Passmed - Cardio Flashcards
Angina not controlled by beta-blocker?
a longer-acting dihydropyridine calcium channel blocker should be added (amlodipine)
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.
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
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
Stage 1 hypertension (clinic reading)?
140/90
Acute heart failure not responding to treatment?
Consider CPAP
Heart failure acute management?
For all patients - IV loop diuretics (furosemide, bumetanide)
(Possibly oxygen and vasodilators)
Angina management: if a patient has an inadequate response to verapamil?
Adding long-acting nitrates is suitable (isosorbide mononitrate)
Angina medication?
All - aspirin and statin
Acute - sublingual glyceryl trinitrate
NICE - beta blocker or calcium channel blocker
Common cardio drugs contraindicated in pregnancy?
ACEi (e.g. ramipril)
Pulmonary embolism triad?
Pleuritic chest pain
Dyspnoea
Haemoptysis
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
PE likely on Wells?
More than 4 points
4 or less = PE unlikely
If PE is likely?
CTPA
(Give anticoagulant if CTPA is delayed)
CTPA +ve = PE diagnosed
CTPA -ve = proximal leg vein USS if DVT suspected
If PE is unlikely?
Arrange D-dimer
If +ve = immediate CTPA
If -ve = stop anticoagulant, PE unlikely
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
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
Investigating suspected PE: if the CTPA is negative then consider what investigation?
a proximal leg vein ultrasound scan if DVT is suspected
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)
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
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
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)
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
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
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
