General Flashcards
Actions of BNP
- vasodilator
- diuretic and natriuretic
- suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
Conditions that decrease BNP
Obesity
Appropriate management of HF
Pericardial constriction
Use of ACEi, ARBS, diuretics
Conditions that increase BNP
Cardiac Causes: heart failure, myocardial ischaemia, AF, valve disease Hypertension Female gender Lung conditions: COPD, pneumonia, sepsis Sepsis Chemotherapy Age Worsening renal function/CKD
Dyspnoea in ticagrelor-treated patients is due to the impaired clearance of ____
Adenosine
What medication do you use instead of adenosine in an asthmatic for SVT
Verapamil
In JVP waveform, what does absent a waves mean?
AF
In JVP waveform, what does large a waves mean?
pulmonary hypertension
pulmonary stenosis
In JVP waveform, what does cannon a waves mean?
complete heart block
ventricular arrhythmias/ectopics
In JVP waveform, what does large v waves mean?
tricuspid regurgitation
what does rise in JVP during inspiration (Kussmaul’s sign) mean?
Also has associated x and y descent
constrictive pericarditis
Which part of aorta does aortic dissection normally occur?
Ascending aorta
Causes of aortic dissection
Acquired
- Hypertension
- Trauma - deceleration injury
- Vasculitis - takayasu, syphilis
- Use of amphetamines, cocaine
- Atherosclerosis
- 3rd trimester pregnancy
Congenital
- Connective tissue disease - marfans, ehlers danls
- Bicuspid aortic valve
- Coarctation of aorta
Classification of aortic dissection and treatment
Stanford
- Stanford A AD: ascending aorta, requires surgery, complication include AR and tamponade
- Stanford B AD: beyond brachiocephalic vessels
Mx: medical therapy - verapamil, beta blockers
Clinical features of aortic dissection
- Sudden and severe tearing/ripping pain to the back
- Hypertension
- Asymmetrical
- Wide pulse pressure
- Syncope
Investigations for aortic dissection
- CXR: widened mediastinum
- CT angiography: looking for false lumen
- TOE: more suitable for unstable patients who are too risky to take to CT
Causes of wide pulse pressure (large difference between systolic and diastolic)
- aortic regurgitation, aortic sclerosis (both heart valve conditions)
- severe iron deficiency anemia (reduced blood viscosity)
- arteriosclerosis (less compliant arteries)
- hyperthyroidism (increased systolic pressure)
A 69-year-old man presents with sudden onset tearing chest pain that radiates through to his back.
He is sweaty. His BP is 160/90 mmHg and pulse 95 bpm. A CXR shows a widened mediastinum and CT scan confirms an aortic dissection of the descending aorta.
Which of the following is the most appropriate initial management of this patient?
A. Verapamil orally B. Refer for cardiac catherisation C. Immediate surgical referral Incorrect answer selected D. Observe on high dependency unit E. IV labetolol
E. IV labetolol
Lesions limited to the descending aorta (type B) generally have better survival compared with those involving the ascending aorta.
What causes QT shortening
Digoxin
Hypercalcaemia
Hypermagnesaemia
Thyrotoxicosis
Atrial myxoma
- Atrial myxomas in the heart make up 50% of primary cardiac tumours.
- They are most common in the left atrium arising from a pedicle on the fossa ovalis. One third present with emboli, a third with systemic inflammation (erythrocyte sedimentation rate [ESR] elevated in a third), and a third are asymptomatic when detected.
- They can intermittently flop through the mitral valve and cause a MID-DIASTOLIC click (tumour plop) when they stop moving.
- Elevated left atrial pressures cause dilatation. Syncope can occur due to obstruction. They are more common in women.
Carney’s complex is a familial multiple neoplasia and lentiginosis syndrome, associated with:
- Primary adrenal hypercortisolism
- Lentigines and naevi of the skin
- Various tumours including myxoma.
In aortic stenosis, what indicates possibly a congenital bicuspid valve?
A systolic ejection click, best heard at the apex, implies that the site of the stenosis is mostly valvular and of congenital origin, that is, bicuspid valvular disease.
What does rheumatic AS result from?
Rheumatic AS results from fibrosis of the leaflets and fusion of the commissures.
Features of cardiac tamponade
Beck Triad of:
- Hypotension
- Raised JVP
- Muffled heart sounds
Pulsus paradoxus: >10mmHg fall in systolic BP on inspiration
Loss or blunted Y descent on JVP
A 55-year-old man presents with severe dyspnoea with tachycardia. Clinical examination raises the possibility that pericardial disease may be the cause.
Which of the following clinical features best distinguishes cardiac tamponade from constrictive pericarditis?
A. Muffled heart sounds B. Raised JVP C. Pulsus paradoxus D. Hypotension E. Kussmaul's sign
Hypotension
What does the waves of the JVP indicate?
a wave - right atrial contraction
x descent - relaxation of right atrium causing drop in pressure
c wave - tricuspid valve closes and right ventricle contracts
x’ descent- end of right ventricular contraction creates extra space within pericardium, allowing right atrium to begin filling with blood
v wave - filling of right atrium against a closed tricuspid valve
y descent - tricuspid valve opens and blood from right atrium begins to fill the ventricles
Causes of pulsus paradoxus
Pulsus paradoxus is defined as an inspiratory drop in blood pressure of 10mmHg or more during normal breathing.
Causes
- pericardial tamponade
- acute asthma
- massive pulmonary embolism
- constrictive pericarditis
- hypovolaemia (especially during positive pressure ventilation)
PCI vs CABG
Patients who are sicker (severity of symptoms, multivessel disease, left main disease/proximal LAD disease LV dysfunction) benefit more from CABG
What genes are involved in familial hypercholesterolemia?
LDLR gene - chromosome 19
APOB gene - chromosome 2
PCSK9 gene - chromosome 1
Complications after MI
- Cardiac Arrest
- Cardiogenic Shock
- Chronic Heart Failure
- Tachyarrhythmias - VF (most common), VT
- Bradyarrhythmia: AV block more common following inferior MI
- Pericarditis + Dressler
Dressler: occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs. - Left ventricular aneurysm
- Left ventricular free wall rupture
- VSD
- MR
Causes of sudden cardiac death (most common to least) in children and young adults
- Unexplained (40%)
- CAD
- Dilated cardiomyopathy
- Myocarditis
- Arrhythmogenic RV cardiomyopathy
- HOCM
- Aortic dissection
MI with stent
MI + AF with stent
DAPT for 12 months and normally aspirin only
Aspirin + P2Y12 inhibitor + apixaban for 4 weeks then continue on P2Y12 inhibitor +
apixaban for 12 months, then apixaban alone.
Patient with stent needing surgery
Stable Disease:
DES: DAPT at least 6 months, delay OT
BMS: DAPT at least 1 month, delay OT
Which NSAID has the lowest association with cardiovascular disease?
A. Ibuprofen B. Diclofenac C. Naproxen D. Celecoxib E. Meloxicam
Answer C
- Available evidence suggests that high-dose naproxen may have the best cardiovascular risk profile among all NSAIDs
- Celecoxib (COX2) may have the best profile with regard to GI risk.
A 70 year old gentleman presents with CCF and LVEF of 30%. He has a history of paroxysmal AF. What is the most appropriate treatment for his atrial fibrillation?
A. Flecainide
B. Lignocaine
C. Metoprolol
D. Verapamil (avoid due to neg inotropic effects)
C. Metoprolol
Rhythm control > Rate control
Rationale:
- Atrial contraction useful in heart failure
- Ventricular function and CCF improve with rhythm control
- Rate and haemodynamic response better in sinus rhythm than rate control.
Preferred agents
- Amiodarone
- Sotalol – Avoid in LVEF <30% (HFrEF) due to increased risk of torsades
Has beta-blocking effects – Sometimes not tolerated.
- Dofetilide
Flecainide – IC antiarrhythmic
- Increased risk of proarrhythmia and SCD in setting of AF in HF
- Avoid
When delivering shocks to perform electrical cardioversion, the synchronization function is used to shock appropriately. At which part of the ECG is the shock delivered when synchronization occurs successfully? P wave Q wave R wave S wave T wave
R wave
Adrenaline is an agent used during cardiopulmonary resuscitation. Which of its following properties is most useful in this situation? Increased cardiac contractility Increased HR Peripheral vasoconstriction Peripheral vasodilation Increased venous return
Peripheral vasoconstriction
Adrenaline Mechanism:
Potent beta-1 adrenergic activity
Moderate beta-2 and alpha-1 adrenergic receptor effects.
Noradrenaline
Mechanism:
Acts on alpha-1 and beta-1 adrenergic receptors
Receptors
Alpha-1: Vascular walls. Induces significant vasoconstriction
Beta-1: Most commonly in heart. Increases inotropy and chronotropy. Minimal vasoconstriction
Beta-2: Blood vessels. Effect: Vasodilation
