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DPD COURSE > Interactive cardiology cases - amir sam > Flashcards

Interactive cardiology cases - amir sam Flashcards

1
Q

associated symptoms of cardiac pain

A

nausea, sweating, sob, dizziness, ankle swelling

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2
Q

risk factors of cardiac pain

A

htn, high cholesterol, dm

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3
Q

investigations for mi in order

A

ecg, troponin and echocardiography

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4
Q

why do you do an ecg first for mi

A

to know if there is st elevation

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5
Q

management for stemi

A

aspirin and clopidogrel and send to cath lab for percutaneous coronary intervention (PCI) aka angioplasty

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6
Q

management for nstemi

A

aspirin, clopidogrel, lmwh, inpatient angiogram. thrombolyse (tPA or streptokinase) before sending to cath lab

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7
Q

what do the results of the troponin test indicate

A

positive - coronary angiogram

negative - exercise tolerance test

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8
Q

when is troponin done

A

tradionally at 12h but high sensitiity troponins can be done at 3h and 6hr after onset of chest pain

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9
Q

what will echocardiography show

A

ventricular dysfunction and regional wall motion abnormality. if there is blockage of one of the coranaries there will be rwma in that area

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10
Q

why isnt there regional wall motion abnormality in myocarditis

A

the whole heart is affected

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11
Q

what are the cardiac ddx of chest pain

A

ihd, aortic dissection, pericarditis

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12
Q

ischaemic heart disease (ihd) signs n symptoms

A

radiation to jaw and left arm. pressure like pain, sweating and nausea

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13
Q

what are the signs n symptoms of aortic dissection

A

sudden onset tearing chest pain radiates to back. difference in bp in both arms

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14
Q

what should you do in every patient with chest pain, hypotension, or murmur

A

listen to echo sound with s2. ask patient to breath out and lean forward. s2 and murmur sounds will combine

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15
Q

signs n symptoms of pericarditis

A

pleuritic chest pain that is worse on inspiration. relieved by leaning forward. may have had flu like illness recently.

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16
Q

resp ddx of chest pain

A

pe, pneumonia, pneumothorax

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17
Q

pe signs, symptoms

A

sudden onset sob, pleuritic chest pain, haemoptysis, swollen leg

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18
Q

pe risk factors

A

immobility, previous history/fh of dvt/pe, smoking, recent surgery, ocp, hrt, long haul flight

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19
Q

pneumonia signs n symptoms

A

cough, sputum, fever

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20
Q

pneumothorax signs n symptoms

A

sudden onset sob, tall thin young man or someone w resp disease

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21
Q

if sudden onset sob what could it be

A

pe, ptx or foreigh body. if no risk factors likely to be ptx

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22
Q

gi ddx of chest pain

A

oesophageal spasm, oesophagitis, gastritis

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23
Q

gastrtitis signs n symptoms

A

waterbrash - sour taste in mouth, retrosternal pain and alcohol use (rf)

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24
Q

musculoskeletal ddx of chest pain

A

costochondritis

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25
Q

what will cxr show in aortic dissection

A

widening of the mediastinum. so need to ask for ct angiogram of the aorta

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26
Q

difference between stable and unstable angina

A

stable - pain on exertion, unstable - pain at rest

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27
Q

ddx of pleuritic chest pain

A 
pericarditis
pe
pneumonia
pneumothorax
pleural pathology 
sub-diaphragmatic pathology
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28
Q

what can the ecg tell you

A

ischaemia, conduction problems and structural problems

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29
Q

what is an anterolateral stemi

A

evidence of ischaemia - st elevation in v2,v3,v4,v6 and I. st depression in the other leads - reciprocal changes

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30
Q

what is an anterior mi

A

changes seen in v1,, v2, v3,v4 and left anterior descending artery is affected

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31
Q

what is a lateral mi

A

changes seen in v5,v6, I and aVL and circumflex artery is affected

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32
Q

what is an inferior stemi and which artery is affected

A

st elevation in II, III and aVF. it affects the right coronary artery

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33
Q

what does the hpc of this collapse case tell you:
before - no warning
during - no tongue biting
after - not confused

A

no warning suggests cardiac cause with VT (brady/tachyarrhtmia). not an epileptic fit as no prodromal aura
no tongue biting –> cardiac
not confused –> usually drowsy/confused after a seizure but not after an arrhythmia

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34
Q

ddx of this collapse case

A

aortic stenosis - examination would show ejection systolic murmur with a soft s2 and slow rising pulse
pe - no risk factors
postural hypotension - lying and standing bp were same
seizure - no post-ictal phase
tachyarrhythmia

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35
Q

hypoglycaemia cause of collapse - what do you do

A

ask for capillary blood glucose. fast test - insulinoma

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36
Q

cardiac ddx of collapse

A

VOAP - vasovagal, outflow obstruction, arrhythmia, postural hypotension

37
Q

vasovagal collapse causes

A

P’s: posture, prodrome, provoking factors - standing up in hot weather, cough reflex, micturition reflex. associated with increased vagal activity slowing down the heart. benign

38
Q

how to tell if arrhythmia caused collapse

A

look at ecg… is there a fh of sudden death

39
Q

right vs left outflow obstruction causes

A

left - aortic stenosis (old) or HOCM (young)

right - pe

40
Q

neurological cause of collapse

A

seizure

41
Q

o/e and investigations of arrhythmia

A
  1. ECG: Long QT - predisposes to VT
  2. Cardiac monitor: to catch episode
  3. 24h tape
42
Q

o/e and investigations of outflow obstruction

A

Left -> Low volume/slow rising pulse, ejection systolic murmur, echocardiogram.
Right -> d-dimer and ct pulmonary angiogram

43
Q

o/e and investigations of postural hypotension

A

Lying and standing blood pressure

44
Q

how to know if they have long qt syndrome from ecg

A

Draw a line between two R waves. The t wave should finish before the half-way point.

45
Q

causes of abnormal ventricular repolarisation aka long qt interval

A

Congenital: mutations in K channels (long qt syndrome) –> FH of sudden death.
Acquired: low K/Mg, drugs.

46
Q

difference between left and right sided murmurs

A

Left sided murmurs are louder on expiration. Right sided murmurs are louder on inspiration.

47
Q

causes of pan systolic murmurs

A

mirtal and tricuspid regurg

48
Q

ddx of high jvp

A

r heart failure. tricuspid regurg. constrictive pericarditis.

49
Q

what would make you think ddx is r heart failure

A
  1. Would see a precipitating factor → pulmonary hypertension, infarction, left sided heart failure.
  2. Could be secondary to left HF (Congestive cardiac failure, previous MI)
  3. Pulmonary HTN (recurrent PE, long-standing COPD etc) → High pressure in the
    pulmonary artery, the heart would be working really hard and may fail.
  4. Infarction – patient may present with chest pain.
50
Q

what would make you think ddx is tricuspid regurg

A

high temp. infective endocarditis. right ventricular dilation

51
Q

what is common in iv drug users

A

right sided endocarditis that can damage valve leaflets

52
Q

causes of constrictive pericarditis

A

infection - tb
inflammation - connective tissue disease (lupus, sarcoidosis)
malignancy

53
Q

constrictive pericarditis signs

A

raised jvp, hepatomegaly, peripheral oedema

54
Q

ddx of systolic murmurs

A
  1. Aortic stenosis
  2. Mitral regurgitation
  3. Tricuspid regurgitation
  4. Ventricular septal defect (VSD)
55
Q

how to differentiate between ddx of systolic murmurs

A
  1. Where is it loudest?
    a. Aortic area: AS
    b. Mitral area: MR
    c. Does it radiate?
    i. To carotids = AS.
    ii. To axilla = MR.
  2. Associated features?
    a. AS - Slow rising pulse (thrill under thumb), soft S2
    b. Hyperdynamic displaced apex beat mitral area (MR)
    c. TR: Pulsatile liver, high JVP
  3. normal fit man w no other features of other murmus -> VSD
56
Q

What would you expect to see on his ECG:

pr - 160 irregular

A

atrial fibrillation or sinus tachycardia

57
Q

if ecg shows sinus tachycardia what is the ddx

A

1) Sepsis → hypotension (reflex tachy)
2) Hypovolemia
3) Endocrine: thyrotoxicosis, phaeochromocytoma

58
Q

what does a supraventricular tachycardia (SVT) look like on ecg

A
  • Missing p wave
  • Fast and regular
  • QRS-T pattern
  • Narrow complex < 3 small squares
59
Q

how to treat svt

A

adenosine

60
Q

what type of svt has a slurred upstroke (delta wave)

A

avrt

61
Q

if ecg shows SVT what is the ddx

A

re-entry circuit: re-entrant tachycardias

62
Q

what is avnrt

A
  • Reentry circuit at the AV node: conducted down and goes round in circles
  • No p wave because the depolarisation comes from the AVN not the SAN
  • Normal ECG after it has resolved - no slurred upstroke
63
Q

what is avrt - Wolff Parkinson White

A
  • Big accessory bundle

- Depolarisation gets to AVN, travels down the septum and then back up the accessory pathway to reach the AVN again

64
Q

if ecg shows atrial fibrillation what is the ddx

A

Metabolic: Thyrotoxicosis, alcohol
Heart (by layer): pericarditis, muscle (CM, IHD, HTN, myocarditis), valves (MS, MR)
Lungs: pneumonia, PE, cancer

65
Q

if ecg shows VT what is the ddx

A

Ischaemia (collapse w mi due to arrhythmia), electrolyte abnormality (check k,mg) , long QT(look at old ecgs)

66
Q

atrial fib on ecg

A

no p waves, irregular, narrow qrs

67
Q

vt on ecg

A

broad qrs complexes,regular

68
Q

what is the management for svt and bp 120/80

A
  1. vagal manoeuvres - massage n valsalva
  2. adenosine w cardiac monitor if vagal manoeuvres dont work
  3. dc cardioversion if haemodynamically compromised
69
Q

contraindication of adenosine

A

asthmatics and warm patients

70
Q

what patients have dc cardioversion

A

anyone with

any arrhythmia that has haemodynamic instability needs DC cardioversion.

71
Q

Management Plan for Acute Fast AF and BP 120/80

A
  1. Rhythm control → convert to sinus rhythm. If onset > 48hours, anticoagulate for 3-4 weeks before cardioversion or a clot may dislodge –> stroke
  2. Rate control using Beta blocker or Digoxin
  3. Treat underlying Cause (pnuemonia, infection - abx n fluid)
  4. think of the Complications (Anticoagluation - warfarin)
72
Q

how do you manage a ventricular tachycardia

A
  1. If no haemodynamic compromise (hypotn): IV amiodarone.
  2. Look for and treat underlying cause - electrolyte abnormalities
  3. ICD - implanted cardiac defibrillator
  4. Pulseless VT: defibrillate
73
Q

what is the voltage criteria for left ventricular hypertrophy and ddx

A

deep S in v1 and v2
tall R in v5/v6
S in v1 and R in v5 or V6 (whichever is larger) ≥ 7 large squares
ddx - hypertension as ventricle has hypertrophied due to working hard against systolic pressure

74
Q

1st degree heart block in ecg

A

prolonged pr interval (>1 large square)

75
Q

what to look at when interpreting an ecg

A
  1. rate, rhythm, axis - sinus, positive QRS in I and II so normal axis
  2. any ischaemia , st elevation or depression or t wave inversion
  3. electrical abnormalities - pr, qrs, qt intervals
76
Q

2nd degree heart block in ecg

A

p waves that are not followed by QRS complexes

77
Q

3rd degree (complete) heart block in ecg

A

no association between p waves and QRS complexes . broad QRS complexes

78
Q

pathologies suggested by ECG

A
  1. Ischaemia - ST ele/dep , T inversion (NNSTEMI), Q (old infarct)
  2. Arrhythmias or conduction defects:
    - Rate, rhythm
    - PR interval (prolonged → 1st degree HB), QRS intervals (prolonged → BBB), QT interval
    (prolonged → predisposes to VT).
  3. Ventricular strain or hypertrophy
    - Axis (R/L deviation), R, S waves
79
Q

quickest way to find axis

A
  1. If QRS complexes in V1 and V2 both positive → no axis deviation.
  2. If either is negative → axis deviation. Right or left?
     aVL is positive → Left axis.
     aVL negative → right axis.
80
Q

what is s3 associated with

A

ventricular filling (heart failure)

81
Q

what is s4 associated with

A

ventricular hypertrophy - atria contracting against stiff ventricle

82
Q

Can you tell the difference between the fixed wide splitting of S2 and S3?

A

The fixed wide splitting is best heard with the diaphragm whereas S3 is a low pitched sound and is
therefore better heard with the bell.

83
Q

acute heart failure management

A
  1. Sit up
  2. 60-100% O2
  3. Reduce preload - GTN infusion - venodilators
  4. Diamorphine
  5. Furosemide (IV) - (not for diuresis, venodilator as well)
    a. Given IV because if they have gut oedema they will not absorb the drug orally
    b. Daily weights needed
  6. Treat the underlying cause e.g. MI
84
Q

chronic heart failure management

A

beta blocker and acei and spironolactone

85
Q

causes of cardiac arrest (4Fs and 4Ts)

A
  • Hypoxia
  • Hypothermia
  • Hypovolaemia
  • Hypo/hyperkalaemia
  • Tamponade
  • Tension pneumothorax
  • Thromboembolism
  • Toxins / metabolic disorders: drugs, therapeutic agents, sepsis
86
Q

what is the management for VF/pulseless VT

A
  1. shock
  2. CPR (2mins)
  3. Re-assess rhthym
  4. Adrenaline every 3-5 mins
  5. correct reversible causes
87
Q

why do you not give adrenaline to patient that is cold (hypothermia)

A

metabolism slows down when the patient is cold. so adreanaline would build up and could be toxic

88
Q

what is the management for asystole/pulseless electrical activity –> ecg looks fine but pt has no pulse

A
  1. cpr
  2. correct reversible causes
  3. no drugs

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