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Cardiology > Management > Flashcards

Management Flashcards

1
Q

Bradycardia (4)

A
  1. No Rx needed if asymptomatic and rate is above 40
  2. First treat underlying cause if manageable eg drugs or MI
  3. Atropine 0.6 - 1.2mg (max 3mg) IV
  4. Isoprenaline

DEFINITIVE

  1. Pacing
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2
Q

5 heart conditions that may require pacing (5)

A
  1. Sick Sinus
  2. Mobitz 2
  3. Complete AV block
  4. AF
  5. Drug resistant tachys
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3
Q

List the 5 drugs ACS patients must be on for life after an episode (5)

A
  1. A statin
  2. Aspirin
  3. DAPT - so an additional anitplatelet like Clopidogrel
  4. ACEi
  5. Beta Blocker
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4
Q

Medical Management of STEMI (8)

A

MONA BASH

  1. Morphine
  2. Oxygen if <94%
  3. Nitrates (careful if low BP)
  4. Aspirin 300mg PO
  5. BB
  6. Clopidogrel
  7. Statin
  8. Heparin
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5
Q

Defnitive Management of STEMI (3)

A
  1. PCI if possible wihtin 120 minutes of presentation AND if patient presented wihtin 12 hours of onset OR if after 12 hours but strill clinically having a STEMI (+ signs and symptoms)
  2. if going for PCI then give Prasugrel - unless bleed risk or on blood thinners, then give clopidogrel
  3. Fibrinolysis and an antirhombin drug at the same time if PCI can’t be offered wihtin 2 hours of presentaiton eg if in a rmeote DGH
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6
Q

Pericarditis

A
  1. inpatient if fever >38 or raised troponins otherwise outpatient
  2. Mostly viral so no specific Tx
  3. NSAIDS and Colchicine
  4. Avoid vigorous exercise
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7
Q

ALS Algorithm - Shockable rhythm (11)

A
  1. Non repsonsive and no sings of breathing, no pulse, no chest rise
  2. Crash call
  3. Compressions 30:2
  4. Attach defib and analyse
  5. Deliver shock (assuming shockable)
  6. Immediate return to CPR for 2 mins before next shock
  7. Attempt IV or IO access
  8. Deliver up to 3 shocks before using drugs
  9. Use Adrenaline 1mg IV after 3 shocks unsuccessful then every 3-5 minutes

10 Administer amiodarone 300mg IV after 3rd shock and again at 5 shocks

  1. Thrombolysis considered if PE suspected - then do CPR for 1-1.5 hrs
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8
Q

ALS Algorithm - Non-Shockable rhythm (7)

A
  1. Non-responsive, not breahting, no pulse
  2. Crash Call
  3. Compressions 30:2 100bpm
  4. Attach defib and analyse (finds non-shockable PEA or Asystole)
  5. Attempt IV or IO Access
  6. Administer Adrenaline 1mg IV immediately then repeat every 3-5 minutes
  7. Cycle CPR 2 minutes and analyse rhythms to see if flipped to shockable
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9
Q

Angina (8)

A

For everyone:
1. Aspirin
AND
2. Statin

  1. GTN to abort attacks

Either:
4. CCB - rate limiter one like diltiazem or verapamil
OR
5. Beta Blocker

If maxed monotherapy dose and no improvement then combine CCB and BB:

IF combined BB and CCB then
6. NEVER Rx Verapamil and a BB - risks total heart blick

  1. Use a long acting CCB like Amlodipine or mod release Nifedipine

ONLY add a third drug like a long-acting nitrate or (ivabradine, nicorandil, ranolazine) if awaiting PCI

  1. Assess for PCI or CABG
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10
Q

Antiplatelet use in ACS (3)

A

1st line:
1. Aspirin lifelong
AND
2. Ticagrelor (12 months)

2nd Line:
if CI to Aspirin then
3. Clopidogrel Lifelong

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11
Q

Antiplatelet use in PCI (4)

A

1st Line:
1. Aspirin (Lifelong)
AND
2. Prasugrel (12 months)

UNLESS high bleed risk or on other anticoagulants then
3. Ticagrelor/Clopidogrel (12 months)

2nd Line:
if CI to Aspirin then
4. Clopidogrel Lifelong

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12
Q

Antiplatelet use in TIA (3)

A

1st Line:
1. CLopidogrel (Lifelong)

2nd Line:
2. Aspirin
(lifelong)
AND
3. Dipyridamole (lifelong)

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13
Q

Antiplatelet use in Ischaemic Stroke (3)

A

1st Line:
1. Clopidogrel (lifelong)

2nd Line:
2. Aspirin (lifelong)
AND
3. Dipyridamole (lifelong)

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14
Q

Antiplatelet use in PCI (2)

A

1st Line:
1. Clopidogrel (lifelong)

2nd Line:
2. Aspirin (lifelong)

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15
Q

Aortic Dissection (4)

A
  1. Type A: Surgical
    AND
  2. Keep low BP of 100-120 mmHg prior to op
  3. Type B: Conservative, bed rest, BP control with
  4. Labetalol IV
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16
Q

Aortic Stenosis (2)

A
  1. Replace (TAVI) if symptomatic or severe BP compromise >40mmHg
  2. Ballon valvuloplasty in kids
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17
Q

AFib Rate Control (5)

A

Rate Control:
1. BB
or
2. Rate-limiting CCB like diltiazem

if mono-therapy doesn’t work then combine any 2 of:

  1. BB
  2. Diltiazem
  3. Digoxin
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18
Q

AFib Cardioversion (4)

A
  1. if AFib <48hrs old, then heparin and cardiovert
  2. If >48hrs then anticoagulate with heparin for 3wks prior to DC (rather than chemical) cardioversion. Can also TOE to r/o thrombus in atrial appendage.
    2a. MUST ANTICOAGULATE 4WKS AFTER
  3. IF STABLE - Chemical cardioversion
  4. IF UNSTABLE - DC cardioversion
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19
Q

Recommended DOACs for AFib (4)

A
  1. Apixaban
  2. Dabigatran
  3. Edoxaban
  4. Rivaroxaban

Warfarin is now 2nd Line to DOACs in AFib anticoagulation/stroke PPx

Aspirin is not recommended

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20
Q

How to assess need for anticoagulation in AFib? (4)

A
  1. CHA2DS2-Vasc Score
  2. Score = 0 - none needed
  3. Score = 1 - Men: Consider Anticoagulation, Women: No Tx
  4. Score = 2 or more - offer anticoagulation
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21
Q

Agents used in Chemical Cardioversion of AFib in UK (2)

A
  1. Amiodarone
  2. Flecainide
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22
Q

AFib Anticoagulation following TIA/Stroke (4)

A
  1. Exclude Bleed!!
  2. If TIA then start immediately (DOAC Xa inhibitor or Warfarin)
  3. If ischaemic stroke - wait 2 weeks with antiplatelets instead for the first 2 weeks
  4. Delay anticoagulation in huge ischaemic strokes
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23
Q

Indications for Rhythm control/cardioversion over rate control in AFib (5)

A

Do cardioversion instead of rate control if:

  1. AFib has a reversible cause
  2. Patient has HF thought to be causing this episode of AF
  3. New ONset <48hr old AFib
  4. AFlutter suitable for ablation
  5. Consultant clinical judgement
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24
Q

Drugs used for long-term AFib Rhythm control (3)

A
  1. Beta-Blockers
  2. Dronedarone following cardioversion
  3. Amiodarone - good in coexisting HF
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25
Q

AFib Ablation - indication and medical management (3)

A
  1. Last resort for patients not responding to or not wanting rhythm control drugs
  2. Percutaneous procedure
  3. Antiocoagulation as per CHA2DS2Vasc is still needed as stroek risk not reduced
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26
Q

Complications of AFib Ablation (3)

A
  1. Tamponade
  2. Stroke
  3. Pulmonary Vein Stenosis
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27
Q

Success rate of AFib Ablation (2)

A
  1. 50% have self resolving early recurrence
  2. 80% at 3 years with multiple procedures
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28
Q

Mx of Atrial Flutter (2)

A
  1. More sensitive to DC cardioversion than AFib so lower levels needed
  2. Radio-frequency Ablation of the Tricuspid valve isthmus is usually curative
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29
Q

Brugada Syndrome (2)

A
  1. ICD placement
  2. Quinidine (class 1a anti-arrhythmic)
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30
Q

Buerger’s Disease(1)

A
  1. Completely stop smoking - major improvement
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31
Q

Choking (3)

A
  1. 5 back blows
  2. 5 abdominal thrusts
  3. Repeat cycle

Obviously CPR if at any point its indicated

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32
Q

Wolf Parkinson White Syndrome (4)

A
  1. Surgical Radiofrequency Ablation is curative

Medical management
2. Sotalol if nor AFib

  1. Amiodarone
  2. Flecainide
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32
Q

Heart Failure Chronic Management (10)

A

1st Line:

  1. ACE
    AND
  2. BB - Bisoprolol, Carvedilol, Nebivolol
    No effect on mortality in HFpEF

2nd Line:

  1. Aldosterone antagonist - Spironolactone / eplerenone
  2. SGLT-2is - Dapaglaflozin reduce hospitalisations and cardiac death

3rd Line: SPECIALIST

  1. Ivabradine - >75 bpm and EF<35%
  2. Sacubitril-valsartan - EF<35% and Sxs on ACE/ARB
  3. Digoxin - if coexisting AFib

next is resynchronization or implanted defib

ALONGSIDE:

  1. Annual Flu Vaccine
  2. One-off Pneumococcal Vaccine

ACUTELY / FLUID OVERLOAD:

  1. Loop diuretics - no evidence for long term benefit on marotality, just use to get the fluid off them acutely
33
Q

Blood Pressure target for Type 2 Diabetes (1)

A
  1. <140/90
34
Q

Blood Pressure target for Type 1 Diabetes (2)

A
  1. <135/85

unless albuminuria or metabolic syndrome then:

  1. <130/80
35
Q

Mx of Acute Heart Failure w/o hypottension (7)

A
  1. IV Loop Diuretics

Possibly:
2. Oxygen - 94 -98%

  1. Vasodilators - Nitrates shouldn’t be routinely given but have a role if coexisting ischaemia or valcvular disease or severe HTN

WITH RESP FAILURE:
4. CPAP - prevents alveolar derecruitment in pul oedema

  1. Continue normal chronic meds like ACE/ARBs
    AND
  2. Only stop BBs if HR<50
  3. DO NOT routinely give Opiates due to suggested increased mortality
36
Q

Mx of Acute Heart Failure with Hypotension/cardiogenic shock

A

Very challenging and probably specialist lead as some meds typically given like loops may worsen hypotension

  1. Ionotropes
    - Dobutamine for patients with significant Left Vent Dysfunction with reversible shock
  2. Vasopressors if no repsonse and end-organ damage - defo not an F1 decision
  3. Mechanical circulatory assistance
37
Q

Next appropriate step according to NICE if BP reading of >180/120 (7)

A
  1. IMMEDIATELY check for end-organ damage

If none found:
2. Consider immediate start of drug therapy even before 24hr monitoring

  1. Recheck BP wihtin 7 days +/- use abulatory 24hr monitoring to Dx

If YES organ damage
4. Refer emergently for same day asessment to specialist if:

  1. Retinal haemorrhage or papilloedema
  2. Suspected Phaeo
  3. Life threatening Sxs
38
Q

HTN NICE drug management algorithm (8)

A
  1. <55, non-black OR anyone with Diabetes = ACE or ARB (ARB better if black and diabetes)
  2. > 55, Black Heritage, No Diabetes = CCB
  3. Add either a CCB, ARB/ACE, Thiazide to everyone (ACE less effective in black so choose accordingly)
  4. Get em on all 3
  5. Low dose spironalactone if potassium <4.5
  6. A-blocker or BB if Potassium >4.5

7.Confrim elevated BP with 24hr monitoring , discuss adherence and check for postural drop

  1. Specialist referral if not controlled on 4 drugs
39
Q

Classify HTN according to NICE (11)

A

On ambulatory testing:

NO HTN:
1. <135/85

STAGE 1
2. > 135/85 and <150/95)

Tx stage 1 IF:
3. <80
AND
4. End organ damage
5. CVD
6. DM
7. Renal disease
8. QRISK >10%

STAGE 2:
9. >150/95
10. TREAT EVERYONE REGARDLESS

  1. SEVERE = >180/120
40
Q

HOCM (6)

A

ABCDE

  1. Amiodarone
  2. Beta-blockers or Verapamil for Sxs
  3. Cardioverter Defib (implanted ICD)
  4. Dual Chamber pacemaker
  5. Endocarditis PPx
  6. AVOID DEHYDRATION AT ALL COSTS
41
Q

Drugs to avoid in HOCM (3)

A
  1. Nitrates
  2. ACEis
  3. Inotropes
42
Q

Infective Endocarditis Initial Empirical Tx with a Native valve (4)

A
  1. Amoxicillin
    and consider
  2. Low-dose Gentamicin

IF PEN ALLERGIC

  1. Vancomycin
    and consider
  2. Low-dose Gentamicin
43
Q

Infective Endocarditis Initial Empirical Tx with a Prosthetic valve (3)

A
  1. Vancomycin
    and
  2. Rifampicin
    and
  3. Low-dose Gentamicin
44
Q

Native Valve IE caused by Staphyloccoci (3)

A
  1. Flucloxacillin

IF PEN ALLERGIC or MRSA
2. Vancomycin
and
3. Rifampicin

45
Q

Prosthetic Valve IE caused by Staphylococci (6)

A
  1. Flucloxacilling
    and
  2. Rifampicin
    and
  3. Low-dose Gentamicin

IF PEN ALLERGIC OR MRSA
4. Vancomycin
and
5. Rifampicin
and
6. Low-dose Gentamicin

46
Q

IE caused by Fully-sensitive Streptococci (viridans) (3)

A
  1. BenPen

IF PEN ALLERGIC
2. Vancomycin
and
3. Low-dose Gentamicin

47
Q

IE caused by less sensitive Strep (not viridans) (4)

A
  1. BenPen
    and
  2. Low-dose Gentamicin

IF PEN ALLERGIC
3. Vancomycin
and
4. Low-dose Gentamicin

48
Q

Indications for Surgery in IE (5)

A
  1. Severe Valvular Incompetence
  2. Aortic Abcess - indicated by long PR interval
  3. Resistant Infections
  4. HF refractory to medical management
  5. Recurrent emboli even after ABx
49
Q

Prognosis of IE according to organism (3)

A

mortality:

  1. Staph - 30%
  2. Bowel / enterococci - 15%
  3. Strep - 5%
50
Q

Poor prognostic factors for IE (4)

A
  1. S.Aureus infection
  2. Prosthetic Valve infeciton esp if early
  3. Culture negative endocarditis
  4. Low complement levels
51
Q

IE Prophylaxis (2)

A

NOT NEEDED for dental procedures, GI procedures, GU or Gynae procedures, ENT or Resp procedures

Is needed for

  1. Any infetions in people at risk - should eb investigated very promptly and PPx if necessary
  2. if at risk of IE undergoing GI or GU surgery with suspected infection site - offer IE antibiotics
52
Q

Long QT Syndrome (3)

A
  1. Avoid QTc drugs
  2. BB - just not sotalol
  3. Implantable cardioverter defibrillator
53
Q

Mitral Regurgitation (8)

A
  1. Nitrates
  2. Inotropes
  3. Diuretics
  4. Aortic Balloon Pump to increase CO

If in HF
5. ACEi
6. BBs
7. Spironolactone

  1. Surgery for repaire or pig valve replacement if SEVERE
54
Q

Mitral Stenosis (4)

A
  1. If AFib concurrent - Anticoagulate with WARFARIN if mod/severe, with a DOAC if mild
  2. ASx patients monitored with regular echoes
  3. Sx patients - percutaneous ballon valvotomy
  4. SEVERE - Replacement or commissurotomy (reopening)
55
Q

Dressler’s Syndrome (1)

A
  1. NSAIDS
56
Q

ACS / MI in a Diabetic (2)

A
  1. VRII monitoring BMs to keep BMS below
  2. 11.0 mmol/L
57
Q

Myocarditis (2)

A
  1. Treart underlying infection - abx if bacterial
  2. Supportive otherwise - eg support HF or arrhythmias
58
Q

Orthostatic Hypotension (3)

A
  1. Remove offending agent / swap BP control if indicated
  2. Midodrine
  3. Fludrocortisone
59
Q

Indications for a Temproary Pacemaker (3)

A
  1. Symptomatic / haemodynamically unstable brayd not responding to atropine
  2. Post - Anterior MI with Type 2 or complete Heart block if severe or unstable
  3. Trifasicular block awating surgery
60
Q

Peri-arrest Bradycardia (4)

A
  1. Atropine IV 500mcg
  2. Dose up to 3mg if no response
  3. Isopraline / Adrenaline infusion titrated to repsonse if still failing to abort
  4. Call cardiology for help from specialist for transcutaneous or transvenous pacing
61
Q

Peri-arrest Tachycardia (Summary Card) (10)

A
  1. Up to 3 DC shocks
  2. CALL FOR HELP NOW

Further treatment specialist lead and depends on QRS narrow/broad, regular or irregular

BROAD COMPLEX:
Regular:
3. Assume VT (unless obvious/previous SVT with BBB) and load with Amiodarone 300mg 10mins-1hr followed by 24hr infusion

Irregular:
4. AFib with BBB, AFib with prem ventricular repsonse or Torsades - GET HELP and give MAGNESIUM 2g in 10 mins

NARROW COMPLEX:
Regular:
5. Vagal Manouvres
6. IV Adenosine 6mg IV bolus rapid, repeat with 12mg if no response, then give 18mg if no repsonse (6,12,18 rule)
7. If neither work assume Atrial Flutter and give BBs

Irregular:
8. Probably AFib - follow AFib algorithm (48hr rule and anticoag)
9. Control Rate with BBs

  1. If all fails, if regular rhythm then can give up to 3 DC shocks
62
Q

Broad Complex Regular Tachycardia (assuming no life-threatening signs) (3)

A

Assume VT

  1. Amiodarone 300 mg IV 10 - 60 Mins
  2. If fails, up to 3 shocks

If certain previous Dx of SVT with BBB (which would cause the same ECG appearance)

  1. Treat as regular narrow complex tachy
63
Q

Broad Complex Irregular Tachycardia (assuming no life-threatening signs) (3)

A

AFib with BBB
1. Treat as for AFib

Polymorphic VT (Torsades)
2. IV Magnesium 2g over 10 mins

  1. Call for help
64
Q

Narrow Complex Regular Tachycardia (assumiong no life-threatneing signs) (5)

A
  1. Vagal Manouvres

If no response
2. Adenosine 6,12,18mg rule

  1. Continuous ECG monitoring

If failed
4. Verapamil OR BB (NEVER together)

If failed
5. up to 3 DC shocks +/- sedation

65
Q

Narrow Complex Irregular Tachycardia (4)

A

AFib

  1. Control Rate with BB
  2. Consider Digoxin or Amiodarone if HF
  3. Anticoagulate for 3wks if >48hrs old
  4. Cardiovert if <48hrs old
66
Q

Rheumatic Fever (3)

A
  1. ABx - Peneicillin V PO
  2. NSAIDS
  3. Tx any complications like Heart Failure / Valve disorders
67
Q

Syndrome X (1)

A
  1. Nitrates can help
68
Q

Takayasu’s Arteritis (1)

A
  1. Stroiiiids (as with all vasculitities)
69
Q

Torsades de Pointes (1)

A
  1. IV Magnesium Sulphate
70
Q

What is the Valsalva Manoeuvre and give 2 uses (3)

A
  1. Forced expiration against resistance
  2. Terminate SVT
  3. Normalise inner ear pressures
71
Q

Describe the Stages of the Valsalva Manoeuvre (5)

(probably dont memorise, here for completeness and understanding)

A
  1. Increased Intrathoracic Pressure
  2. Resultant increase in venous and right atrial pressure reduces Venous Return
  3. Reduced Preload leads to drop in CO (as per Frank-Starling)
  4. When pressure release there is a further slight fall in CO from increased aortic volume
  5. Return to normal Output
72
Q

VSDs (3)

A
  1. most small ones close on their own
  2. HF management
  3. Surgery if severe
73
Q

Management of High INR (MAJOR BLEED) (3)

A
  1. Stop Warfarin
  2. Give IV Vit K 5mg
  3. Prothrombin complex concentrate - if not available FFP
74
Q

Management of High INR (INR >8 + Minor Bleed) (4)

A
  1. Stop Warfarin
  2. Give IV Vit K 1-3 mg
  3. Repeat Vit K if INR still high after 24hrs
  4. Restart Warfarin when INR<5
75
Q

Management of High INR (INR>8 + NO Bleeding) (4)

A
  1. Stop Warfarin
  2. Give Vit K 1-5mg PO - drink IV preparation
  3. Repeat after 24hrs if INR not low enough
  4. Restart when INR<5
76
Q

Management of High INR (INR 5-8 + MInor Bleeding) (3)

A
  1. Stop Warfarin
  2. Give IV Vit K 1-3mg
  3. Restart when INR<5
77
Q

Management of High INR (INR 5-8 + NO Bleeding) (2)

A
  1. Withhold 1 or 2 doses
  2. Reduce next maintenance dose
78
Q

Target INR for aortic valves (1)

A
  1. 3.0
79
Q

Target INR for mitral Valves (1)

A
  1. 3.5
80
Q

Which Thiazide is preferred by NICE for HTN management when already on a CCB and ACEi (1)

A
  1. Indapamide

better than bendro

Cardiology (8 decks)

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