MLA: Cardiology Flashcards
which investigation should all patients with suspected acute pericarditis have?
transthoracic echocardiography
what is acute pericarditis?
a condition referring to inflammation of the pericardial sac, lasting less than 4-6 weeks
what are some of the causes of acute pericarditis?
- viral infections (Coxsackie)
- TB
- uraemia
- post MI
- radiotherapy
- connective tissue disease -> SLE and RA
- hypothyroidism
- malignancy - lung and breast
- trauma
what are the features of acute pericarditis?
- chest pain: may be pleuritic - often relieved by sitting forwards
- non-productive cough, dyspnoea and flu-like Sx
- pericardial rub
what are the ECG changes seen in acute pericarditis?
- global/widespread
- saddle-shaped ST elevation
- PR depression = most specific ECG marker for pericarditis
what is the first line treatment of acute idiopathic/viral pericarditis?
a combination of NSAIDs and colchicine
which criteria is used to diagnosed infection endocarditis?
if:
1. pathological criteria positive OR
2. 2 major OR
3. 1 major and 3 minor criteria OR
4. 5 minor criteria
what is the pathological criteria for infective endocarditis?
positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery (valve tissue, vegetations, embolic fragments or intracardiac abscess content)
what are the major criteria in the Duke’s criteria for infective endocarditis?
- two positive blood cultures showing typical organisms consistent with infective endo e.g. streptococcus viridans
- persistent bacteraemia from two blood cultures taken >12 hours apart or 3/+ positive blood cultures where the pathogen is less specific such as staph aureus
what make up the minor criteria in the Duke’s criteria for infective endocarditis?
- predisposing heart condition or IV drug use
- microbiological evidence does not meet major criteria
- fever >38
- vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
- immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots
what are the components of the CHADVASc score?
C = congestive HF
H = HTN
A2 = aged >75 (2)/aged 65-74 (1)
D = diabetes
S2 = prior stroke, TI or VTE
V = vascular disease (IHD and PAD)
S = sex (female)
if someone scores 2 or more on their CHADVASc, what is the management?
offer anticoagulation
what is the ORBIT score?
replacing the HAS-BLED scoring system, which works out the risk of a patient bleeding - and helps evaluate the risk vs benefit of anticoagulation
which DOACs are recommended by NICE for reducing stroke risk in AF?
apixaban, dabigatran, edoxaban and rivaroxaban
a lateral MI is generally caused by a lesion in which artery?
left circumflex artery lesion
which valvular defect has a holosystolic murmur, which is high-pitched and ‘blowing’ in character?
mitral regurgitation
which valvular defects have an ejection systolic murmur, loudest on expiration?
aortic stenosis and HOCM
which defects have an ejection systolic murmur, louder on inspiration
pulmonary stenosis, atrial septal defect and TOF
gram positive cocci cause the majority of cases in which pathology?
infective endocarditis
what are the echo findings for HOCM?
MR SAM ASH
Mitral regurgitation
Systolic anterior motion of the anterior mitral valve leaflet
Asymmetric hypertrophy
what are the signs and symptoms of malignant HTN?
- papilloedema
- retinal bleeding
- increased cranial pressure causing headache and nausea
- chest pain due to increased workload on the heart
- haematuria due to kidney failure
- nosebleeds which are difficult to stop
which investigations also need to be done in a patient with newly diagnosed HTN to ensure they do not have end-organ damage?
- fundoscopy = check for hypertensive retinopathy
- urine dipstick = to check for renal disease, either as a cause or consequence of HTN
- ECG: to check for left ventricular hypertrophy or IHD
which tests need to also be done for newly diagnosed HTN?
- U&E = check for renal disease
- HbA1c = co-existing DM
- lipids = hyperlipidaemia
- ECG
- urine dipstick
what are the common side effects of ACE-i?
cough, angioedema, hyperkalaemia
how do calcium channel blockers work?
they block voltage-gated calcium channels, relaxing vascular smooth muscle and the force of myocardial infarction
what are some of the common side effects of CCBs?
flushing, ankle swelling and headache
what is the mechanism of action of thiazide type diuretics?
inhibit sodium absorption at the beginning of the distal convoluted tubule
what are the common side effects of thiazide like diuretics?
hyponatremia, hypokalaemia, dehydration
what is the mechanism of action of A2RB?
block effects of angiotensin II at the AT1 receptor
when are ARBs generally used?
in situations where patients have not tolerated ACE inhibitors, usually due to the development of a cough
what is an established side effect of A2RBs?
hyperkalaemia
how is rheumatic fever diagnosed?
evidence of recent streptococcal infection and either 2 major criteria, or 1 major with 2 minor
which components make up the major criteria for rheumatic fever?
- erythema marginatum
- Syndenham’s chorea (late)
- polyarthritis
- carditis and valvulitis
- subcutaneous nodules
which components make up the minor criteria for rheumatic fever?
- raised ESR and CRP
- pyrexia
- arthralgia
- prolonged PR interval
as well as dual antiplatelet therapy, which other drug should be offered to non-ST elevation MI for patients not at a high risk of bleeding and who are not having angiography immediately?
Fondaparinux
what is the most common ECG change in PE?
sinus tachycardia
what is atrial flutter?
a form of supra ventricular tachycardia characterised by a succession of rapid atrial depolarisation waves
what are the common ECG findings for atrial flutter?
- sawtooth appearance
- 2:1 block - atrial to ventricular
- flutter waves may be visible following carotid sinus massage or adenosine
which new ECG feature is of great concern?
LBBB = always pathological and never normal
what are the causes of LBBB?
- MI
- HTN
- aortic stenosis
- cardiomyopathy
- rare: idiopathic fibrosis, digoxin, toxicity and hyperkalaemia
what are the ECG features of hypokalaemia?
- small or absent T waves (occasionally inversion)
- prolonged PR interval
- ST depression
- long QT
what are the normal ECG variants in an athlete?
- sinus bradycardia
- junctional rhythm
- first degree heart block
- Mobitz type 1 (Wenckebach)
which type of antihypertensives cause erectile dysfunction?
Beta-blockers
which drug should be offered to a patient, in addition to an ACE-i/BB, who has HF with reduced ejection fraction if they are continuing to have Sx of HF?
mineralocorticoid receptor antagonist e.g. Spironolactone
what are the 4 H’s of reversible causes of cardiac arrest
hypoxia, hypvolaemia, metabolic disorders (hyper/hypokalaemia etc), hypothermia
what are the 4 T’s of reversible causes of cardiac arrest?
thrombosis (coronary or pulmonary), tension pneumothorax, tamponade, toxins
when should amiodarone be administered?
amiodarone 300mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered
how does pulmonary oedema occur in chronic heart failure?
impaired LVF results in a chronic backlog of blood waiting to flow into and through the left side of the heart. The left atrium, pulmonary veins and lungs experience an increase volume and pressure of blood. They then start to leak fluid
what is ejection fraction?
the percentage of blood in the left ventricle squeezed out with each ventricular contraction - one above 50% is considered normal
what is HF with preserved ejection fraction?
when someone has the clinical features of HF with an EJ greater than 50%. This is the result of diastolic dysfunction, where there is an issue with the left ventricle filling with blood during diastole (the left ventricle relaxing)
what are the NYHA classes of severity of HF symptoms?
Class I = no limitation on activity
Class II = comfortable at rest but Sx with ordinary activities
Class III = comfortable at rest but Sx with any activity
Class IV = symptomatic at rest
what are the five principles of management for HF?
RAMPS
Refer to cardiology
Advise them about the condition
Medical Rx
Procedural or surgical interventions
Specialist HF MDT
what is the urgency of referral to cardiology for someone presenting with HF?
dependent on the NT-proBNP result:
From 400-2000ng/litre - echo within 6 weeks
Above 2000ng/litre = seen and echo within 2 weeks
what is the first line medical Rx of chronic HF?
ABAL:
ACE-inhibitor
Beta-blocker
Aldosterone antagonists when Sx are not controlled with A and B
Loop diuretics (furosemide and bumetanide)
blood supply to the brain can be disrupted by what?
thrombus/embolus, atherosclerosis, shock, vasculitis
what is a TIA?
involves temporary neurological dysfunction (lasting less than 24 hours) caused by ischaemia but without infarction. Sx have a rapid onset and often resolve before the patient is seen
what are crescendo TIAs?
two or more TIAs within a week and indicate a high risk of stroke
what are the common symptoms of stroke?
limb weakness, facial weakness, dysphasia (speech disturbance), visual field defects, sensory loss and ataxia + vertigo (posterior circulation infarct)
what is the ROSIER tool for stroke?
Recognition of stroke in the emergency room = gives a score based on the clinical features and duration. Stroke is possible in patients scoring one or more
what is involved in the initial management of stroke?
- exclude hypoglycaemia
- immediate CT brain (non-contrast) to exclude haemorrhage
- Aspirin 300mg daily for 2 weeks (start after haemorrhage is excluded with a CT)
- admission to a specialist stroke centre
when is thrombectomy considered?
in patients with a confirmed blockage of the proximal anterior circulation or proximal posterior circulation - it may be considered within 24 hours of the Sx onset and alongside IV thrombolysis
patients with TIA or stroke are investigated for which conditions?
carotid artery stenosis and AF with carotid imaging and ECG or ambulatory ECG monitoring
what are the associated effects of anterior cerebral artery stroke?
contralateral hemiparesis and sensory loss, lower extremity > upper
what are the associated effects of a stroke in the middle cerebral artery?
contralateral hemiparesis and sensory loss, upper extremity > lower.
Contralateral homonymous hemianopia and aphasia
what are the associated effects of a posterior cerebral artery stroke?
contralateral homonymous hemianopia with macular sparing and visual agnosia
what is an embolic stroke?
embolic stroke occurs when a blood clot or other debris (embolus) from another part of the body travels through the bloodstream and becomes lodged in an artery supplying blood to the brain
what is an intracerebral haemorrhage causing stroke?
caused by a blood vessel within the brain parenchyma, often due to HTN, cerebral amyloid angiopathy, or vascular malformations
what is the pathophysiology of ischaemic stroke?
the reduction in blood flow to the affected brain region leads to inadequate oxygen and glucose delivery, resulting in energy failure and the disruption of cellular ion homeostasis.
what is the pathophysiology of cerebral haemorrhage?
in haemorrhagic stroke, the rupture of a blood vessel causes blood to accumulate within the brain tissue or subarachnoid space. This can lead to ICP, compression of brain tissue, and disruption of cerebral blood flow + can trigger a local inflammatory response, resulting in further neuronal injury
what is the criteria assessed in the Oxford Stroke Classification?
- unilateral hemiparesis and/or hemisensory loss of the face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
total anterior circulation infarcts involve which arteries?
middle and anterior cerebral arteries
which arteries are involved in partial anterior circulation infarcts
smaller arteries of anterior circulation e.g. upper division of middle cerebral artery
which arteries are involved in lacunar infarcts?
involves perforating arteries around the internal capsule, thalamus and basal ganglia
lacunar infarcts present with 1 of the following…?
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three
- pure sensory stroke
- ataxic hemiparesis
which arteries are involved in posterior circulation infarcts?
vertebrobasilar arteries
in the ROSIER score, new onset of which symptoms score one point each?
- asymmetric facial weakness
- asymmetric arm weakness
- asymmetric leg weakness
- speech disturbance
- visual field defect
how should you immediately manage blood pressure in stroke?
do not lower the BP in the acute phase unless there are complications e.g. hypertensive encephalopathy
regarding AF causing stroke, when should anticoagulation be commenced?
they should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days post ischaemic stroke
what are the absolute contraindications to thrombolysis?
- previous intracranial haemorrhage
- seizure at the onset of stroke
- intracranial neoplasm
- suspected SAH
- stroke/traumatic brain injury in the preceding 3 months
- LP in preceding 7 days
- GI haemorrhage in preceding 3 weeks
- active bleeding
- pregnancy
- oesophageal varices
- uncontrolled HTN >200/120mmHg
what is the characteristic iron study profile in haemochromatosis?
raised transferrin saturation and ferritin, with low TIBC
what is the first line for myoclonic seizures in females?
Levetiracetam
what is the immediate treatment of patients with bradycardia and signs of shock?
500mcg of atropine (repeated up to max 3mg)
which drug is used in the immediate management of tachycardias?
amiodarone
which drug is used in rate control of longstanding tachycardias?
bisoprolol
what is the immediate action of patients with suspected viral meningitis whilst waiting for LP result?
start IV abx and antivirals, particularly if immunocompromised or elderly
