, no infarct - can get ECG change) NSTEMI is plaque rupture. Top rise +/- ECG change STEMI is trop and ST elevation
46
Histological infarct timeline
0-12h has limited evidence 12-24h has necrotic fibres and oedema 24-72h has acute inflammation (pale macroscopically) 3-14 days is macrophage removal and granulation occurs 14-21 days is fibrous granulation tissue 21-56 is scaring
47
MI sequalae
PE (thrombus in heard), stroke, arrythmia, cardiac tamponade, valvular problem, haemopericardium (myocardial rupture), fibrinous pericardium
48
Aortic dissection RF
CT disorder, vascular inflammation (inc. giant cell arteritis), trauma, surgery, HTN, age, smoking atheromas
49
Aortic dissection classes
De Bakey 1 is intimal tear on ascending that continues to descending De bakey 2 is ascending only De bakey 3 is descending only Standard A is 1 and 2, B is 3
50
Dissection sequalae
Can occlude branches, can track back along and cause abscesses, valvular problems and haemopericardium Can compress nearby structures Can rupture into the vessel, or around the vessel
51
Left ventricle on CXR?
Not visible
52
Causes of hemidiaphragn elevation on CXR
Can be loss of lung volume pulling it up. Also applies to hila Can also be ipsilateral phrenic nerve palsy (malignancy invading/compressing nerve or C3, C4, C5 root.
53
Carina >90 on CXR
Atrial enlargement
54
Peaked P waves
RAH
55
Notched/broad P waves
LAH
56
PR interval
Start of P to start of QRS AVN delay 3-5 squares Longer is 1dHB Increases then drops is wenckebach/mobitz 1 Intermittent drpo then mobitz 2 (pacing needed) If p and QRS have no relationship then 3rd degree
57
QRS>120
ventricular origin or BBB
58
RV hypertrophy
R and S transition point (R and S equal) shifts from V3/4 to V5/6
59
LVHypertrophy
R in V5, or S depth in V1 and V5 <25mm
60
ST elevation
If all leads then ?pericarditis >2mm chest >1mm limb
61
ST depression
Ischaemia/digoxin
62
T wave inversion
aVR, III, V1/V2 (? V3 in black people) | Otherwise, ischaemia, ventricular hypertrophy, BBB, digoxin
63
Q waves are normal in
I, aVL, V5/V6 | Can indicate old infarction elsewhere
64
Prolonged QT
Start of QRS to end of T Should be <0.45s (2 large squares) Can lead to VT
65
RBBB
M shape in V1 W in V6 with deep S Consider underlying ASD/PE
66
LBBB
W in V1, M in V6. No further interpretation If asymptomatic then ?aortic stenosis If chest pain then ? MI
67
RAD
Can indicate PE
68
LAD
Can indicate conduction defect
69
aVR, V1, V2
Look at right ventricle
70
aVL, I
Left surface
71
V5/V6
Left ventricle
72
V3/V4
Septum
73
II, III and aVF
Inferior surface
74
WPW
Short PR interval Slurred upstroke delta RAD Can cause paroxysmal tachycardia (re-entry circuit with no tachycardia)
75
Hypocalcaemia on ECG
Prolonged QT
76
Hypercalcaemia on ECG
QT shortening
77
Atrial flutter
>250, no baseline between p waves. Tx as pre AF
78
AF causes
HTN, valvular heart disease, HF, IHD, chest infection, PE lung cancer, alcohol excess, thyrotoxicosis, electrolyte depletion, infection, DM Tx with BB or rate limiting CCB. May use cardioversion if unstable
79
CHAD2DS2VASC
Assess stroke risk. Intervene is 1+ in men, 2+ in women
80
Ventricular tachycardia
Wide QRS in all leads. Can become VF so tx urgently (cardioversion if <90 systolic, chest pain, HF or rate >150. Otherwise amiodarone).

CP1 revision (16 decks)

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