Cardiology Flashcards

Question

What factors favour a rate control strategy for atrial fibrillation?

Answer 1

- Older than 65 years | - History of ischaemic heart disease

Answer 2

- Younger than 65 years - Symptomatic - First presentation - Lone AF or AF secondary to a corrected precipitant (e.g. Alcohol) - Congestive heart failure

Answer 3

1. Beta-blockers - a common contraindication for beta-blockers is asthma 2. Calcium channel blockers 3. Digoxin - not considered first-line anymore as they are less effective at controlling the heart rate during exercise - however, they are the preferred choice if the patient has coexistent heart failure

Answer 4

1. Sotalol 2. Amiodarone 3. Flecainide 4. Others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine

Answer 5

Pulsus paradoxus: - Greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration - Severe asthma, cardiac tamponade Slow-rising/plateau - aortic stenosis Collapsing - Aortic regurgitation - Patent ductus arteriosus - hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy) Pulsus alternans - When the upstroke of the pulse alternates between strong and weak. It indicates systolic dysfunction and is seen in patients with heart failure (severe LVF).

Answer 6

Nitrates are a group of drugs which have vasodilating effects. The main indications for their use is in the management of angina and the acute treatment of heart failure. Sublingual glyceryl trinitrate is the most common drug used in patients with ischaemic heart disease to relieve angina attacks. In angina they both dilate the coronary arteries and also reduce venous return which in turn reduces left ventricular work, reducing myocardial oxygen demand. Side-effects: - Hypotension - Tachycardia - Headaches - Flushing

Answer 7

Myocardial infarction: STEMI management In the absence of contraindications, all patients should be given: 1. Aspirin 2. P2Y12-receptor antagonist. Clopidogrel was the first P2Y12-receptor antagonist to be widely used but now Ticagrelor is often favoured as studies have shown improved outcomes compared to clopidogrel, but at the expense of slightly higher rates of bleeding. They also recommend that Prasugrel (another P2Y12-receptor antagonist) could be considered if the patient is going to have a percutaneous coronary intervention 3. Unfractionated heparin is usually given for patients who're are going to have a PCI. Alternatives include low-molecular weight heparin Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI With regards to thrombolysis: - Tissue plasminogen activator (tPA) has been shown to offer clear mortality benefits over streptokinase - Tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile. An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation; - If there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis - For patients successfully treated with thrombolysis, PCI has been shown to be beneficial. The optimal timing of this is still under investigation

Answer 8

Alteplase Tenecteplase Streptokinase

Answer 9

Acute myocardial infarction (MI): 1. Hyperacute T waves are often the first sign of MI but often only persists for a few minutes. 2. ST elevation may then develop. 3. The T waves typically become inverted within the first 24 hours. The inversion of the T waves can last for days to months. 4. Pathological Q waves develop after several hours to days. This change usually persists indefinitely A posterior MI causes ST depression not elevation on a 12-lead ECG.

Answer 10

The New York Heart Association (NYHA) classification is widely used to classify the severity of heart failure: NYHA Class I no symptoms no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations NYHA Class II mild symptoms slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea NYHA Class III moderate symptoms marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms NYHA Class IV severe symptoms unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Answer 11

Medication: 1. All patients should receive aspirin and a statin in the absence of any contraindication. 2. Sublingual glyceryl trinitrate to abort angina attacks. 3. NICE recommend using either a Beta-Blocker or a Calcium Channel Blocker first-line based on 'comorbidities, contraindications and the person's preference'. 4. If a calcium channel blocker is used as monotherapy a rate-limiting one such as Verapamil or Diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release Nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block). 5. If there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose. 6. If a patient is still symptomatic after monotherapy with a beta-blocker add a calcium channel blocker and vice versa. 7. If a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine. 8. 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

Answer 12

- An ejection systolic murmur (ESM) is classically seen in aortic stenosis. - Classically radiates to the carotids - this is decreased following the Valsalva manoeuvre - chest pain - dyspnoea - syncope 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 Management - if asymptomatic then observe the patient is general rule - if symptomatic then valve replacement - if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery

Answer 13

HAS-BLED is a scoring system developed to assess 1-year risk of major bleeding in patients taking anticoagulants for atrial fibrillation.

Answer 14

All patients should receive: - Aspirin 300mg - Nitrates or morphine to relieve chest pain if required Whilst it is common that non-hypoxic patients receive oxygen therapy there is little evidence to support this approach. The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic. - Antithrombin treatment. FONDAPARINUX should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l unfractionated heparin should be given. - Ticagrelor and prasugrel are now the preferred second antiplatelet instead of clopidogrel. PRASUGREL is generally favoured if the patient is going to have a percutaneous coronary intervention. They should generally be given to all patients and continued for 12 months, although this may vary according to bleeding and ischaemic risk. - Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission. - Coronary angiography should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.

Answer 15

The CHA2DS2-VASc score, are clinical prediction rules for estimating the risk of stroke in patients with AF. Such a score is used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy, since AF can cause stasis of blood in the upper heart chambers, leading to the formation of a mural thrombus that can cause a stroke. A high score corresponds to a greater risk of stroke, while a low score corresponds to a lower risk of stroke. Score 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 NICE recommend that we offer patients a choice of anticoagulation, including Warfarin and the novel oral anticoagulants (NOACs).

Answer 16

Whilst loop diuretics play an important role in managing fluid overload it should be remembered that no long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide. 1. The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker. - Generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first. - Beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol. ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction 2. Second-line treatment is an aldosterone antagonist these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include Spironolactone and Eplerenone - it should be remember that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored 3. Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy ivabradine. Other treatments: - Offer annual influenza vaccine - Offer one-off pneumococcal vaccine

Answer 17

Antiplatelets Summary of latest Guidance: Acute coronary syndrome (medically treated) 1st line: Aspirin (lifelong) & Ticagrelor (12 months) 2nd line: If aspirin CI, Clopidogrel (lifelong) Percutaneous coronary intervention 1st: Aspirin (lifelong) & Prasurgrel OR Ticagrelor (12 months) 2nd: If aspirin CI, Clopidogrel (lifelong) TIA 1st line: Clopidogrel (lifelong) 2nd line: Aspirin (lifelong) & dipyridamole (lifelong) Ischaemic stroke 1st line: Clopidogrel (lifelong) 2nd line: Aspirin (lifelong) & dipyridamole (lifelong) Peripheral arterial disease 1st line: Clopidogrel (lifelong) 2nd line: Asprin (lifelong)

Answer 18

There are two scenarios where cardioversion may be used in atrial fibrillation: 1. Electrical cardioversion as an emergency if the patient is haemodynamically unstable (shock) 2. Electrical or pharmacological cardioversion as an elective procedure where a rhythm control strategy is preferred.

Answer 19

Anteroseptal: V1-V4 | Left anterior descending artery

Answer 20

Inferior: II, III, aVF | Right coronary artery

Answer 21

Anterolateral: V4-6, I, aVL | Left anterior descending or left circumflex artery

Answer 22

ACE inhibitors eg. ramipril should be used first-line for treating hypertension in diabetics, exceptions to this are people of Afro-Caribbean origin and women for whom there is a possibility of becoming pregnant. ACE-inhibitors are first-line in diabetics regardless of age eventhough >55 years! ACE inhibitors are used first-line in diabetics due to their renoprotective effect.

Answer 23

Beta-blockers should not be combined with non-dihydropyridine Verapamil (CCB) and Diltiazem as it can potentially cause profound bradycardia and asystole.

Answer 24

Pulmonary embolism causes hyperventilation, causing a drop in arterial carbonic dioxide partial pressure and thus respiratory alkalosis.

Answer 25

If a PE is 'unlikely' (4 points or less) arranged a D-dimer test. D-dimer is a very sensitive, but non-specific marker for PE, meaning it is more useful when it is negative than when it is positive and it is therefore used in ruling out PE in patients where there is little clinical likelihood. If the D-dimer comes back positive in this patient, she should then receive a CTPA to look for PE.

Answer 26

Patent ductus arteriosus

Answer 27

Aortic stenosis - pulmonary stenosis, HOCM - atrial septal defect, tetralogy of Fallot

Answer 28

Mitral/tricuspid Regurgitation (high-pitched and 'blowing' in character) ventricular septal defect ('harsh' in character)

Answer 29

Mitral valve prolapse coarctation of aorta

Answer 30

Aortic regurgitation (high-pitched and 'blowing' in character) Graham-Steel murmur (pulmonary regurgitation, again high-pitched and 'blowing' in character)

Answer 31

Mitral stenosis ('rumbling' in character) Austin-Flint murmur (severe aortic regurgitation, again is 'rumbling' in character)

Answer 32

Major criteria: - Erythema marginatum - Sydenham's chorea: this is often a late feature - Polyarthritis - Carditis and valvulitis (eg, pancarditis)* - Subcutaneous nodules JONES CAFEPAL MNEMONIC ``` Joint involvement O looks like heart = myocarditis Nodules, subcutaneous Erythema marginatum Sydenham's chorea ``` Minor criteria: - raised ESR or CRP - pyrexia - arthralgia (not if arthritis a major criteria) - prolonged PR interval Rheumatic fever develops following an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection. Diagnosis is based on evidence of recent streptococcal infection accompanied by: - 2 major criteria - 1 major with 2 minor criteria Evidence of recent streptococcal infection: - raised or rising streptococci antibodies, - positive throat swab - positive rapid group A streptococcal antigen test

Answer 33

- Stop warfarin - Give intravenous vitamin K 5mg - Prothrombin complex concentrate - if not available then FFP

Answer 34

- Stop warfarin - Give intravenous vitamin K 1-3mg - Repeat dose of vitamin K if INR still too high after 24 hours - Restart warfarin when INR < 5.0

Answer 35

- Stop warfarin - Give vitamin K 1-5mg by mouth, using the intravenous preparation orally - Repeat dose of vitamin K if INR still too high after 24 hours - Restart when INR < 5.0

Answer 36

- Stop warfarin - Give intravenous vitamin K 1-3mg - Restart when INR < 5.0

Answer 37

- Withhold 1 or 2 doses of warfarin | - Reduce subsequent maintenance dose

Answer 38

Primary percutaneous coronary intervention is the gold-standard treatment for ST-elevation myocardial infarction but is not available in all centres. Thrombolysis should be performed in patients without access to primary PCI. With regards to thrombolysis: - Tenecteplase is easier to administer and has been shown to have non-inferior efficacy to alteplase with a similar adverse effect profile

Answer 39

Management options in acute heart failure include: - Oxygen - IV loop diuretics - Opiates - Vasodilators - Inotropic agents A patient who has failed medical management of pulmonary oedema with severe dyspnoea should be considered for CPAP - CPAP - Ultrafiltration - Mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices

Answer 40

In general, warfarin is usually stopped 5 days before planned surgery, and once the person's international normalized ration (INR) is less than 1.5 surgery can go ahead. Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.

Answer 41

Gout is a common side effect of thiazide diuretics. Thiazide diuretics reduce uric acid excretion from the kidneys causing hyperuricaemia.

Answer 42

Symptoms - Breathlessness - Reduced exercise tolerance - Oedema - Fatigue Signs - Cyanosis - Tachycardia - Elevated JVP - Displaced apex beat - Chest signs: classically bibasal crackles but may also cause a wheeze - S3-heart sound The diagnostic workup for patients with AHF includes: 1. Blood tests – this is to look for any underlying abnormality such as anaemia, abnormal electrolytes or infection. 2. Chest X-ray – findings include pulmonary venous congestion, interstitial oedema and cardiomegaly 3. Echocardiogram – this will identify pericardial effusion and cardiac tamponade 4. B-type natriuretic peptide – raised levels (>100mg/litre) indicate myocardial damage and are supportive of the diagnosis.

Answer 43

B-type natriuretic peptide (BNP) is a hormone produced mainly by the left ventricular myocardium in response to strain. Whilst heart failure is the most obvious cause of raised BNP levels any cause of left ventricular dysfunction such as myocardial ischaemia or valvular disease may raise levels. Raised levels may also be seen due to reduced excretion in patients with chronic kidney disease. Factors which reduce BNP levels include treatment with ACE inhibitors, angiotensin-2 receptor blockers and diuretics. Clinical uses of BNP: 1. Diagnosing patients with acute dyspnoea - A low concentration of BNP(< 100pg/ml) makes a diagnosis of heart failure unlikely, but raised levels should prompt further investigation to confirm the diagnosis. - NICE currently recommends BNP as a helpful test to rule out a diagnosis of heart failure. 2. Prognosis in patients with chronic heart failure initial evidence suggests BNP is an extremely useful marker of prognosis. 3. Guiding treatment in patients with chronic heart failure, effective treatment lowers BNP level.

Answer 44

First-degree heart block - PR interval > 0.2 seconds - Asymptomatic first-degree heart block is relatively common and does not need treatment

Answer 45

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

Answer 46

Third-degree (complete) heart block - There is no association between the P waves and QRS complexes

Answer 47

Agents with proven efficacy in the pharmacological cardioversion of atrial fibrillation: 1. Amiodarone 2. Flecainide (if no structural heart disease) 3. others (less commonly used in UK): quinidine, dofetilide, ibutilide, propafenone If pharmacological cardioversion has been agreed on clinical and resource grounds for new-onset atrial fibrillation, offer: - Flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or Amiodarone if there is evidence of structural heart disease.

Answer 48

ECG features of hypokalaemia: - U waves! - small or absent T waves (occasionally inversion) - prolong PR interval - ST depression - long QT

Answer 49

Side-effects: 1. Cough occurs in around 15% of patients and may occur up to a year after starting treatment thought to be due to increased bradykinin levels 2. Angioedema: may occur up to a year after starting treatment 3. Hyperkalaemia 4. First-dose hypotension: more common in patients taking diuretics

Answer 50

Agents used to control rate in patients with atrial fibrillation: Beta-blockers - a common contraindication for beta-blockers is asthma Calcium channel blockers Digoxin - not considered first-line anymore as they are less effective at controlling the heart rate during exercise - however, they are the preferred choice if the patient has coexistent heart failure

Answer 51

Ratio of chest compressions to ventilation is 30:2

Answer 52

A crossmatch indicates that you will be giving the patient blood, whereas a group and save only saves the patient's blood type for future reference and future blood transfusions. In this case, you need blood now, thus a crossmatch is the better option.

Answer 53

Mild airway obstruction: Response to question 'Are you choking?' - victim speaks and answers yes Victim is able to speak, cough, and breathe Severe airway obstruction Response to question 'Are you choking?' - victim unable to speak - victim may respond by nodding - victim unable to breathe - breathing sounds wheezy - attempts at coughing are silent - victim may be unconscious If mild airway obstruction - encourage the patient to cough If severe airway obstruction and is conscious: - give up to 5 back-blows - if unsuccessful give up to 5 abdominal thrusts - if unsuccessful continue the above cycle If unconscious - call for an ambulance - start cardiopulmonary resuscitation (CPR)

Answer 54

First-line investigations include: - 12-lead ECG: this will only capture the heart rhythm for a few seconds and hence is likely to miss episodic arrhythmias. However, other abnormalities linked to the underlying arrhythmia (for example a prolonged QT interval or PR interval, or changes suggesting recent myocardial ischaemia) may be seen. - Thyroid function tests: thyrotoxicosis may precipitate atrial fibrillation and other arrhythmias - Urea and electrolytes: looking for disturbances such as a low potassium - Full blood count First-line investigations are often normal in patients complaining of palpitations. The next step is to exclude an episode arrhythmia. The most common investigation is Holter monitoring If no abnormality is found on the Holter monitor, and symptoms continue, other options include: - external loop recorder - implantable loop recorder

Answer 55

Offer primary PCI to all patients presenting within 12h of symptom onset with a STEMI who either are at or can be transferred to a primary PCI centre within 120 minutes of first medical contact. If this is not possible patients should receive thrombolysis and be transferred to a primary PCI centre after the infusion for either rescue PCI (if there is residual ST elevation) or angiography (if successful). Example: A patient who presents with a STEMI to a small DGH which does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for rescue PCI.

Answer 56

Management of STEMI: MONAT 1. Intravenous Morphine + IV anti-emetic, Metoclopramide to help relieve symptoms. 2. Sublingual glyceryl trinitrate. Routine use now not recmmended in acute setting unless patient hypertensive or in acute LVF. Useful as anti-anginal in chronic/stable patients. 3. Oxygen should only be given if the oxygen saturations are < 94%. 4. Aspirin 300mg PO should be given to all patients (unless contraindicated). 5. Second antiplatelet, Ticagrelor. (alternative; Prasugrel, clopidogrel) - If thrombolysis required because >2h then tissue plasminogen activator, Tenectaplase IV.

Answer 57

PIRATES MNEMONIC ``` Pulmonary: PE, COPD Iatrogenic Rheumatic heart: Mitral regurgitation Atherosclerotic: CAD, MI Thyroid: Hyperthyroid Endocarditis Sick sinus syndrome ```

Answer 58

Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include: - Aortic stenosis - Congestive heart failure - Cardiac tamponade

Answer 59

Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.

Cardiology Flashcards

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