ECGs and Cardiology Flashcards
What does a tall P wave show?
P Pulmonale - RA hypertrophy
What may RA hypertrophy be secondary to?
Pulmonary HTN and Tricuspid stenosis
What is P Mitrale?
Bifid P wave, caused by LA hypertrophy, secondary to mitral stenosis
Signs of RVH?
on ECG
RAD
P pulmonale
T wave inversion
Causes of RVH?
1) Pulmonary hypertension
2) Chronic lung disease
3) Mitral stenosis
4) Congenital heart disease
Classic acute right ventricular strain signs? e.g PE
S1Q3T3
Sokolov Lyon Criteria for LVH diagnosis?
LVH present when combined total depth of S wave in V1 and height of R in V5/6 = Over 35mm
What is a pathological Q wave?
1) Greater than 40ms
2) Over 2mm in depth
3) Over 25% of depth of QRS
Causes of prolonged QT?
1) Long QT syndrome (inherited slow ventricular repolarisation)
2) ELectrolytes (hypokal, hypocalc, hypomag)
3) Medications (many..e.g antipsychotics, antiemetics)
4) Other (hypothyroid, intercranial disease)
Medications to increase heart rate?
- Atropine (blocks action of vagus on SAN/AVN)
2. Isoprenaline
Atrial flutter sign?
Sawtooth baseline
Atrial tachycardia?
Abnormal P wave (inverted in inferior)
AVNRT?
Absent P wave
What is Wolff-Parkinson-White syndrome?
Pre-excitation syndrome - congenital accessory pathway named Bundle of Kent
Signs of WPW?
Short PR Delta wave (slurred upstroke of QRS)
Treatment of WPW?
Radiofrequency ablation of accessory pathway + Sotalol/ Amiodarone/ Flecainide
Treatment to shorten QT?
IV Magnesium Sulphate
What is Torsades De Pointes?
Polymorphic VT secondary to prolonged QT/ Myocardial Ischaemia
STEMI ECG changes?
Minutes 0-12hrs 1-12hrs Days Weeks
Minutes = hyperacute T waves
0-12hrs = ST elevation
1-12hrs = Q wave development
Days = T wave inversion
Weeks = T wave normal + persistent Q waves
Pericarditis signs?
ST elevation widespread and PR depression
Causes of J waves? (notch just after QRS)
1) Early repolarisation
2) Hypothermia
3) Hypercalcaemia (short QT)
4) Brugada syndrome
Signs of Digoxin on ECG?
Downsloping ST
Abnormal T
Short QT
Hyperkalaemia signs?
Tall T
Long PR
WIde flat P
Broad QRS
Risk factors for Coronary Artery Spasm (Prinzmetal Angina)
- Cocaine
- Mg deficiency
Diagnosis of Coronary Artery Spasm?
Angiogram (inject Acetylcholine, if vessel constricts - can dx vasospasm)
Tx of Coronary Artery Spasm?
CCB (Verapamil/ Diltiazem)
Angina Triad?
1) Constricted chest pain (radiating down neck/arm)
2) Precipitated by exercise
3) Relieved by rest/ GTN within 5 mins
ANGINA
Anatomical non invasive tested for low risk?
CTCA
What is deemed obstructive CAD?
Over 70% stenosis of 1 major coronary artery segment or over 50% stenosis of left main coronary artery
ANGINA
Example of Non. Invasive Functional Testing?
1) Dobutamine stress Echo
2) Stress/contrast MRI
3) SPECT
ANGINA
What is investigation of choice for high risk patients?
Invasive Coronary Angiography (for assessing stenosed arteries + provide revascularisation at the time of diagnosis)
ANGINA
Lifestyle advice?
WESAD
Weight Loss Exercise 30-60mins Smoking Cessation Alcohol under 12 units weekly Diet (limit sat fats to under 10% of total calorie intake)
ANGINA
Pharmacological management?
GTN +
1) BB / CCB (Amlodipine)
2) Long acting Nitrate
Ivabradine
Nicorandil
Ranolazine
What CCBs are contraindicated with beta blockers?
Non dihydropyridine CCBs such as Verapamil and Diltiazem due to the risk of AV block
Invasive Management of Angina?
PCI and CABG
What medication is given alongside PCI
Dual antiplatelet therapy (Aspirin + Clopidogrel) for 6 months
DIC treatment?
Tranexamic Acid
FFP
Cryoprecipitate
Treatment of GI bleed?
- Ceftriaxone IV 1g
- Octreotide 50 ug bolus + 50ug hourly
- Erythromycin 250mg
- PPI Pantaprazole 80mg IV bolus
Types of Shock?
Cardiogenic Septic Hypovolaemic Neurogenic Anaphylactic
What types of shock have warm peripheries?
Distributive
- neurogenic/ Septic/ Anaphylactic
3 in 3 out management of Septic Shock
3 in - Fluid Bolus, Tazocin (Abx), High flow O2
3 out - Blood cultures, lactate, measure urine output
Treatment of Neurogenic shock?
Vasopressors
What is Sepsis characterised by?
Temperature under 36 or over 38
HR >90
RR >20
WBC >12,000mm3 or <4000mm3
Famous Cause of Toxic Shock syndrome in the 80s?
Infected tampons , containing Staphylococcal Exotoxins
Symptoms of Toxic Shock Syndrome?
- Fever >38.9
- Hypotension
- Sun burn like rash (desquamation of palms/soles)
- 3+ organ involvement
Types of MI?
- due to primary CA event e.g plaque rupture
- due to oxygen supply demand mismatch
3 sudden expected cardiac death
4 Associated with PCI / stent complications
5 Associated with cardiac surgery
Chest Pain differentials?
Cardiac
Respiratory
GI
Other
C - Angina, ACS, Aortic Dissection, Pericarditis
R - PE, Pneumothorax, Pneumonia
GI - Oesophagitis, Peptic Ulcer, Oesophageal spasm
Other - Depression, MSK (rib fracture), herpes zoster
Immediate Management of ACS?
MONA (aspirin 300mg loading dose)
take morphine + anti-emetic (metoclopramide)
What should be done within 120 mins of STEMI
Primary PCI / Coronary Angiography
What should be done if action not completed within 120 minutes of STEMI?
Give fibrinolytic agent e.g alteplase
- Clopidogrel + LMWH/UFH and PCI within 24hrs
what should be given prior to PCI
2nd antiplatelet (Prasugrel/ Clopidogrel/ Ticagrelor)
+ LMWH/ UFH
+ Glycoprotein IIb/IIIa inhibitor
What is GRACE score?
Estimates 6 month mortality risk in patients with NSTEMI/ UA
NSTEMI/UA Management Pathway?
1st - Consider risk using GRACE/HEART score
- GIve antiplatelet + Fondaparinux or UFH if PCI <24hrs
- do Angiography if under 96hrs of presentation and consider PCI/ CABG
IF pain free/ over 96hrs of presentation just do echo, if positive do angiography
Long term management after ACS?
Aspirin, ACE-I, Atorvastatin
BB
Cardiac Rehab, cessation of smoking
Driving, Diet/Alcohol, Dyspepsia (PPI!!)
what should be given alongside dual antiplatelet therapy?
PPI as increased. risk of peptic ulcer disease
What is Dresslers Syndrome?
Autoimmune pericarditis 2/3 weeks post MI.
Autoimmune reaction to myocardial antigens post infarction
3 functions of Pericardium?
Barrier - reduces external friction
Mechanical - limits cardiac dilation (maintains ventricular compliance and aids atrial filling)
Anatomical - fixes heart through ligamentous function
major risk factors of Pericarditis?
Fever over 38 Subacute onset Large pericardial effusion Cardiac tamponade poor response to 1 week of tx
Describe Pericarditis pain?
Sharp pleuritic chest pain
BETTER - leaning forward / sitting up
WORSE - inspiration
How is Pericarditis Diagnosed?
2/4 of:
New/ worsening pericardial effusion
Classic chest pain
Pericardial friction rub (Squeaky sound heard over heart)
Characteristic ECG changes
ECG signs of PEricarditis?
ECG - widespread ST elevation + PR depression
Cardiac Tamponade features?
- Muffled heart sounds
- Distended JVP
- Pulsus Paradoxus (BP drop >10mmHg on inspiration)
- Hypotension
Tx of Pericarditis
NSAID + Colchicine
+ PPI
Tx of tamponade?
Urgent pericardial paracentesis
Management of Acute Pulmonary Oedema?
Furosemide (IV 40mg)
Oxygen (high flow)
Nitrates (sublingual infusion)
Diamorphine (IV)
may require CPAP if fails
What is a synonym of perihilar shadowing
Alveolar Oedema
Hypercalcaemia symptoms?
stones, bones, groans and psychic moans
bone pain, renal stones, abdo pain, low mood
short QT on ECG
Adenosine side effects?
chest pain
bronchospasm
transient flushing
can enhance conduction down accessory pathways, resulting in increased ventricular rate (e.g. WPW syndrome)
What is Adenosine mainly used for?
Termination of SVT
What enhances the effect of Adenosine and what blocks the effect of Adenosine?
Enhances - Dipyridamole (antiplatelet agent)
Blocked - theophyllines
What should Adenosine be avoided in?
Asthmatics due to risk of bronchospasm
HEART FAILURE
Types of heart failure?
Vascular (HTN, IHD)
Muscular (Dilated Cardiomyopathies)
Valvular
Electrical
Definition of preload?
Stretching of cardiomyocytes at the end of diastole
Definition of afterload?
Pressure or load against which the ventricles must contract
Definition of Inotropy?
The force of muscular contraction
HEART FAILURE
Describe the basic pathophysiology
- ESV increases which reduces CO
- Body compensates by:
1) Increase preload (Increase EDV to maintain CO)
2) Increase heart rate
3) Activate RAAS (salt and water retention = oedema)
4) Baroreceptors activate sympathetic - vasoconstriction 1
HEART FAILURE
Symptoms?
SOB Fatigue Oedema Paroxysmal nocturnal dyspnoea Orthopnoea
HEART FAILURE
Signs?
S3/S4 HS Ankle swelling Wheeze Pulsus Alternans Ascites Hepatomegaly Increased JVP Displaced apex beat
HEART FAILURE
Dx?
Echo + BNP
Causes of increased BNP?
- CKD
- Cirrhosis
- Heart failure
- Hypoxaemia
- Diabetes
- Old age
- Sepsis
HEART FAILURE
Management?
1st - ACE-I + BB + DIURETIC
2nd + MRA (Eplerenone)
3rd - Digoxin, Ivabradine, Hydralazine + Nitrate
Last line management of HF?
PCI
CRT
ICD
Heart transplant
What are MRAs / aldosterone receptor antagonists contraindicated in?
Hyperkalaemia
Hyponatraemia
AKI
What would an echo show if a person had Hypertrophic Obstructive Cardiomyopathy>
- Mitral regurgitation
- Systolic anterior motion (SAM) of anterior mitral valve
- Asymmetrical septal hypertrophy
Classic ECG sign in Arrhythmogenic right ventricular dysplasia?
inverted T V1-3 and EPSILON wave (terminal notch in QRS)
Describe flow murmurs? (7 S’s)
- Slow
- Short
- Systolic
- Symptomless
- Sounds (normal S1 and S2)
- Standing/ sitting (positional)
- Special tests normal (Echo/ECG)
Causes of dilated cardiomyopathies?
ABCD Alcohol Beri Beri (Thiamine B1 deficiency) Coxsackie B virus Doxorubicin
What is Becks Triad?
S3 signs of Acute Cardiac Tamponade?
1) Raised JVP
2) Hypotension
3) Muffled heart sounds
What is Aortic Dissection
When the medial aortic layers separate
1) Intimal tear allowed blood to enter intima-media space
2) false lumen fills with blood it may propagate proximally/distally
3) This results in either:
Rupture through adventitia
OR
Reentry to true lumen via 2nd intimal tear
AORTIC DISSECTION
Describe Stanford Classification
Type A - ascending aorta involved
Type B - Ascending aorta not involved
AORTIC DISSECTION
Describe DeBakey classification
Type 1 Involves ascending, extends into arch and beyond
Type 2 Limited to ascending
Type 3a Involves descending thoracic (proximal to coeliac artery)
Type 3b Involves descending aorta and abdominal aorta
AORTIC DISSECTION
Congenital risks?
Noonans Turners Marfans Ehlos Danlos Osteogenesis Imperfecta
AORTIC DISSECTION
Acquired risk?
Cocaine HTN Pregnancy Syphillitic arthritis Iatrogenic (cannulation)
AORTIC DISSECTION
Symptoms?
Tearing chest pain
Back and abdo pain
Dyspnoea
Syncope/ colllapse
AORTIC DISSECTION
Signs?
Horners syndrome
Arm BP differential
Neuro deficit
Absent peripheral pulses
AORTIC DISSECTION
Acute complications?
Cardiac Tamponade and Aortic Regurgitation
Aortic Regurgitation signs
Diastolic murmur
Wide pulse pressure
Heart failure signs
AORTIC DISSECTION
Gold standard imaging?
CT angiogram
Echo - good if ascending and to assess complications - tamponade/ AR
AORTIC DISSECTION
Management of Stanford Type A/B?
Type A = surgery! (50% mortality in first 48hrs)
Type B = Analgesia and BP control (Labetolol)
How big is a AAA?
Over 3cm
AAA are more likely in males. Screening is available to those aged 65, whart are the pathways based on the size of the AAA on screening?
3-4.4cm = Annual USS + seen in 12 weeks
4.5-5.4cm = 3 montly USS + seen in 12 weeks
> 5.4cm = 2 week wait
RIsk factors for AAA?
Family history 12x Male 6x Smokers Hypertensive Diabetics Connective tissue disorders (Marfans)
Marfans complications?
Mitral valve prolapse Aortic Dissection Retinal detachment Fibrillin - 1 - mutation Arachnodactyly Near sighted Sclerosis
Commonest causes of aortic Regurgitation
Congential (bicuspid valve) + degenerative (calcification)
Aortic Regurgitation murmur?
Early diastolic + water hammer pulse
Aortic Stenosis clinical features?
Syncope (exertional)
Angina
Dyspnoea
Murmur heard in Aortic Stenosis?
Ejection systolic murmur + slow rising pulse
INR aim in patients with aortic mechanical valve replacement ?
3.0 - long term anti-coagulation required
warfarin, if ischaemic add aspirin
murmur heard in MR?
Pansystolic + S3 due to rapid filling of dilated ventricle
signs on ECG if MR?
LVH and P Mitrale (bifid P wave)
Murmur heard in. MS?
Mid diastolic (lie on left side while holding expiration)
What is Ortner Syndrome
left recurrent laryngeal palsy (hoarse voice)
can be caused by left atrial enlargement
Management of MR?
Nitrates, Diuretics + Inotropes
INR aim in mechanical mitral valve replacement?
3.5.
If degenerative regurgitation, what should be the surgical treatment?
REPAIR over replace
What can left atrial enlargement cause
Ortner Syndrome Right heart failure (Oedema, raised JVP, hepatomegaly) Pulmonary HTN Mitral facies AF
IF a patient has mitral stenosis and persistent AF, which anticoagulation should they be on
VKA not NOACs
ATRIAL FIBRILLATION
Signs?
Irregularly irregular pulse Palpitations SOB Angina Presyncope
What does HASBLED stand for
Hypertension Abnormal liver/renal func Stroke Bleeding (prior) Labile INR Elderly >65 Drugs/ alcohol
What does CHA2DS2VASc stand for
CCF HTN Age >75 +2 Diabetes Stroke/TIA +2 Vascular disease Age 65-74 Sc- Female
ATRIAL FIBRILLATION
IF pt has paroxysmal AF with no co-morbidities what is the treatment?
Flecainide
ATRIAL FIBRILLATION
Management of rate?
1st - BB Metoprolol
Rate limiting CCB - Verapamil
2nd - Digoxin
ATRIAL FIBRILLATION
Rhythm control?
Cardioversion
if onset <48hrs = immediate
if >48hrs = 3-6 weeks of anticoagulation then cardioversion
Electrical
Pharmacological (amiodarone, sotalol)
ATRIAL FIBRILLATION
Anticoagulation management?
If 1st line contraindicated?
DOACs - Rivaroxaban /Dabigatran
if DOAC contraindicated = Aspirin + Clopidogrel (dual ap treatment)
Rivaroxaban mode of action?
Xa inhibitor
Dabigatran mode of action?
Direct thrombin inhibitor
ATRIAL FIBRILLATION
If drug therapy fails what is final treatment>
ABLATION
ATRIAL FIBRILLATION
When should anticoagulation be used?
If CHADSVASC 2 or more
Treatment of SVT
- electrical cardioversion
- vagal manoeuvres (carotid sinus massage / valsalva)
2nd IV Adenosine 6mg-12mg-12mg
What is Adenosine contraindicated in and what is the preferred treatment
Asthmatics - prefer verapamil
1st line medication in VT
Amiodarone
Drugs that can prolong QT?
Methadone Ondansetron Sotalol Citalopram Haloperidol Amiodarone Terfenadine Erythromycin
electrolyte causes of prolonged QT?
HYPO cal, kal, mag
Management of prolonged QT syndrome
Beta blockers plus avoid exacerbating drug/ strenuous exercise
implantable cardioverter defibs in high risk cases
What is Sodium Nitroprusside?
potent vasodilator (hypertensive crisis)
Acute NSTEMI treatment?
B – Beta blockers unless contraindicated
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose
M – Morphine titrated to control pain
A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm
Treatment of Regular Broad complex Tachycardia?
Assume VT - loading dose amiodarone (after DC)
Cause of irregular broad complex tachycardia?
AF with BBB
AF with ventricular pre excitation
torsades de pointes
Treatment of regular narrow complex tachycardia
Vagal manoeuvres followed by IV adenosine
IF above unsuccesful consider flutter dx and control rate
Cause of irregular narrow complex tachycardia?
Probable AF! if onset <48hrs then cardioversion
control rate with BB
Secondary causes of Hypertension
Endocrine - Aldosteronism, Cushings, Phaeochromocytoma, Acromegaly
Renal - Renovascular disease, Intrinsic disease (CKD, AKI, glomerulonephritis)
Drugs - Glucocorticoids, oral contraceptive, SSRIs, NSAIDs
Coarctation of the Aorta
Signs of hypertension
Cardiomegaly, Arrhythmias, Retinopathy, Proteinuria
What can Nicorandil cause?
Ulceration in GI tract
when can you not give Nicorandil
Patients with LVF
What is Conn’s Syndrome?
Adrenal adenoma causing hyperaldosteronism
What electrolyte disturbances does Conn’s Syndrome cause?
Hypokalaemia
Hypernatraemia
BP targets for under 80 and over 80s with hypertension?
Under = 135/85
Over = 145/85
Give an example of hypertensive emergency
Papilloedema + Retinal Haemorrhage
Treatment of hypertensive crisis
IV Nitroprusside, Labetolol and GTN
Treatment of Pheochromocytoma crisis?
Phentolamine
What is Phaeochromocytoma?
Catecholamine secreting tumour
Pheochromocytoma investigation?
25hr urine collection of metanephrines
treatment of Pheochromocytoma
Surgery definitive but pt must first be stabilised with: 1) Alpha blocker (phenoxybenzamine) MUST BE GIVEN BEFORE 2) beta blocker (propanolol)
What is Metanephrine
Metanephrine is a metabolite of epinephrine created by action of catechol-O-methyl transferase on epinephrine
What are the main Catecholamines
The main catecholamines are epinephrine (adrenaline), norepinephrine (noradrenaline), and dopamine.
What antiplatelet is given for conservatively managed NSTEMI
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
What is a common interaction with statins
Macrolides (cause increase CK)
Aortic stenosis - most common cause:
younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification
INFECTIVE ENDOCARDITIS
Types of endocarditis and their incidence %?
Native Valve Endocarditis
Prosthetic Valve Endocarditis (10-20%)
IV Drug Abuse Endocarditis (50%)
TYPICALLY MITRAL VALVE THEN AORTIC
INFECTIVE ENDOCARDITIS
Risks?
Cardiac Risks?
Age >60
Male
IVDU
Poor dental hygiene
Cardiac: Structural/ valvular HD Congenital HD Prosthetic valves Intravascular devices
INFECTIVE ENDOCARDITIS
Typical bacterial cause of NVE?
Alpha - haemolytic Strep Bovis (70%)
S.aureus (25%)
INFECTIVE ENDOCARDITIS
What is Strep Bovis linked to?
Colorectal cancer
INFECTIVE ENDOCARDITIS
What bacteria accounts for 30% of PVE infections?
Likely Bacterial cause within 1 year of prosthetic?
Over 1 year?
Coagulase - negative staphylococcus (CoNS)
such as Staphylococcus epidermidis
<1 year = staph
> 1 year = strep
INFECTIVE ENDOCARDITIS
What is vegetation made up of?
fibrin platelets WBCs RBCs Clusters of bacteria
INFECTIVE ENDOCARDITIS
Symptoms and signs?
Symptoms: Fever (90%) Malaise weight loss cardiac symptoms
Signs:
regurgitant murmurs (MR and AR)
features of HF
INFECTIVE ENDOCARDITIS
classic signs
Janeway lesions (macules on palms/soles)
Osler Nodes (nodules on pads of finger/toes)
Roth spots (lesion on retina with pale centre)
splinter haemorrhages (under nails)
INFECTIVE ENDOCARDITIS
Investigations of choice?
Echo
Blood cultures (3 sets with 30 min intervals)
INFECTIVE ENDOCARDITIS
Major criteria?
Endocardial involvement with
Typical organisms from two separate blood cultures or persistently positive BCs 12hrs apart
INFECTIVE ENDOCARDITIS
Management of Methicillin sensitive staph?
Methicillin resistant?
Sensitive = Flucloxacillin
Resistant = Vancomycin
INFECTIVE ENDOCARDITIS
Management of prosthetic?
Add rifampicin and gentamicin
INFECTIVE ENDOCARDITIS
Management of strep?
Penicillin G
Amoxicillin
Ceftriaxone or vancomycin
INFECTIVE ENDOCARDITIS
Prophylactic for dental procedures
Amoxicillin 2g orally / clindamycin
Empirical Abx for NVE or late PVE?
Ampicillin, Fluclox and Gent
OR
Vancomycin, Gent and rifampicin
Reversible causes of Cardiac Arrest?
Hypoxia
Hypovolaemia
Hyperkal, hypokal, hypogly, hypocalc
Hypothermia
Thrombosis
Tamponade
Tension pneumothorax
Toxins
1st line antiplatelet for following dx:
ACS
PCI
TIA
Ischaemic stroke
PAD
ACS - Aspirin + Ticagrelor
PCI - Aspirin + Ticagrelor or Prasugrel
TIA - Clopidogrel
Ischaemic stroke - Clopidogrel
PAD - Clopidogrel
Digoxin monitoring rules?
digoxin level is not monitored routinely, except in suspected toxicity
HOWEVER
if toxicity is suspected, digoxin concentrations should be measured within 8 to 12 hours of the last dose
Method of action of Digoxin?
- decreases conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and flutter
- increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump.
Also stimulates vagus nerve
Which drugs might precipitate Digoxin toxicity?
Amiodarone Diltiazem & Verapamil Spironolactone Thiazides and loop diuretics Ciclosporin
Management of Digoxin toxicity?
Digibind
What electrolyte imbalance causes Digoxin toxicity and why?
- classically: hypokalaemia
digoxin normally binds to the ATPase pump on the same site as potassium.
Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects
Digoxin features?
generally unwell, lethargy, nausea & vomiting, anorexia, confusion,
yellow-green vision
arrhythmias (e.g. AV block, bradycardia)
gynaecomastia
Side effects of beta blockers?
bronchospasm cold peripheries fatigue sleep disturbances, including nightmares erectile dysfunction
Side effects of CCBs?
Headache
Flushing
Ankle oedema
Side effects of Bendroflumethiazide?
Gout
Hypokalaemia
Hyponatraemia
Impaired glucose tolerance
How to distinguish between mitral and tricuspid regurgitation murmur?
Both pansystolic
BUT
tricuspid regurgitation becomes louder during inspiration, unlike mitral which is louder on expiration
aortic is also louder on expiration
