Passmed - Cardio Flashcards by Alfie Saunders

Angina not controlled by beta-blocker?

a longer-acting dihydropyridine calcium channel blocker should be added (amlodipine)

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Verapamil should never be used in conjugation with…

a beta-blocker as it is a rate-limiting calcium-channel blocker
Doing so could lead to severe bradycardia and precipitate a patient into heart failure.

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Angina drug management

All should receive aspirin and a statin
sublingual glyceryl trinitrate to abort angina attacks
a beta-blocker or a calcium channel blocker first-line based

if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

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Acute pericarditis

inflammation of the pericardium
Sharp central chest pain, aggravated lying flat, eased leaning forward, ST elevation
Risk factors - auto-immune inflammatory conditions such as SLE, scleroderma and rheumatoid arthritis. Other causes include myocardial infarction, viral infection, TB and uraemia

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Stage 1 hypertension (clinic reading)?

140/90

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Acute heart failure not responding to treatment?

Consider CPAP

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Heart failure acute management?

For all patients - IV loop diuretics (furosemide, bumetanide)

(Possibly oxygen and vasodilators)

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Angina management: if a patient has an inadequate response to verapamil?

Adding long-acting nitrates is suitable (isosorbide mononitrate)

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Angina medication?

All - aspirin and statin
Acute - sublingual glyceryl trinitrate
NICE - beta blocker or calcium channel blocker

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Common cardio drugs contraindicated in pregnancy?

ACEi (e.g. ramipril)

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Pulmonary embolism triad?

Pleuritic chest pain
Dyspnoea
Haemoptysis

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2 level PE Wells score?

Clinical signs and symptoms of DVT - 3
Alternative diagnosis is less likely than PE - 3
Immobile for more than 3 days or surgery in last 4 weeks - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy - 1

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PE likely on Wells?

More than 4 points

4 or less = PE unlikely

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If PE is likely?

CTPA
(Give anticoagulant if CTPA is delayed)

CTPA +ve = PE diagnosed
CTPA -ve = proximal leg vein USS if DVT suspected

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If PE is unlikely?

Arrange D-dimer

If +ve = immediate CTPA
If -ve = stop anticoagulant, PE unlikely

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ECG in hypothermia

bradycardia
‘J’ wave (Osborne waves) - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias

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Myocardial infarction complications?

Cardiac arrest
Cardiogenic shock
Chronic heart failure
Tachyarrhythmias
Bradyarrhythmias
Pericarditis
Left ventricular free wall rupture
Left ventricular aneurysm
Ventricular septal defect
Acute mitral regurgitation

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Investigating suspected PE: if the CTPA is negative then consider what investigation?

a proximal leg vein ultrasound scan if DVT is suspected

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Clinical features of aortic stenosis

-chest pain
-dyspnoea
-syncope / presyncope (e.g. exertional dizziness)
-an ejection systolic murmur (ESM); radiates to the carotids (is decreased following the Valsalva manoeuvre)

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Features of severe aortic stenosis

narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure

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Causes of aortic stenosis

-degenerative calcification (most common cause in older patients > 65 years)
-bicuspid aortic valve (most common cause in younger patients < 65 years)
-William’s syndrome (supravalvular aortic stenosis)
-post-rheumatic disease
-subvalvular: HOCM

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Aortic stenosis management?

Symptomatic - valve replacement
Asymptomatic - discharge
Asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction - consider surgery
(Balloon valvuloplasty (in children with no aortic valve calcification or adults with critical AS and not fit for surgery)

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options for aortic valve replacement (AVR) include:

-surgical AVR - young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, an angiogram is often done prior to surgery so that the procedures can be combined
-transcatheter AVR (TAVR) is used for patients with a high operative risk

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ACS management

-aspirin 300mg
-oxygen (only be given if the patient has oxygen saturations < 94%)
-morphine (only be given for patients with severe pain)
-nitrates (should be used in caution if patient hypotensive)

Percutaneous coronary intervention
Fibrinolysis

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Infective endocarditis in intravenous drug users most commonly affects which valve?

Tricuspid

STEMI management

PCI if presents within 12 hours of onset AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given If PCI delayed, consider fibrinolysis first

First degree heartblock?

PR interval > 0.2 seconds

Second degree heart block

type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs type 2 (Mobitz II): PR interval is constant but the P wave is often not followed by a QRS complex

Third degree heart block?

there is no association between the P waves and QRS complexes

In hypothermia, rapid re-warming can lead to

peripheral vasodilation and shock Distributive shock - decrease in blood pressure due to peripheral vasodilation -> can lead to hypoperfusion and damage to vital organs such as brain, lungs, and kidneys. More gradual re-warming would reduce the risk of this.

Hypothermia temperature?

Mild hypothermia: 32-35°C Moderate or severe hypothermia: < 32°C

Provoked vs unprovoked PE treatment?

Unprovoked - 6 month DOAC Provoked - 3 month DOAC

Choice of anticoagulant?

First-line apixaban or rivaroxaban

If cannot use first-line DOAC?

use LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)

first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)

thrombolysis

Which antibiotic can cause a prolonged QT interval?

Erythromycin

CHA2DS2-VASc score?

Congestive heart failure = 1 Hypertension (or treated hypertension) = 1 A2 Age >= 75 years = 2 Age 65-74 years = 1 Diabetes = 1 Prior Stroke, TIA or thromboembolism = 2 Vascular disease (including ischaemic heart disease and peripheral arterial disease) = 1 Sex (female) = 1

CHA2DS2-VASc score meaning?

0 = No treatment 1 = Males: Consider anticoagulation Females: No treatment (this is because their score of 1 is only reached due to their gender) 2 or more = Offer anticoagulation

If angina is not controlled with a beta-blocker, a

longer-acting dihydropyridine calcium channel blocker should be added (amlodipine)

Angina management?

aspirin and a statin, sublingual glyceryl trinitrate to abort angina attacks

Hypothermia ECG?

J waves

Cardiac tamponade triad?

Classical features - Beck's triad: hypotension raised JVP muffled heart sounds

Cardiac tamponade management?

Urgent pericardiocentesis

Symptomatic bradycardia management?

Atropine (500mcg IV) - first line treatment If there is an unsatisfactory response: atropine, up to a maximum of 3mg transcutaneous pacing isoprenaline/adrenaline infusion titrated to response

Haemodymamic compromise features in bradycardia?

shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness syncope myocardial ischaemia heart failure

Posterior MI typically present on ECG with

tall R waves V1-2

Verapamil and x should never be taken concurrently

Beta blockers - possibility of heart block and fatal arrest

Poorly controlled hypertension, already taking an ACE inhibitor

add a calcium channel blocker or a thiazide-like diuretic

ECG features of hypokalaemia

U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT

Recent sore throat, rash, arthritis, murmur →

?rheumatic fever

First line management of acute pericarditis involves

combination of NSAID and colchicine

If angina is not controlled with a beta-blocker

a longer-acting dihydropyridine calcium channel blocker should be added (amlodipine)

in elevated JVP, persistent hypotension and tachycardia despite fluid resuscitation in a patient with chest wall trauma, consider

Cardiac tamponade

Infective endocarditis in intravenous drug users most commonly affects

The tricuspid valve

Ischaemic changes in leads V1-V4

left anterior descending

Signs of right-sided heart failure are

raised JVP, ankle oedema and hepatomegaly

The main ECG abnormality seen with hypercalcaemia is

shortening of the QT interval

For patients of black African or African-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider

an angiotensin receptor blocker in preference to an ACE inhibitor

Cardiovascular disease: medication and doses for primary vs secondary?

atorvastatin 20mg for primary prevention, 80mg for secondary prevention

Investigating suspected PE: if the CTPA is negative then consider

a proximal leg vein ultrasound scan if DVT is suspected

the first line investigation for stable chest pain of suspected coronary artery disease aetiology

Contrast-enhanced CT coronary angiogram

Massive PE + hypotension management?

Thrombolyse - alteplase

apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of…

a PE if renal impairment is severe (e.g. < 15/min), anti-phospholipid syndrome or cannot take the above, then LMWH, unfractionated heparin or LMWH followed by a VKA

Patients taking warfarin should avoid eating…

foods high in vitamin K, such as sprouts, spinach, kale and broccoli

Ischaemic changes in leads V1-V4 artery?

left anterior descending, anteroseptal

Ischaemia changes in leads II, III, aVF artery?

Right coronary, inferior

Ischaemia changes in leads V1-6, I, aVL artery?

Proximal LAD, anterolateral

Ischaemic changes in leads I, aVL +/- V5-6 artery?

Left circumflex, lateral

Ischaemic changes in leads V1-3 artery?

Usually left circumflex, also right coronary. Posterior

Patients with SVT who are haemodynamically stable and who do not respond to vagal manoeuvres, the next step is treating with

adenosine

Pericarditis ECG?

ST elevation PR depression

Pericarditis ECG?

ST elevation PR depression

Verapamil and x should never be taken concurrently - possibility of y

x = beta-blockers y = heart block and fatal arrest

A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination -

ventricular septal defect

Diastolic murmur + AF →

?mitral stenosis

First line management of acute pericarditis involves combination of

NSAID and colchicine

aortic dissection treatment

type A - ascending aorta - control BP (IV labetalol) + surgery type B - descending aorta - control BP(IV labetalol)

Beck's triad

falling BP, rising JVP and muffled heart sound is characteristic of cardiac tamponade

x is used to treat torsades de pointes

IV magnesium sulfate

Tension pneumothorax is a reversible cause of x in cardiac arrest resulting from trauma

PEA

For an SVT, if adenosine cannot be given (e.g. due to asthma) then x is an alternative

verapamil

x may be a useful investigation in clinically unstable patients with a suspected aortic dissection

Transoesophageal echocardiography (TOE)

A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound -

left ventricular aneurysm

Moderate-severe aortic stenosis is a contraindication to x

ACE-i

For an SVT, if adenosine cannot be given (e.g. due to asthma) then x is an alternative

verapamil

A man presents with central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated - x

Dressler's syndrome

Atrial fibrillation - cardioversion: medications

amiodarone + flecainide

Patients with heart failure with reduced LVEF should be given x as first-line treatment

a beta blocker and an ACE inhibitor

Kussmaul's sign

In constrictive pericarditis, the JVP will rise on inspiration;

Long QT syndrome drug causes?

-amiodarone, sotalol, class 1a antiarrhythmic drugs -tricyclic antidepressants, selective serotonin reuptake inhibitors -(especially citalopram) -methadone -chloroquine -terfenadine -erythromycin -haloperidol -ondanestron

Other long QT causes

-electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia -acute myocardial infarction -myocarditis -hypothermia -subarachnoid haemorrhage

Warfarin causes a prolonged

prothrombin-time

x presents with ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness

Myocarditis