Medicine - Cardiology Flashcards
Recall 2 observations about a person’s pulse that may be seen if they have aortic stenosis vs aortic regurgitation
Aortic stenosis: NARROW pulse pressure, slow rising pulse
Aortic regurgitation: WIDE pulse pressure, ‘waterhammer’ pulse (Corrigan’s pulse)
Pulse pressure = SBP-DBP (eg if BP = 120/80, PP = 40)
How would you describe the heart sounds that are auscultated in aortic stenosis vs regurgitation?
Aortic stenosis = soft S2 +/- S4
Aortic regurgitation = soft S2 +/- S3
What is the difference in cause between an S3 and S4 heart sound?
S3 heart sound is caused by blood filling against a non-compliant ventricle, whereas S4 is blood filling against a compliant ventricle
How can you hear the difference between an S3 and S4 heart sound?
S3 is early diastolic
S4 is late diastolic
What clinical examination findings can help differentiate aortic stenosis caused by valve sclerosis from aortic stenosis caused by HOCM?
In HOCM, the valsalva manoevre increases the volume of the murmur, whereas squatting decreases it
What might a CXR reveal in aortic stenosis?
Left ventricular hypertrophy
Pulmonary oedema
Valve calcification
What is the most useful investigation for assessing the severity of aortic stenosis?
Echo +/- doppler
Recall some general principles of management of heart valve disease
QRISK3 score to stratify risk
Manage risk with a statin (eg atorvastatin) and an antiplatelet (aspirin/ clopidogrel)
Manage coexistent HTN/ angina etc
Recall some indications for open replacement of the aortic valve (rather than cath lab procedure)
Symptomatic
Non-symptomatic with a low EF
Severe undergoing CABG
What does CABG stand for?
Coronary artery bypass graft
What are the 2 main types of artificial aortic valve?
Ball-in-cage
Bileaflet/ tilting disc
Recall some pros and cons of TAVI
Pros: no bypass required, no large scars
Cons: higher risk of stroke compared to open replacement
What is a balloon aortic valvuloplasty
Procedure which stretches the aortic valve to improve symptoms of aortic stenosis
When is the aortic stenosis murmur heard vs aortic regurgitation?
AS: Ejection systolic
AR: Early diastolic
What is an Austin Flint murmur?
‘Rumbling diastolic murmur’
- Associated with severe aortic regurgitation
- Best auscultated in 5th ICS in MCL
- Caused by blood flowing back through the aortic valve and over the mitral valve
When in the heart cycle is an Austin flint murmur heard, and what causes it?
Mid-diastole
Caused by regurgitant jet that runs over the mitral valve leaflets
Which heart murmurs are best heard on expiration?
Left heart murmurs
Where is the aortic regurgitation murmur best auscultated?
Erb’s point - Left 3rd ICS parasternal
Where is the main site of production of BNP?
Left ventricle (not actually brain, as name may suggest)
What is the advantage of measuring NT-proBNP over BNP?
NT-proBNP has a much longer half life as it is inactive - BNP, being an active hormone, has a much shorter half life
What can an echo and doppler be used to determine in cases of aortic regurgitation?
Severity
LV function
Cause
What is the mainstay of medical management for aortic regurgitation (other than managing cardiac risk with statins etc)?
Reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
Which 2 antihypertensives are contra-indicated in aortic stenosis?
Beta blockers (don't want to depress LV function) Nitrates (may precipitate life-thretening hypotension)
Which heart murmur is most associated with atrial fibrillation?
Mitral stenosis
Which of the left heart murmurs will NOT produce a displaced apex beat?
Mitral stenosis (causes atrial hypertrophy not ventricular)
By what mechanism can heart valve disease cause a parasternal heave, and which murmurs can cause this?
Right ventricular hypertrophy (RVH) is cause of PSH (right ventricle is most anterior chamber of the heart so can cause heave)
MS and MR can cause RVH - as increased left atrial pressure –> pulmonary HTN –> RVH
Why might the apex beat be displaced in mitral regurgitation?
Left ventricle is pumping the stroke volume AND the regurgitant volume
Differentiate the timing of mitral stenosis and mitral regurgitation
Mitral stenosis is a MID DIAstolic murmur
Mitral regurgitation is a pan SYStolic murmur
Which of the heart murmurs might radiate to the axilla?
Mitral regurgitation
Recall some clinical signs of pulmonary hypertension
Malar flush
Raised JVP
Right ventricular (parasternal) heave
Loud S2
What might be seen on an ECG in mitral valve disease
Atrial fibrillation P mitrale (bifid 'm-shaped' p waves in lead II as well as V1-V6)
What is the mainstay of medical management for mitral stenosis, other than heart disease risk modification eg statins?
RhF prophylaxis with benzylpenicillin
AF (rate control + DOAC)
Diuretics for symptomatic relief
What is the first line surgical treatment for mitral stenosis?
Balloon valvuloplasty
What is the mainstay of medical management for mitral regurgitation (other than managing cardiac risk with statins etc)?
Like AR, reduce afterload - can use:
ACE inhibitors (eg enalopril/ captopril)
Beta blockers (bisoprolol etc)
Diuretics (furosemide etc)
Describe briefly the NYHA classifications
1 - no limitation on activity
2 - comfortable at rest but dyspnoea on ordinary activity
3 - marked limitation on ordinary activity
4 - dyspnoea at rest
Recall the broad approach to medically managing heart failure
BASHeD up by the heart:
(Beta blocker or
ACE inhibitor)
Spironolactone
Hydralazine (+ nitrate)
Digoxin
Which extra immunisations should be offered in patients with heart failure?
Annual influenza
Pneumococcal
What must be monitored whilst patients are on spironolactone?
Potassium (as is a potassium-sparing diuretic)
Recall some drugs that are contra-indicated in heart failure
Thiozolidinediones (type 2 diabetes)
Verapamil (as is negative inotrope)
NSAIDs (can cause fluid retention)
Glucocorticoids (can cause fluid retention)
Flecainide (negative inotrope, arrhythmogenic)
How quickly should GTN spray relieve angina pain?
Within 5 minutes
What is the first line investigation for angina in stable patients, and what score is this investigation used to calculate?
CT coronary angiography
Calcium score
What are some pharmacological options for preventing angina (NOT symptomatic relief)?
Aspirin (75mg, OD)
Atorvastatin (80mg, ON)
ACE inhibitor (especially if co-existent DM)
Antihypertensives
What calcium score would be classified as low risk, and what score would be high risk?
Low risk < 100
High risk > 400
What care needs to be taken when prescribing CCBs and BBs together?
If you prescribe a non-dihydropyrimidine CCB (eg verapamil) with a BB it can cause complete heart block
What are some medical options for managing angina symptoms?
1st line: GTN (spray or sublingual) + beta blocker or CCB (if CCB used as monotherapy, use a rate limiting one like verapamil or dilitiazem)
2nd line: GTN + BB AND CCB
3rd line options:
- Long-acting nitrates eg Isosorbide mononitrate
- Ivabradine
What are the 3 types of AF?
Acute (<48 hours)
Paroxysmal (self-limiting, <7 days, recurs)
Persistent (>7 days, may recur even after cardioversion)
How does anti-clotting drug choice differ following a stroke, depending on whether or not they have AF?
If they have AF –> anti-coagulant (DOAC or warfarin if DOAC is CI)
If they do NOT have AF –> anti-platelet
Why are anti-platelets not used in AF?
Anti-platelets are specifically for artherogenic causes of clots eg atheroma
Within what window of AF beginning can it be treated differently to longer-standing AF? What is this different treatment? Why is it so difficult to treat within the initial window of time?
AF <48 hours duration and HAEMODYNAMICALLY UNSTABLE can be cardioverted electrically
Difficult to establish onset of AF as patient may not have palpitations, or may be unsure as to when they started
For how long before and after cardioversion for arrhythmia should a patient be anti-coagulated?
3w before and 4w after OR lifelong (if CHA2DS2VASc high or if paroxysmal AF)
How can chadsvasc score be used to determine the need for longterm anticoagulation?
Score:
0 = no need for longterm anticoagulation
1 = anticoagulate if male, do not anticoagulate if female
2 or more: anticoagulate
What is the main contraindication to be aware of for all CCBs?
Peripheral oedema (increased capillary hydrostatic pressure that results from greater dilation of pre-capillary than post-capillary vessels)
What are the 1st, 2nd and 3rd line options for rate control in AF?
1st line: beta blocker or CCB (verapamil is better than dilitiazem)
2nd line: digoxin
3rd line: amiodarone
With what waveform on the ECG should DC cardioversion be synchronised?
R wave
If synchronised with T wave it can cause VT
Recall 2 options for chemical cardioversion, and any important indications/ contra-indications for each
Flecainide - if young and no structural heart disease
Amiodarone - in structural heart disease (eg HF)
Recall 2 surgical options for managing AF
- Radiofrequency ablation of AV node
- Maze procedure
Recall the components of the CHA2DS2VASc score
CHF
HTN
Age >75
DM
Stroke
Vascular disease
Age 65-74
Sex Category (female)
In HTN, what BP is defined as ‘severe’?
>180/110
What is the first line treatment for HTN for diabetics?
ACE inhibitor
What is the first line treatment for HTN for black Africans?
CCB
What is the first line treatment for HTN for under vs over 55s who are not diabetic or Black African?
Under 55: ACE inhibitor or ARB
Over 55: CCB
Recall some side effects of ACE inhibitors
Angioedema (for around 4 weeks), cough, hyperkalaemia
Recall the name of one thiazide-like diuretic
Indapamide
nb bendoflumethiazide is thiazide, not thiazide-like
Why do CCBs cause oedema?
Cause dilation of arterioles but not venules
What is the atorvastatin dose for primary vs secondary prevention?
Primary prevention: 20mg OD
Secondary prevention: 80mg OD
What is the most commonly affected heart valve in infective endocarditis when the patient is an IVDU?
Tricuspid
What is the most common pathogen to cause an acute presentation of infective endocarditis?
Strep epidermidis
How does strep viridans infective endocarditis most commonly present?
Subacute presentation, most commonly in the developing world
What is Libman-Sacks endocarditis?
Non-infective endocarditis caused by SLE
Differentiate the empirical antibiotics used in native vs prosthetic valves affected by infective endocarditis
Native valve: amoxicillin +/- gentamicin
Prosthetic valve: vancomycin + rifampicin + gentamicin
How far apart should blood cultures be taken to investigate infective endocarditis?
12 hours
What is the most likely pathogen to cause rheumatic fever?
GAS (strep pyogenes)
What is the broad pathophysiology of rheumatic fever?
AB cross reactivity with myosin, muscle glycogen and VSMC
What is the latent period between pharyngeal infection and onset of rheumatic fever?
2-6 weeks
Recall some of the key symptoms of rheumatic fever
Pericarditis
Polyarthritis
Erythema marginatum
What are sydenham’s chorea?
Unwanted jerky movements that appear 2-6 months following rheumatic fever
Recall the Duckett-Jones diagnostic criteria
For diagnosing rheumatic fever:
CASES (major) FRAPP (minor)
Carditis
Arthritis
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules
What is the antibiotic treatment recommended in rheumatic fever?
Phenoxymethylpenicillin QDS 10/7
What drugs can be used to treat sydenham’s chorea?
Haloperidol
Diazepam
How long does penicillin treatment need to continue following an episode of rheumatic fever to prevent rheumatic heart disease?
If carditis and residual heart disease: 10 years or until age 40 (whichever is longer), possibly lifetime
If carditis but NO residual heart disease: 10 years or until age 21 (whichever is longer)
If NO carditis: 5 years or until age 21 (whichever is longer)
What is ‘fibrinous’ pericarditis?
Pericarditis caused by uraemia
Recall some signs and symptoms of pericarditis
Pleuritic chest pain
Non-productive cough
Dyspnoea
Flu-like symptoms
Pericardial rub
Tachypnoea + tachycardia
What are the typical ECG findings in pericarditis?
Widespread PR depression or saddle-shaped ST elevation
How should pericarditis be broadly managed?
Treat cause
NSAIDs and colchicine
Recall some cardiac causes of clubbing
Atrial myxoma
Cyanotic heart disease
Infective endocarditis
What can cause a collapsing pulse other than aortic regurgitation?
Pregnancy
Thyrotoxicosis
Anaemia
What do the S1 and S2 heart sounds represent?
S1 = mitral valve closure S2 = aortic valve closure
What would cause a split S1?
Mitral and tricuspid valve closing at different times - normal in some
What are the 2 types of purely genetic primary cardiomyopathy?
HOCM
Arrhythmogenic right ventricular dysplasia
What are the 2 types of purely acquired primary cardiomyopathy?
Peripartum cardiomyopathy
Takotsubo cardiomyopathy
Recall 2 types of primary cardiomyopathy that have mixed genetic/ acquired causes?
Dilated cardiomyopathy
Restrictive cardiomyopathy
Recall 4 possible causes of dilated cardiomyopathy
Alcohol
Cocksackie B
Wet beri beri
Doxorubicin
Recall 3 possible causes of restrictive cardiomyopathy
Amyloidosis
Post-radiotherapy
Loeffler’s endocarditis (due to eosinophillic infiltration)
What is the most common gene mutation causing HOCM?
Beta-myosin heavy chain protein mutation
What would the following echo findings be suggestive of:
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve
Asymmetrical septal hypertrophy
HOCM
What is arrhythmogenic right ventricular dysplasia?
Replacement of right ventricular myocardium with fatty and fibrofatty tissue
What is the following description of an abnormal ECG most suggestive of:
Abnormalities in V1-3, typically T wave inversion. Possible epsilon wave.
Arrhythmogenic right ventricular dysplasia
What would the following echo findings be suggestive of:
All 4 heart chambers dilated
Tricuspid and mitral regurgitation
Dilated cardiomyopathy
What condition does the following describe: “transient, apical ballooning of the myocardium”?
Takotsubo cardiomyopathy
Recall some causes of secondary cardiomyopathy
Infiltration (eg amyloidosis )
Inflammation (eg sarcoidosis)
Storage (eg haemochromatosis)
Deficiencies (eg beri beri)
Neuromuscular (eg Friedereich’s ataxia, duchenne-becker musculdystrophy)
Infective (cocksackie B, chagas)
Endocrine (thyrotoxicus, diabetes mellitis, acromegaly)
Why is long QT syndrome dangerous?
Can cause VT –> death
Recall 2 causes of congenital long QT syndrome, and how they can be differetiated?
Jervell-Lange-Nielsen syndrome (deafness)
Romano-Ward syndrome (no deafness)
Recall some drugs that can cause long QT syndrome
METH CATS
Methadone
Erythromycin
Terfenadine
Haloperidol
Clarithromycin
Amiodarone/ arythromycin
TCAs
SSRIs (especially citalopram)
What is the 1st line management of torsades de pointes?
IV magnesium sulphate
What is torsades de pointes?
A type of polymorphic VT that is associated with QT prolongation
How much does BP have to drop on standing to classify as ‘orthostatic hypertension’?
Over 3 mins, BP needs to fall by 20/10
What is pulsus paradoxus, and in which conditions would it be seen?
>10mmHg fall in SBP during inspiration
Seen in severe asthma and cardiac tamponade - why?:
Inspiration –> reduced intrathoracic pressure –> blood pulled into right side of heart
Interventricular septum bulges into the left side of the heart –> reduced CO –> transient BP drop
You will feel varying strength of the pulse with inspiration and expiration
What is pulsus alternans and in which condition is it seen?
Regular alternation of the force of the arterial pulse
Seen in severe LVF
In which disease might a ‘jerky’ pulse be felt?
HOCM
What is the inheritance pattern of HOCM?
Autosomal dominant
How can HOCM cause sudden death?
Can cause spontaneous VF/VT
How might the JVP be abnormal in a patient with HOCM?
Large a waves
What are the 3 key features of HOCM on echo?
Mitral regurgitation
Systolic anterior motion (SAM)
Asymmetric hypertrophy
Recall some general principles of HOCM management
A to E
Amiodarone
Beta blockers
Cardioverter defibrillator
Dual chamber pace maker
Endocarditis prophylaxis
What are the classical clinical signs of pulmonary oedema?
Reduced exercise tolerance
Raised jugular venous pressure
Audible third heart sound
Which electrolyte abnormalities may cause torsades de pointes?
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
Name 2 drugs that can increase the effect of warfarin
Metronidazole
Sertralline
Name one drug that can decrease the effect of warfarin
Phenobarbital
When should DC cardioversion be attempted before chemical cardioversion for a tachyarrhythmia?
If SBP <90
What should an inferior MI + aortic regurgitation raise suspicion of?
Ascending aortic dissection
When would thrombolysis be the first line for treating PE, rather than anticoagulative medicines?
If circulatory collapse - eg hypotension
What is the antibiotic of choice in native valve infective endocarditis?
IV amoxicillin
What should the initial management be for patients with bradycardia and signs of shock?
500micrograms of atropine (repeated up to max 3mg)
What ECG abnormality is most likely in hypercalcaemia?
Lengthened QT interval
What are prominent V waves in the JVP indicative of?
Tricuspid regurgitation
What are cannon A waves in the JVP indicative of?
Complete heart block
What is a prominent x descent in the JVP indicative of?
Can be caused by:
Acute cardiac tamponade
Constrictive pericarditis
Which 2 beta blockers have been proven to be effective in stable heart failure?
Carvedilol and bisoprolol
What are the 3 most-commonly used drugs for treating NSTEMI medically?
Aspirin, ticagrelor, and fondaparinux
(Take special care to avoid GTN in hypotensive patients)
When would you NOT use flecainide for rate control?
In structurally abnormal hearts (which includes those with a PMH of ischaemic heart disease)
What is Beurger’s disease also known as?
Thromboangiitis obliterans
What are the symptoms of Beurger’s disease?
Raynaud’s syndrome, intermittent claudication and finger ulcerations
What is the biggest risk factor for Beurger’s disease?
Smoking
What is the medical management of choice for conservative management of an NSTEMI?
Dual antiplatelet therapy:
Aspirin + clopidogrel/ ticagrelor
Clopidogrel if high bleeding risk, ticagrelor if low bleeding risk
What is the biggest risk factor for renal impairment following prescription of an ACE inhibitor?
If the patient already has bilateral renal artery stenosis it can cause significant renal impairment
What is radiofemoral delay a sign of?
Aortic coarctation
Which congenital condition is strongly associated with aortic coarctation?
Turner’s
In which arrhythmia is verapamil contraindicated and why?
Ventricular tachycardia
Verapamil is a CCB - may reduce cardiac contractility
Recall the location on the praecordium where each valve is best auscultated
Aortic: Right 2nd ICS
Pulmonary: Left 2nd ICS
Tricuspid: left 4th ICS at sternal border
Mitral: left 5th ICS, MCL
Where is aortic regurgitation best auscultated
Tricuspid area: left 3rd ICS parasternally (Erb’s point)
At what point in the breathing cycle is aortic regurgitation best auscultated, and in which position?
End expiration
Sat up and forward
Put stethoscope at Erb’s point
Why are right-sided murmurs louder on inspiration?
Increased venous return to the RHS
Recall 2 types of murmur that are louder when there is LESS blood flow across the affected area
HOCM murmurs
Mitral valve prolapse
Which murmur is best auscultated when the patient is in the left lateral decubitus position?
Mitral stenosis
Which murmurs can radiate? Where do they radiate to?
Aortic stenosis –> carotids
Mitral regurgitation –> axilla
Describe the meaning of each of the 6 grades of heart murmur
Grade 1 - Difficut to hear
Grade 2 - Quiet
Grade 3 - Easy to hear
Grade 4 - Easy to hear with a palpable thrill
Grade 5 - Easy to hear with stethoscope barely touching chest
Grade 6 - Easy to hear with stethoscope away from patient
How does mitral stenosis vs regurgitation affect the heart structurally and why?
Stenosis –> atria have to work really hard to push blood through valve –> hypertrophic left artium
Regurgitation –> backflow of blood into atria stretches chamber –> left atrial dilatation
What are the 2 main possible causes of mitral stenosis?
Rheumatic heart disease is the most common (learn!)
Infective endocarditis
Why do you get a loud S1 in mitral stenosis?
Thickened valve needs a large systolic force to shut - once this systolic threshold is met the valve will shut very suddenly
What is the cause of malar flush in patients with mitral stenosis?
Backflow of blood into the pulmonary system –> rise in CO2 and vasodilation
What is the link between mitral regurgitation and congestive heart failure?
Backflow of blood –> reduced ejection fraction
–> backlog of blood waiting to pass through left side of heart
What are the possible causes of mitral regurgitation and which of them is most common?
Age-related weakening is most common
Also associated with:
- IHD
- Infective endocarditis
- Rheumatic heart disease
- Connective tissue disease (EDS/Marfan’s)
Which type of valve disease is associated with exertional syncope and why?
Aortic stenosis
Difficulty perfusing brain
What is the most common cause of aortic stenosis?
Idiopathic age-related calcification
What is Corrigan’s pulse?
Also known as collapsing pulse
Pulse rapidly appears and then disappears
Recall 2 causes of aortic regurgitation
Age-related calcification
Connective tissue disease
What is paroxysmal nocturnal dyspnoea?
Waking up suddenly in the night feeling acutely SOB with a really bad cough/ wheeze
They have to get up and gasp for air
Symptoms typically improve after a few minutes
What is the mechanism of PND (3 aspects)?
- Lying flat –> fluid settling across large surface area of lungs
- Respiratory centre in the brain is less responsive during sleep - so lungs can become much more congested that they would normaly do before they wake up
- Adrenaline levels are much lower at night so myocardium is more relaxed –> reduced CO
Recall the immediate management of rheumatic fever
Aspirin prn
Benzylpenicillin IM stat
10 day course of benzylpenicillin PO
When in the course of rheumatic fever/heart disease is valve imcompetence most likely?
Acutely
Which murmur is best heard at the apex with the bell of the stethoscope?
Mitral stenosis
Is pericarditis more commonly viral or bacterial?
Viral
ST elevation in which leads would represent an anteroseptal STEMI?
V1-V4
In the setting of acute pulmonary oedema post MI, how can severe hypotension be managed?
CPAP - it effectively pushes fluid out of your lungs
Which artery is occluded in an anterior MI?
Left anterior descending
Which artery is occluded in an anterolateral MI?
Left anterior descending
Which artery is occluded in inferior MI?
Right coronary artery (RV branch included)
Which artery is occluded in a posterior MI?
Circumflex
In which leads would you see ST elevation in an inferior STEMI?
II, III, aVF
In which leads would you see ST elevation in an anterior STEMI?
V3, V4
In which leads would you see ST elevation in a lateral STEMI?
I, aVL, V5, V6
What is always the first thing to do in an acute exacerbation of heart failure?
Sit up and give 60-100% O2
Which valve is most commonly affected by strep viridians infective endocarditis, and why?
Mitral
Strep viridians usually associated with teeth (commensal there)
Affects mitral valve as this valve is under higher pressures than in right side of heart and so is under higher pressure
What is the most likely pathogen in infective endocarditis in IVDUs?
Staphylococcus
Recall some causes of atrial fibrillation
PIRATES:
Pulmonary cancer
Ischaemic heart disease
Rheumatic heart disease
Atrial myxoma/ alcohol binge
Thyrotoxicosis
Embolus
Sepsis
If you see a Q wave as well as ST elevation on an ECG, what does that mean?
Tissue death
What may appear to be an anterior STEMI on an ECG post-MI, that is not actually an anterior STEMI?
Left ventricular aneurysm
What class of drug is ticagrelor?
P2 Y12 inhibitor
When would heparin be used in MI management?
In cath lab prior to PCI to prevent thrombosis
Why does ticagrelor work more quickly than clopidogrel?
Clopidogrel is a pro-drug and so takes longer to work
Recall one diuretic that improves prognosis post-MI and one that isn’t proven to
Improves prognosis: eplerenone
Does not improve prognosis: furosemide
How long can someone not drive for post-MI?
- Patients who are completeley revascularised with okay LVEF = 1 week
- Patients with severely reduced LVEF = 4 weeks
Recall 3 uses of SGLT2 inhibitors
Diabetes mellitus
Chronic kidney disease
Symptomatic chronic heart failure with reduced ejection fraction
What is sacubitril with valsartan used for?
Improves LVF in patients who are already on other heart failure therapy
How long after an MI might an ICD (implantable cardioverter defibrillator) be indicated?
40 days
Which drug should be held 48 hours before and after angiogram?
Metformin
How do you manage atrial flutter?
- Treat underlying cause
- Anticoagulate as you would for atrial fibrillation
If haemodynamically unstable: rate control or cardioversion
How would you manage SVT in an asthmatic patient in whom vagal manoevres have failed?
IV verapamil
How do you differentiate between aortic stenosis and sclerosis?
Aortic sclerosis is:
- normal in the elderly
- has a normal pulse (not narrow pulse pressure)
- No radiation
Recall 5 causes of raised JVP other than right-sided heart disease
Tricuspid regurgitation
Complete heart block
CCF
Pericardial effusion
SVC obstruction
Recall 5 complications of a prosthetic valve
Failure
Infection
Bleeding
Anaemia
Thromboembolic
Recall 3 causes of an irregularly irregular pulse that aren’t AF
Ventricular etopics
Atrial flutter
Sinus arrhythmias
If in a suspected DVT the D-dimer is positive but the the USS is negative, what should you do?
Stop anticoagulation and repeat scan in one week
What is the most appropriate anti-anginal treatment in a pateint with known heart failure?
Bisoprolol (verapamil CI in the case of CF)
In ALS, when would 3 shocks be given instead of 1?
If arrest witnessed in the cath lab/ CCU/ critical care and rhythmn is VF/pVT
What should be the initial drug treatment for patients with low EF heart failure?
Bisoprolol + ramipril
Which class of abx can cause torsades de pointes?
Macrolides eg azithromycin
Why is a pericardial friction rub heard in pericarditis?
The inflammed visceral and parietal pericardium rub against each other
What is the basic pathophysiology of Sydenham’s chorea?
Autoimmune reaction against the basal ganglia
What drug should be added to CPR for a patient in cardiac arrest if pulomnary emboli are suspected?
Alteplase
When would you not use IV beta blockers to treat fast AF, and hwat would you do instead?
In fast atrial fibrillation not associated with shock, syncope, myocardial ischaemia or heart failure - do up to 3 synchronised DC shocks instead
How can nitrate tolerance be prevented when prescribing isosorbide mononitrate?
Asymmetric dosing regimen
What complication of MI does the following describe: sudden heart failure, raised JVP, pulsus parodoxus
Left ventricular free wall rupture
What is the most useful blood test for detecting re-infarction post-MI?
CK-MB
Why can non-dihydropyridine and beta blockers be put together?
Risk of bradycardia
If a patient is on monotherapy and cannot tolerate addition of CCB / BB what should be added?
a long-acting nitrate
ivabradine
nicorandil
ranolazine
What are the side effects of Loop Diuretics?
hypotension
hyponatraemia
hypokalaemia, hypomagnesaemia
hypochloraemic alkalosis
ototoxicity
hypocalcaemia
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout
What are ECG signs of Mitral Stenosis?
P - mitrale = LAH (bifid P wave)
Heart failure with reduced LVEF should be given what for first line?
BB + ACEi
If new onset AF is within 48 hrs and has a reversible cause what should be done
DC Cardioversion
Factors that potentiate warfarin
liver disease
P450 enzyme inhibitors e.g. antibiotics
cranberry juice
drugs which displace warfarin from plasma albumin, e.g. NSAIDs
inhibit platelet function: NSAIDs
If a patient is haemodynamically stable in SVT and does not respond to vagal manoeuvres - what should be done?
IV Adenosine - rapid IV 6mg - then 12mg - 18mg (verapamil in asthmatics)
In ALS once adrenaline has been given what should happen next?
Adrenaline again in 3-5 minutes if ALS continues
When should Ivabradine be considered for Heart Failure?
sinus rhythm > 75/min and a left ventricular fraction < 35%
Not responding to ACEi, BB and aldosterone antagonist therapy
Major bleeding on warfarin what should be done?
Stop warfarin, give IV VitK 5mg, prothrombin complex concentrate
Drug therapy for broad complex tachycardia and haemodynamically stable
Amiodarone - central line
Persistent ST elevation following MI with no chest pain
Ventricular aneurysm - need anticoagulation
If a person with NSTEMI and grace score of 10% what should be done?
patients with a GRACE score > 3% should have coronary angiography within 72 hours of admission
medical therapy of aspirin, pain relief, anti-emetic, nitrates and oxygen in the interim
If a strong suspicion of PE but a delay in scan what should be done?
Start treatment of DOAC whilst awaiting V/Q (if allergy to CTPA)
Side effects of Beta Blockers
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
Best DUAP post MI
Aspirin + Ticagrelor / prasugrel (infinitely + 12 months)
if not then Clopidogrel e.g. patient has undergone thrombolysis
`Which condition is associated with congenital aortic stenosis?
Williams Syndrome
How common is depression post MI?
20%
What is a seatbelt sign characteristic of?
Aortic Rupture
Infective endocarditis: How should blood cultures be taken?
3 sets of blood cultures from different venous sites 1 hour apart before antibiotics
What antibiotic is given for Staphylococcus in IE?
Flucloxacillin
Treatment for Wolff Parkinson white
Radiofrequency ablation
What are the ECG changes in Hypokalaemia?
ST depression
QT interval prolongation
increased PR interval
visible U waves
T wave flattening/ inversion.
If atropine does not work in bradycardia what should be done
transcutaneous pacing
isoprenaline infusion
Main investigation for aortic dissection
CT angiography - finding the false lumen - TOE if risky
Why is Labetalol given pre aortic dissection?
To control blood pressure and reduce stress on aortic walls
If a patient with heart failure has poor renal function what should be done?
Escalating doses to achieve the concentration
What are shockable rhythms?
ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT)
What are non-shockable rhythms?
‘non-shockable’ rhythms: asystole/pulseless-electrical activity (asystole/PEA)
When is adrenaline given in ALS?
1mg - asap in non-shock
after third shock - in shockable
repeat every 3-5 minutes during
When should amiodarone be given during ALS?
300mg - shockable after 3 shocks
further 150mg - after 5 shocks
Reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade – cardiac
Toxins
In AF, if a CHA2DS2-VASc score suggests no need for anticoagulation what should be done
Echo for VHD - transthoracic
What is a Epsilon wave characteristic of?
arrhythmogenic right ventricular dysplasia (ARVD)
(a small positive deflection at the end of the QRS complex)
What are posterior MI changes?
v1-v3
reciprocal changes
ST depression
Tall broad R waves and upright T waves
posteior leads v7-v9
left circumflex
Benefit of switching standard release isosorbide mononitrate to modified
Gives a nitrate free period, decreasing the change of nitrate tolerance occuring
What patients can get a MI without chest pain?
Elderly, diabetic and female
What type of drug is candesartan?
Angiotensin receptor blocker
Why is CPAP useful in heart failure?
increases the intrathoracic pressure, which reduces venous return to the heart and lowers preload, as well as decreases afterload by decreasing the pressure difference between the left ventricle and the extrathoracic arteries. These pressure changes increase stroke volume and promote the movement of fluid from the interstitial fluid compartment into the intravascular fluid compartment, reducing oedema and alleviating symptoms of dyspnoea
Order of therapies for heart failure
- BB + ACEi
- Aldosterone antagonist / SGLT2 inhibitors
- Ivabradine / hydralazine etc
What drug is particularly useful in afro c patients in heart failure
Hydralazine
What is a indication for cardiac resynchronisation therapy in heart failure?
Widened QRS e.g LBBB
What type of drug is bumetanide?
Loop diuretic - inhibit Na/k/cl cotransporter in ascending limb
reduce absorption of NaCl
If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI: what should be commenced
CABG
When giving DUAP prior to PCI when is each one given?
Prasugrel - not already on a AC
Clopidogrel - if they are
If QRISK3 is higher than 10% what should be offered in addition to ACEi in hypertension
Statin
What would make Aortic stenosis quieter?
Left ventricular systolic dysfunction
n.b it is a consideration for arotic valve replacement surgery
decreased flow rate across aortic valve
Can LBBB be considered normal?
Always pathological - left ventricle takes longer to polarise
What are causes of LBBB?
MI
HTN
AS
Cardiomyopathy
William Marrow
NSTEMI management, if grace score more than 3% what should be done?
Coronary angiogram within 72 hrs of admission
What should be given to all ACS patients?
Aspirin 300mg
Oxygen if low sats
Morphine if severe pain (IV)
Nitrates
Nitrates = caution if hypotensive
STEMI criteria: heights
- clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
- 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
- 1.5 mm ST elevation in V2-3 in women
- 1 mm ST elevation in other leads
- new LBBB (LBBB should be considered new unless there is evidence otherwise)
STEMI management: When should PCI be offered compared to fibrinolysis?
PCI: presents within 12 hrs of symptoms and can be given in 120 minutes of time when fibrinolysis could be given
radial access, using drug eluding stents
PCI using a drug eluding stent what should be given before?
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
How long do you repeat a ECG after fibrinolysis for a MI
60-90 minutes
if it persists do PCI
What are the normal heart variants in athletes?
sinus bradycardia
junctional rhythm
first degree heart block
Mobitz type 1 (Wenckebach phenomenon)
Prosthetic valve anti-thrombotics
Bioprosthetic: aspirin
mechanical: warfarin + aspirin
Mechanical valves have an increased risk of thrombosis
Target INR in mitral and aortic valves
aortic: 3.0
mitral: 3.5
In AF, if a CHA2DS2-VASc score suggests no need for anticoagulation what should be done?
echo to look for valvular heart disease
24-holter for symptomatic AF
Treatment for acute heart failure
IV loop diuretics
+oxygen, nitrates (MI, AR, MR, HTN)
Treatment for acute heart failure with hypotension
Inotropic agents e.g dobutamine - left ventricular failure
When should beta blockers be stopped during acute heart failure
heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock
Reversal agent to DOAC
Andexanet alfa
half if renal failure / aki
Bleeding on dabigatran
Idarucizumab
Metallic valve warfarin level
Warfarin INR 3-4
NT-proBNP levels
<400 - HF unlikely
400-2000 - refer for echo + specialist review < 6 weeks
2000< - echo + specialist < 2 weeks
bloods, cxr, echo
Initial management of all ACS
IV opiate analgesia
antiemetics
aspirin 300mg
o2 if hypoxic
gtn infusion uncontrolled pain / htn / pulmonary oedema
Types of MI
1 = acute plaque rupture
2 = supply over deamnd mismatch
Complications post MI
DARTH VADER
Death
Arrythmia
Ruptured aneurysm
Thrombus
Heart Failure
VSD
Another MI
Dresslers syndrome
Embolus
Regurgitant valve
Cold peripheries and poor urine output
Cardiogenic shock
Bradycardia & AV nodal block
Inferior MI
Clinic BP 140/90
ABPM monitoring
180/120 - same day assessment and treatment
ABPM - < BP 135/85
recheck in 5 yrs
ABPM 135/85 - 150<95
Treat if:
-10 yr CVD risk >10%
- End-organ damage
- diabetes / CVD / CKD
ABPM > 150/95
treat + assess secondary causes if <40yrs
Causes of secondary hypertension
Renovascular - renal artery stenosis
Primary kidney disease
Sleep apnoea syndrome
Endocinre
- primary hyperaldosteronism
- cushing syndrome
- hypothyroidism
- pheochromocytoma
Accerlated / malignant HTN
180/120< - retinal haemorrhages or papilloedema
Management for malignant HTN
Reduce BP slowly, aiming <160/120 over hrs to days
- IV nitroglycerin (GTN)
- IV nitroprusside
- IV beta blocker e.g. labetolol
- oral - amlodipine if no end organ damage
Side effects of aldosterone antagonists
Hyperkalaemia
Gynaecomastia
Headache, sweating, palpitations with severe HTN
Phaeo
Pedal oedema resistant to diuretics
Calcium channel blocker S/E
ECG features of HOCM
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
atrial fibrillation may occasionally be seen - bifid p waves for atrial hypertrophy
Interpret this ECG
100bpm (3 large squares between each QRS)
sinus rhythm (regular p-waves preceding each QRS)and has a normal axis
p-waves: they are present and regular - the ‘m-shaped’ or bifid p-waves in multiple leads which likely represent left atrial enlargement
PR interval is ~120-160ms (normal)
extremely high-voltage QRS complexes which represent extreme left ventricular hypertrophy (LVH).
high-voltage R-waves in the precordial leads (V1-V6) which suggest septal hypertrophy
ST depression in the precordial leads and T-wave inversion in the anterolateral leads (I/avL/V2-V6) which may represent ischaemia secondary to LVH.
HOCM
What is HOCM associated with?
Friedreichs ataxia
Wolff parkinson white
Drugs to avoid in HOCM management
nitrates
ACE-inhibitors
inotropes
Wedge-shaped opacification on CXR
Pulmonary embolism
pulmonary infarction due to the clot occluding the blood flow and oedema due to the local inflammatory response to lung tissue necrosis
Features of hypercalcaemia
‘bones, stones, groans and psychic moans’
corneal calcification
shortened QT interval on ECG
hypertension
How is haemopytsis a symptom of mitral stenosis
due to pulmonary pressures and vascular congestion
may range from pink frothy sputum to sudden haemorrhage secondary to rupture of thin-walled and dilated bronchial veins
Patients with mechanical heart valves what is used for AF
Warfarin
inferior myocardial infarction and AR murmur
ascending aorta dissection
Features of right BBB
broad QRS > 120 ms
rSR’ pattern in V1-3 (‘M’ shaped QRS complex)
wide, slurred S wave in the lateral leads (aVL, V5-6)
Why are lung crackles bad asuculataion with MI
cardiogenic shock - indicate heart failure has occured and leading to pulmonary oedema
causes of heart failure with reduced systolic dysfunction (reduced ejection fraction)
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Arrhythmias
causes of heart failure with preserved ejection (reduced diastole function)
Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis
Causes of high output heart failure
anaemia
arteriovenous malformation
Paget’s disease
Pregnancy
thyrotoxicosis
thiamine deficiency (wet Beri-Beri)
normal heart unable to meet metabolic needs
3 things to classify angina
constricting discomfort front of chest
worse on exercise
relieved by rest or nitrates withing 5 minutes
if only 2 = atypical angina
What should be given with aspirin in ACS
PPI
Side effects of Amiodarone
thyroid
PS
PF
Liver toxicity
blue skin
myocarditis
Side effects of SGLT2 inhibitors
weights loss
reurrent genital thrush
euglycaemia diabetic ketoacidosis
Describe pulsus paradoxus
-normal inspiration produces a decrease in
intrathoracic pressure, this increases preload
-as the pulmonary vasculature expands, less
blood enters the left circulation, which causes a
drop in blood pressure during inspiration
(NORMAL)
-in tamponade, the increased preload in the RV
results in bowing of the ventricular septum in to
the LV, resulting in reduced cardiac output
Collapse is indicative of what type of heart problem
Arrythmogenic
How is orthostatic hypotension diagnosed?
A drop by 20 in BP from 3 minutes of standing
What pulse isexpected in mixed aortic valve disease?
bisferiens
In acute stroke that was caught late when should AC be started
2 weeks time
Normal variants in athletes
sinus bradycardia
junctional rhythm
first degree heart block
Mobitz type 1 (Wenckebach phenomenon)
Side effects of statins
myopathy - check CK
t2dm
haemorrhagic strokes
Mx of stable angina
RAMP
refer to cardiology
advise of diagnosis and safety net
medical treatment
procedural / surgical interventions
GTN for stable
take prn, if pain not go after 5 minutes, re do, if still present call ambulance
NSTEMI
ST depression
deep t wave inversion
pathological q waves
Alternatives of raised troponins
chronic renal failure
sepsis
myocarditis
aortic dissection
PE
Complications of MI
DREAD
death, rupture of heart septum, oedema, arrhythmia and aneurysm, dresslers
Dressler diagnosis
ecg - st elevevation and t wave incersion
echo - periocardial effusion
rasied inflammatory markers
nsaids +/- pericardiocentesis
Triggers of acute LVF
sepsis
aggressive iv fluids
MI
arrhythmias
rapid onset breathlessness
What type of resp failure does LVF cause
type 1 - low oxygen
treatment acute heart failure
pour sod
stop iv fluids
oxygen
diuretics - iv furosemide
monitor fluid balance
Patho of malar flush
back pressure of blood into pulmonary system causing a rise in CO2 and vasodilation
Valve with highest risk of thrombus formation
starr edwards - ball in cage
INR 2.5-3.5
af vs vent ectopic
make do exercise, vent ectopics disappear once a certain threshold is met
Side effects of HTN drugs
Why are ARBs better than ACE for afro c patients second line htn
reduced incidence of cardiovascular events and reduced adverse effects.
Becks triad
hypotension
raised jvp
muffled heart sounds
```
Features of cardiac tamponade
Becks
dyspnoea
tachycardia
an absent Y descent on the JVP - this is due to the limited right ventricular filling
pulsus paradoxus - an abnormally large drop in BP during inspiration
Kussmaul’s sign - much debate about this
ECG: electrical alternans
Treatment of tamponade with malignancy
Percutaneous balloon pericardiotomy
Benefit of using drug-eluting stents in PCI
anti-proliferative drugs that significantly decrease the likelihood of restenosis
Patients nitrates should be used in caution with
hypotensive
Prefered vessel for PCI access
radial
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI
criteria for angina - 2 of = atypical
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN in about 5 minutes
ECG signs of HOCM
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
atrial fibrillation may occasionally be seen
persistent st elevation
ventricular aneurysm
right bundle branch block and left axis deviation
bifasciular block
Sudden heart failure, raised JVP, pulsus parodoxus, recent MI
left ventricular wall free rupture
what marker is useful for re-infarction
CK-MB is useful to look for reinfarction as it returns to normal after 2-3 days
Causes of LBBB
New LBBB is always pathological. Causes of LBBB include:
myocardial infarction
diagnosing a myocardial infarction for patients with existing LBBB is difficult
rhe Sgarbossa criteria can help with this - please see the link for more details
hypertension
aortic stenosis
cardiomyopathy
rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
Main poor prognostic indicator in ACS
cardiogenic shock
Digoxin signs
ECG Features:
- Down-sloping ST depression (‘reverse tick’, ‘scooped out’)
- Flattened/inverted T waves
- Short QT interval
- Arrhythmias e.g., AV block, bradycardia
