Year-6 > Cardiovascular > Flashcards

Cardiovascular Flashcards

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1
Q

What are the appropriate investigations for someone presenting with palpitations?

A

12-lead ECG

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

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2
Q

What is the best investigation for episodic palpitations?

A

Holter monitor

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3
Q

What type of Murmur is Aortic Stenosis?

A

Ejection Systolic Murmur, louder on expiration

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4
Q

Where does Aortic Stenosis Radiate?

A

Carotids

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5
Q

What is the best management for Aortic Stenosis?

A

if asymptomatic then observe the patient is a general rule

if symptomatic then valve replacement if valvular gradient >40mmHg

  1. surgical AVR is the treatment of choice for young, low/medium operative risk patients.
    1. transcatheter AVR (TAVR) is used for patients with a high operative risk
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6
Q

What is the anticoagulant of choice for mechanical valves?

A

Warfarin

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7
Q

Before valve replacement surgery what should you do and why?

A

Cardiovascular disease may coexist.

Angiogram is often done prior to surgery so that the procedures can be combined

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8
Q

What is the first line test for Chronic Heart Failure?

A

NT-pro BNP test

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9
Q

What is a high and raised BNP levels

A

High: > 400 pg/ml
Raised: 100-400 pg/ml

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10
Q

What is a high and raised NT-proBNP level?

A

High: > 2000 pg/ml
Raised: 400-2000 pg/ml

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11
Q

How do you manage a high and a raised BNP/ proBNP level?

A

High: 2 week referal for specialist (echo)
Raised: 6 week referal for specialist (echo)

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12
Q

What is the management of Hypertrophic Obstructive Cardiomyopathy?

A

ABCDE

1.Amiodarine
2.Beta-blocker
3.Cardiovascular Defibrilator
4.Dual Chamber Pacemaker
5.Endocarditis Prophylaxis

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13
Q

What are the Echo findings for Hypertopchic Obstructive Cardiomyopathy?

A

MR SAM ASH

  • Mitral Regurgitation (MR)
  • Systolic Anterior Motion (SAM) of the anterior mitral valve leaflet
  • Asymmetric Hypertrophy (ASH)
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14
Q

What drugs should be avoided in HOCM?

A

Nitrates
Inotropes
ACE-inhibitors

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15
Q

Fatty and Fibrofatty Tissue

A

Arrhythmogenic right ventricular cardiomyopathy

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16
Q

What is the best management of Arrhythmogenic right ventricular cardiomyopathy?

A
  1. drugs: sotalol is the most widely used antiarrhythmic.
  2. catheter ablation to prevent ventricular tachycardia.
  3. implantable cardioverter-defibrillator
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17
Q

Fatty and Fibrofatty Tissue, woolly hair and palmoplantar keratosis (yellow heel)

A

NAXOS DISEASE

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18
Q

What scale can be used to stratify risk post MI?

A

Killip Class

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19
Q

What inital intervention do you provide patients with ACS?

A
  1. aspirin 300mg
  2. Oxygen only if oxygen saturations < 94%
  3. morphine should only be given for patients with severe pain
  4. NItrates
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20
Q

In which patients with ACS should Nitrates be avoided?

A

Hypotensive

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21
Q

What are medications should patients receive following an ACS?

A
  1. dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
  2. ACE inhibitor
  3. beta-blocker
  4. statin
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22
Q

What is the management of a STEMI?

A

Give ASPIRIN
if PCI is availiable within 120 min then do that
if not fibronolysis- following procedure give tricegrelor

Fibrinolysis for patients with STEMI

Fibrinolysis used to be the only form of coronary reperfusion therapy available. However, it is used much less commonly now given the widespread availability of PCI.

The contraindications to fibrinolysis and other factors are described in other notes.

Patients undergoing fibrinolysis should also be given an antithrombin drug. Fondaparinux

An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.

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23
Q

What medication should you give prior PCI?

A

DUAL ANTIPLATELET
Aspirin and another drug

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24
Q

What anti-platelet should you give prior to PCI if patient is not taking an oral anticoagulant

A

prasugrel

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25
What anti-platelet should you give prior to PCI if patient is taking an oral anticoagulant
clopidogrel
26
How do you manage a patient with NSTEMI/UNSTABLE ANGINA?
Give Aspirin Calculate GRACE score if <3% then conservative management (tricegrelor) if >3% then PCI, should be immediate if hypotensive otherwise within 72 hrs
27
What further anticoagulation therapy do you give to patients with NSTEMI/UNSTABLE ANGINA?
**Fondaparinux** should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately If immediate angiography is planned or a patients creatinine is > 265 µmol/L then **unfractionated heparin** should be given Dual antipletelet therapy
28
What is the management of Stable angina?
Aspirin Statin Nitrate Beta-blocker, if does not control it then add longer-acting dihydropyridine calcium channel blocker: Nifedipine
29
How can you manage Nitrate Tolerance?
Asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
30
What medication is first line to prevent Angina Attacks?
CCB or Beta-Blocker
31
Patient has Angina like pain during exercise but there are normal arteries on angiogram, how to manage
Syndrome X, give nitrates
32
Stage 1 Hypertention
Clinic BP >= 140/90 mmHg ABPM daytime average or HBPM average BP >= 135/85 mmHg
33
Stage 2 hypertention
Clinic BP >= 160/100 mmHg ABPM daytime average or HBPM average BP >= 150/95 mmHg
34
Severe Hypertention
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
35
Patient presents with Severe HTN, bilateral retinal haemorrhages and exudates
Malignant Hypertention
36
What are the features of Right Heart Failure?
JVP Ankle Oedema Hepatomegaly
37
When do you treat HNT?
If Stage 1 and <80 yrs with end organ damage, or a 10-year cardio risk score over 10% Everyone with Stage 2
38
What is the only CCB that can be given in Heart failure?
Amlodipine
39
What is the blood pressure target for people with diabetes?
< 140/90 mmHg
40
What is the management of HTN
41
What is the management of Acute Heart Failure?
1. IV loop diuretics: furosomide-bumetanide 2. Oxygen keep it 94-98% 3. Vasodilators (nitrates if concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease) 4. Continue regular medication: beta-blocker unless HR less than 50
42
How do you manage Acute Heart Failure but with hypotention?
Inotropic agents: dobutamine Vasopressor agents: norepinephrine Mechanical circulatory assistance: intra-aortic balloon counterpulsation or ventricular assist devices Loop diuretics cannot be given cause they make hypotention worse
43
What is the management of Chronic Heart Failure?
The first-line treatment for all patients is a combination of the following 4 medications: **ACE-inhibitor** ** Beta Blocker** **mineralocorticoid receptor antagonist (MRA)** **SGLT2-inhibitor** If patients on the above combination of 4 medications continue to have symptoms switch ACE-inhibitor for an angiotensin receptor-neprilysin inhibitor e.g. sacubitril-valsartan NICE recommend seeking advice from a heart failure specialist before initiating this treatment Second; Ivabradine (should be started by specialist) There is an increasing role for SGLT-2 inhibitors in the management of heart failure with a reduced ejection fraction
44
What vaccinations should people with Chronic Heart failure receive?
* offer annual influenza vaccine * offer one-off pneumococcal vaccine
45
Do duiretics have an effect in the mortality for patients with Chronic Heart failure ?
NO
46
Patient with Chronic Heart failure that is not controlled with any of the interventions, presentes with widened QRS complex, how do you manage ?
Cardiac resynchronisation therapy (CRT), also known as a biventricular pacemaker
47
What happens in a First degree heart block?
PR interval is >0.2 seconds
48
What are the types and what happens in second degree heart block?
Mobitz type 1: PR interval increases until it skips a beat Mobitz type 2: PR interval is constant, but then skips beat
49
What happens in third degree heart block?
Complete disociation between P wave and QRS complex
50
What is the management of a heart block?
1. Atropine: up to 3 times 2. Transcutaneous pacing-external pacing 3. Isoprenaline/ Adrenaline: titrated equivalently 4. if there is no response then transvenous pacing
51
How do you manage bradycardia in a patient?
1. A to E approach 2. Obtain IV access, monitor ECG, give 02 3. If life threatening signs or heart block then do (i) otherwise observe (i) Atropine 500 mcg(IV), repeat up to three times then if still unstable: Isoprenaline 5 mcg, adrenaline 2-10 mcg--> transcuteneous pacing --> transvenous pacing
52
CT with contrast shows flase lumen and CXR has widened mediastanum
Aortic Dissection
53
If patient is suspected to have aortic dissection but is unstable to have CT with contrast, what do u do?
Transesophangeal Echocardiography
54
Which aortic dissection needs immediate surgery?
Any type if size is >5.5cm
55
How do you manage Type B aortic Dissection?
Type B: descending aorta manage with **bed rest** and **labetalol** to slow progression
56
What blood pressure should be aimed for Type A aortic dissection before intervention?
100-120 mmHg
57
What is an Ejection Systolic Murmur that is louder on Inspiration
Pulmonary stenosis
58
What is an Ejection Systolic murmur that is louder on Expiration?
Aortic Stenosis
59
What is a pansystolic murmur that is louder on inspiration?
Tricuspid regurgitation
60
What is a pansystolic murmur that is louder on expiration?
Mitral regurgitation
61
What is a mid-diastolic murmur?
MITRAL STENOSIS
62
Continuous machine-like murmur
Patent ductus arteriosus
63
What can result in a collapsing pulse?
Aortic regurgitation Patent Ductus Arteriosus
64
What can give a jerky pulse?
Hypertrophic obstructive cardiomyopathy
65
Patient with AF and haemodynamic instability
Electrically cardioverted
66
Patient with AF with haemodynamic instability and there are contraindications to anti-coagulant medication
Pharmacological cardioversion: amiodarone + flecainide 'f 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.'
67
Patient with AF and haemodynamic stability
< 48 hours: rate or rhythm control ≥ 48 hours or uncertain: rate control
68
What is RATE control for AF?
1. beta-blockers: a common contraindication for beta-blockers is asthma 2. calcium channel blockers (rate limiting) 3. digoxin
69
What is RHYTHM control for AF?
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation 1. beta-blockers 2. dronedarone: second-line in patients following cardioversion 3. amiodarone: particularly if coexisting heart failure
70
What do you for patients that have not responded or do not wish to receive antiarrhythmic medication?
Catheter Ablation
71
What score to judge the need for anticoagulation?
CHA2DS2-VASc o if score = 0: 2 months anticoagulation recommended o if score > 1: longterm anticoagulation recommended
72
What do you need to do before Catheter ablation?
Anticoagulation should be given 4 weeks before and during the procedure
73
What anti-coagulation do you give me after AF?
1. DOAC (apixaban, dabigatran) 2. Warfarin Aspirin is not recommended for reducing stroke risk in patients with AF If there is renal failure then give LMWH
74
What scale is used to assess bleeding risk ?
ORB score
75
What is Beck's Triad and which condition does it present in?
1.Muffled heart sounds 2.raised JVP 3.Hypotention Seen in Cardiac Tamponade
76
What is the characteristc JVP feature in Cardiac Tamponade?
Absent Y descent
77
How to manage Cardiac Tamponade?
urgent pericardiocentesis
78
CXR shows pericardial calcification
Contrictive Pericarditis
79
JVP with X + Y present
Contrictive Pericarditis
80
Patient presents with pleuritic chest pain which is worse on lying down
Acute Pericarditis
81
ECG shows saddle shaped ST elevation
Acute Pericarditis
82
What is the investiagtion of choice for Acute Pericarditis?
Transotharic Echocardiography
83
Patient has pleutic fever,chest pain 4 weeks after MI
Dressler's Syndrome
84
How to manage Acute Pericarditis?
NSAID and colchicine
85
How to manage Dressler's Syndrome?
NSAID
86
Young patient with acute history of CP that does not change based on position
Myocarditis
87
Which valve is usually affected in Infective Endocarditis?
Mitral Valve
88
Which valve is most likely to be affected in Infective Endocarditis and IUD?
Tricuspid Valve
89
Infective endocarditis and bad oral hygiene
Streptococcus virdans
90
Most common organism for Infective endocarditis
Staphylococcus Aureus
91
Infective endocarditis and Bowel Surgery
Staphylococcus Bovis
92
Infective endocarditis and within 2 weeks of valve surgery,what microorganism?
Staphylococcus epidermis
93
What antibiotics for Native valve Infective Endocarditis?
amoxicillin, consider adding low-dose gentamicin
94
What antibiotics for Prosthetic valve Infective Endocarditis?
vancomycin + rifampicin + low-dose gentamicin
95
Provoked vs Unprovoked DVT
DOAC: apixaban. Rivaroxaban provoked 3 months Unprovoked: 6 months
96
What is the INR aim for a prosthetic Aortic valve?
Aortic valve: 3.0
97
What is the INR aim for prosthetic Mitral Valve?
mitral valve: 3.5
98
What is the INR aim for AF?
2.5
99
What is the INR for VTE, how does it change if its reacurrent?
venous thromboembolism: target INR = 2.5 (2.0-3.0), if recurrent 3.5 (2.5-3.5)
100
INR and Major Bleed
Stop warfarin Give intravenous vitamin K 5mg Prothrombin complex concentrate - if not available then FFP*
101
INR > 8.0 Minor bleeding
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
102
INR > 8.0 No bleeding
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
103
INR 5.0-8.0 Minor bleeding
Stop warfarin Give intravenous vitamin K 1-3mg Restart when INR < 5.0
104
INR 5.0-8.0 No bleeding
Withhold Warfarin for 1-2 days
105
What is the first line investigation for Stable Angina?
1st line: CT coronary angiography 2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia) 3rd line: invasive coronary angiography
106
What is the mechanism for death in HOCM?
Hypertrophic obstructive cardiomyopathy - is associated with sudden death in young athletes due to ventricular arrhythmia
106
How should you manage a patient that has AF and just had a stroke?, how does this change for a TIA?
Anticoagulation with Aspirin and Clopidogren (75mg) and 2 weeks laters switch clopidogrel to either Warfarin or DOAC (unless imaging shows a very large area of infraction--> then it should be delayed) for TIA: following a TIA, anticoagulation for AF should start immediately once imaging has excluded haemorrhage
107
How should you monitor after fibronolysis?
An ECG should be repeated after** 60-90 minutes** to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.
108
Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?
1. **immediate**: patient who are clinically **unstable** (e.g. hypotensive) 2. **within 72 hours: patients with a GRACE score > 3%** i.e. those at intermediate, high or highest risk coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission Conservative management for patients with NSTEMI/unstable angina Further drug therapy further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) if the patient is not at a high risk of bleeding: ticagrelor if the patient is at a high risk of bleeding: clopidogrel
109
How does kidney disease affect pro-BNP?
Renal dysfunction (eGFR < 60) can cause a raised serum natriuretic peptides
110
What medication for Heart failure with preserved ejection fraction
The first-line treatment for all patients is a combination of the following medications: mineralocorticoid receptor antagonist SGLT2-inhibitor
111
111
U waves
hypokalaemia
112
In chronic HF if ace inhibitor cuases cough switch to what
**ACE-inhibitor** if not tolerated (e.g. due to a cough) switch to angiotensin receptor-neprilysin inhibitor (ARNI)
113
In chronic HF if ace inhibitor cuases angiodema switch to what
if angioedema develops, switch to an angiotensin receptor blocker (ARB) beta-blocker
114
can you give bb with verapamil
Beta-blockers combined with verapamil can potentially cause profound bradycardia and asystole.
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