FINALS - Passmed > cardio > Flashcards

cardio Flashcards

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1
Q

what would make a high risk pericarditis pt and how would you manage them

A
  • fever > 38°C
  • elevated trop
  • manage them as inpatients
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2
Q

a life threatening complication of ACS is

A

cariogenic shock a condition in which the heart is unable to pump blood effectively to meet the body’s demands

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3
Q

signs of myocarditis vs cardiac tamponade

A
  • tamponade: The fluid leads to muffled quiet heart sounds, not dull heart sounds. There also would be low blood pressure, and tachycardia expected. An examination may reveal signs of venous congestion and an ECG may show electrical alternans.
  • myocarditis: non-specific ECG changes to the ST segment or to the T wave. The dull heart sounds are due to the myocardium being inflamed and thickened. The shortness of breath and bibasilar crackles are likely due to myocardial dysfunction causing pulmonary congestion. Trop rise may occur due to cardiac damage
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4
Q

what is the mainstay of Tx for ACS and why

A

anti platelets as the thrombus causing the blockage and sx is mainly formed of platelets.

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5
Q

STEMI ECG findings

A
  1. ST-segment elevation
  2. New left bundle branch block
  3. T-wave inversion +/or pathological Q waves after a few hours – days

detailed answer:

  • ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
  • ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
  • New Left bundle branch block
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6
Q

NSTEMI ECG findings

A

ST segment depression
T wave inversion

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7
Q

T or F: a raised troponin and ST elevation on ECG are required to diagnose STEMI

A

FALSE
clinical presentation and ECG findings are sufficient

Troponin results are used to diagnose an NSTEMI.
They are not required to diagnose a STEMI, as this is diagnosed based on the clinical presentation and ECG findings.

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8
Q

causes of raised troponin

A

Chronic kidney disease
Sepsis
Myocarditis
Cardiomyopathy (e.g. Takotsubo)
HF
Aortic dissection
Pulmonary embolism
Coronary spasm

this makes it a non-specific marker.

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9
Q

how are AF pts assessed for anticoagulation

A

CHA2DS2-VASc is a mnemonic for the factors that score a point:

C – Congestive heart failure
H – Hypertension
A2 – Age above 75 (scores 2)
D – Diabetes
S2 – Stroke or TIA previously (scores 2)
V – Vascular disease
A – Age 65 – 74
S – Sex (female)

NICE (2021) recommends, based on the CHA2DS2-VASc score:

0 – no anticoagulation
1 – consider anticoagulation in men (women automatically score 1)
2 or more – offer anticoagulation

Bleeding risk is assessed using ORBIT score. but for most pts the risk of clotting outweighs the risk of bleeding.

O – Older age (age 75 or above)
R – Renal impairment (GFR less than 60)
B – Bleeding previously (history of gastrointestinal or intracranial bleeding)
I – Iron (low haemoglobin or haematocrit)
T – Taking antiplatelet medication

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10
Q

X-ray findings of heart failure

A

ABCDE:

A - alveolar oedema (bat wing opacities)
B - Kerley B lines
C - cardiomegaly
D - dilated upper lobe vessels
E - pleural effusion

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11
Q

CXR findings seen in aortic dissection or aneurysm

A

Widened mediastinum is a sign of aortic dissection or aneurysm.

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12
Q

secondary prevention following ACS

A

6 A’s

  1. aspirin
  2. a second antiplatelet if appropriate (e.g. clopidogrel)
  3. a beta-blocker
  4. an ACE inhibitor
  5. a statin
  6. aldosterone antagnosit for pts with signs of HF
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13
Q

when is PCI used in ACS

timeframes

A
  • Patients diagnosed with a STEMI, who present within 12 hours of onset of chest pain should be referred for PCI within 120 mins
    • STEMI identified, aspirin given + SECOND anti platelet required prior to PCI [clopidogrel, ticagrelor or prasugrel]
  • within 72 hours
    • NSTEMI identified, aspirin given, 6-month mortality intermediate/high(>3%)
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14
Q

what are the possible rhythms in a pulseless patient

A

Shockable rhythms:

  • Ventricular tachycardia
  • Ventricular fibrillation

Non-shockable rhythms:

  • Pulseless electrical activity (all electrical activity except VF/VT, including sinus rhythm without a pulse)
  • Asystole (no significant electrical activity)
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15
Q

define a narrow complex tachycardia

A

A fast heart rate with a QRS complex duration of less than 0.12 seconds or <3 small squares

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16
Q

There are four main differentials of a narrow complex tachycardia:

A
  1. Sinus tachycardia (treatment focuses on the underlying cause)
  2. Supraventricular tachycardia (treated with vagal manoeuvres and adenosine)
  3. Atrial fibrillation (treated with rate control or rhythm control)
  4. Atrial flutter (treated with rate control or rhythm control, similar to atrial fibrillation)
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17
Q

what antithrombin is used for STEMI and NSTEMI

A
  • STEMI = alteplase
    • Mx = PCI or alteplase
  • NSTEMI = fondaparinux [same applies to unstable angina]
    • Mx = BATMAN
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18
Q

aortic dissection Ix’s

A
  • 1st line = CT angiogram of the chest, abdomen and pelvis for a suspected aortic dissection when the patient is haemodynamically stable.
  • 2nd line [or 1st line for haemodynamically unstable pts] = echocardiogram

other helpful Ix:

  • Chest Xray - shows widened mediastinum
  • Bloods: Troponin may be raised, D-dimer may be positive
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19
Q

list the reversible causes of cardiac arrest

A

4H’s and
1. Hypoxia
1. Hypovolaemia
1. Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
1. Hypothermia

4T’s
1. Thrombosis (coronary or pulmonary)
1. Tension pneumothorax
1. Tamponade - cardiac
1. Toxins

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20
Q

1st and 2nd line Mx for stroke prevention in AF pts

A

1st line = DOAC
2nd line = warfarin

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21
Q

criteria for STEMI Mx with a PCI and what is the alternative if not met

A
  • pt must present to hospital within 12 hours of onset of Sx and PCI should be undergone within 120 mins.
  • if not met–> fibrinolysis
    • alteplase [thrombolytic agent]
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22
Q

what is classed as a shockable rhythm

A

ventricular fibrilation
pulseless ventricular tachycardia

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23
Q

when is adrenaline used during advanced adult life support

A
  • adrenaline 1 mg as soon as possible for non-shockable rhythms
  • during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
  • repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
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24
Q

Causes of ST elevation

A
  • myocardial infarction
  • pericarditis/myocarditis
  • normal variant - ‘high take-off’
  • left ventricular aneurysm
  • Prinzmetal’s angina (coronary artery spasm)
  • Takotsubo cardiomyopathy
  • rare: subarachnoid haemorrhage
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25
indication and MoA of digoxin
* indication = AF, atrial flutter and symptomatic relief of HF. * decreases conduction through the atrioventricular node which slows the ventricular rate in atrial fibrillation and flutter * increases the force of cardiac muscle contraction due to inhibition of the Na+/K+ ATPase pump. Also stimulates vagus nerve * digoxin has a narrow therapeutic index
26
digoxin toxicity: - presentation - precipitants - monitoring requirement
presentation: - generally unwell, lethargy, nausea & vomiting, anorexia, confusion, **yellow-green vision** - arrhythmias (e.g. AV block, bradycardia) - gynaecomastia precipitants: - hypokalaemia - thiazide and loop diuretics esp precipitate this. - increasing age * renal failure * myocardial ischaemia * hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis * hypoalbuminaemia * hypothermia * hypothyroidism * drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone monitoring requirements: - if toxicity is suspected, digoxin concentrations should be measured within 8 to 12 hours of the last dose
27
digoxin toxicity Mx
Digibind correct arrhythmias monitor potassium
28
ECG findings of right-sided heart strain
* P pulmonale (peaked P waves) * Right ventricular hypertrophy (tall R waves in V1 and V2 and deep S waves in V5 and V6) * Right axis deviation * Right bundle branch block
29
Mx of iron deficiency in HFrEF
NICE 2025 guidelines recommend IV iron therapy for patients with HFrEF who have haemoglobin < 150 g/L and either transferrin saturation < 20% or ferritin < 100 ng/mL.
30
what drug shouldn't be used in VT
Verapamil should NOT be used in VT.
31
Tricuspid regurgitation vsmitral regurgitation
Tricuspid regurgitation becomes louder during inspiration, unlike mitral regurgitation both have pansystolic murmurs
32
what is Kussmaul's sign
The JVP increasing with inspiration, a feature of constrictive pericarditis
33
hyperkalaemia mx
1. calcium gluconate if >6,5 or ECG changes. * Stabilises the cardiac membrane 2. dextrose 50% - 50ml + rapid acting insulin 3. salbutamol nebs * Short-term shift in potassium from extracellular (ECF) to intracellular fluid (ICF) compartment 4. calcium resonium 5. loop diuretics * to remove potassium from the body
34
an inferior MI on ECG and a new Aortic Regurgitation murmur suggests..
proximal aortic dissection.
35
features of digoxin toxicity
* generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision * arrhythmias (e.g. AV block, bradycardia) * gynaecomastia
36
pricipitants of digoxin toxicity
* classically: **hypokalaemia** - * digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects * *be wary of pts with N+V or diarrhoea as this => hypokalaemia* * increasing age * renal failure * myocardial ischaemia * hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis * hypoalbuminaemia
37
Persistent ST elevation after a myocardial infarction, along with fatigue, may indicate...
the development of a left ventricular aneurysm
38
The most common cause of aortic stenosis in a young patient
bicuspid aortic valve
39
what blood test finding is most indicative of a repeat MI
* Creatinine kinase MB. * As CK-MB levels normalise 48 to 72 hours after myocardial ischemia (vs. troponins, which can persist for days), it is the best marker to assess whether re-infarct has occurred.
40
pericarditis vs dresslers syndrome
BOTH are complications of MI * pericarditis tends to present a lot earlier (within 48 hours) compared to Dressler's syndrome, which presents within 4 weeks following myocardial infarction. * Dresslers is characterised by a combination of: * fever, * pleuritic pain, * pericardial effusion * **raised ESR**
41
inferior MI --> what type of arrythmia + why
- bradyarrhythmia - The AV node is primarily supplied by the right coronary artery (RCA) in most people. - Inferior MIs typically involve occlusion of the RCA, → ischaemia of the AV node and surrounding conduction tissue.
42
all pts with PAD should get what treatment?
Drugs - statin - atorvastatin 80mg - antiplatelet - clopidogrel 75mg exercise programme smoking cessation advice
43
infective endocarditis MC organisms | overall and differrent pt scenarios
- MC overall = staph aureus [especially with IVDU] - MC <2 months after valve surgery = Staphylococcus epidermidis - Streptococcus viridans is associated with dental surgery and/or poor oral hygeine.
44
hypokalaemia on ECG
* visible U waves * small or absent T waves (occasionally inversion) * prolong PR interval * ST depression * long QT
45
hypocalcaemia on ECG
Isolated QTc elongation
46
Infective endocarditis causing congestive cardiac failure is an indication for emergency ...
valve replacement surgery
47
Posterior MI typically present on ECG with
tall R waves V1-3 Reciprocal ST depression in V1-3
48
Mechanical valves - target INR:
aortic: 3.0 mitral: 3.5
49
Peri-arrest Brady (<50 bpm + HI/AE): Mx pathway
1st → Atropine 500mg 2nd → Atropine up to 3g (5 further doses) 3rd → Trancutaneous pacing 4th → Adrenaline/ Isoprenaline/ Dopamine 5th → Specialist advice; Transvenous Pacing
50
aortic dissection Ix in unstable pts
Transoesophageal echocardiography (TOE) may be a useful investigation in clinically unstable patients with a suspected aortic dissection
51
aortic dissection Mx | by type
Stanford classification * type A - ascending aorta - control BP (IV labetalol) + surgery * blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention * type B - descending aorta - control BP(IV labetalol)
52
what does a 3rd heart sound suggest in an elderly pt
- rapid filling of the ventricles - dilated cardiomyopathy - congested heart failure.
53
MI ECG changes
* ST elevation * peaked T waves * inverted T waves * a prolonged PR interval * right bundle branch block * a long QT interval * left bundle branch block * ST depression
54
pts at risk of asystole Mx of these pts
There is a risk of asystole in: * Mobitz type 2 * Third-degree heart block (complete heart block) * Previous asystole * Ventricular pauses longer than 3 seconds Management of unstable patients and those at risk of asystole involves: * Intravenous atropine (first line) * Inotropes (e.g., isoprenaline or adrenaline) * Temporary cardiac pacing * Permanent implantable pacemaker, when available
55
rheumatic fever key CFs
56
rheumatic fever diagnostic critera
JONES critera JONES - FEAR
57
Rheumatic fever Mx
58
Rheumatic fever Ix
* Throat swab for bacterial culture - often negative due to post-infective nature of RF * ASO antibody titres * Echocardiogram, ECG and chest xray can assess the heart involvement * ECG may show heart block type 1 * Xray may show cardiac congestion or cardiomegaly * echo may show valvular dysfunction
59
heart failure Mx - HFpEF specifically
1st line = - MRA e.g. spironolactone - SGLT2-i | new guidelines
60
Heart failure Mx - HFrEF
four key pillars of heart failure with reduced ejection fraction: 1. ACEi OR ARNI [sacubirtril] OR ARB [if pt develops cough --> ARNI, if they develop angioedema --> ARB] 2. BB - Bisoprolol, carvedilol 3. SGLT2 - dapagliflozin 4. MRA - spironolactone or eplerenone
61
genereal non-pharmacological Mx for heart failure
* Weight loss if BMI >30. * Smoking cessation * Salt and fluid restriction - improves mortality * Supervised exercise-based group rehabilitation programme for people with heart failure. * Offer annual influenza and one-off pneumococcal vaccinations for patients diagnosed with heart failure
62
key investigations for heart failure
Bloods: - NT-pro-BNP - - >2000 = urgent 2ww TTE - >400 = raised t4 6ww TTE - iron studies: transferrin sats, ferritin and Hb - if deficiency found must rule out other causes - consider IV ferritin - FBC, U+E [for drug mx], LFT [hepatic congestion] TFTs [hyperthyroid -> high output HF] Imaging: - Transthoracic echo - x-ray = ABCDE ECG - usually normal - rule out underlying cause e.g. arrythmia
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