UKMLA: Cardiology

ACS: How can troponin status help differentiate between different types of ACS?

• Unstable angina is troponin negative or normal→ due to partial artery occlusion

• STEMI is troponin positive→ due to full artery occlusion

ACS: What is a silent MI and the symptoms?

MI in diabetics and elderly that causes no classic symptom of ACS but may present with:

• Syncope

• Confusion

ACS: What are the non-ACS causes of chest pain?

• PE

• Pneumothorax

• Aortic dissection

• Oesophageal spasm

• Peptic ulcers

ACS: What is the criteria for STEMI diagnosis on ECG?

• >2mm elevation in chest leads

• >1mm elevation in limb leads

• New BBB

ACS: Which leads and artery are affected in an INFERIOR MI?

RCA:

• II

• III

• AVF

ACS: Which leads and artery are affected in a SEPTAL MI?

LAD:

• V1

• V2

ACS: Which leads and artery are affected in an ANTERIOR MI?

LAD:

• V3

• V4

ACS: Which leads and artery are affected in a LATERAL MI?

LCx:

• I

• AVL

ACS: What is Dressler’s syndrome?

Post MI complication that causes pericarditis a few weeks or months later

ACS: What is the management of a STEMI?

1. Loading dose of 300mg aspirin

2. PCI if pain is less than 12 hours within 2 hours

3. Give prasugrel if patient is not on coagulation OR clopidogrel if patient is on coagulation

4. IV morphine with metoclopramide (morphine can cause nausea)

5. GTN (sublingual for symptom relief, IV only for blood pressure changes)

ACS: What is the management of a NSTEMI?

1. Loading dose of 300mg aspirin AND fondaparinux

2. Calculate the GRACE Score:

• if less than 6 month mortality risk→ prasugrel or ticagrelor

• If more than 6 month mortality risk→ clopidogrel 300mg AND angiogram within 96 hours

ACS: What is the management post-MI?

1. Aspirin 75mg and Clopidogrel 75mg

2. Bisoprolol

3. Ramipril

4. Atorvastatin 80mg

ACS: What type of drugs are clopidogrel, ticagrelor and prasugrel?

P2Y12 inhibitors

ACS: Which drugs are contraindicated in patients with a high bleeding risk e.g. the elderly?

• Fondaparinux

• Ticagrelor

AF: What is AF?

• Irregularly irregular pulse

• No P waves

• Associated with stroke and mitral regurgitation

• Fast AF is 300-600 bpm

• Slow AF is less than 40 bpm

AF: What are the symptoms?

• Palpitations

• SOB

• Syncope

• Stroke

• Mitral regurgitation

AF: What is the management of rate in ACUTE AF?

Within 48 hours:

DC cardioversion ± amiodarone (older patients)

AF: What is the management of rate in PAROXYSMAL AF?

Less than 7 days but self resolves:

24 hour holter ECG device + fleicanide pill in the pocket (younger patients)

AF: What is the management of rate in STABLE AF?

Less than 48 hours onset:

DC cardioversion + amiodarone if older or fleicanide if younger patient

More than 48 hours onset:

1. Bisoprolol

2. Ditiazem (CCB)

3. Digoxin to reduce BP

AF: Which drug is contraindicated in asthmatic and COPD patients?

Bisoprolol (any beta blockers are contraindicated!!)

ACS: How is the rhythm controlled?

1. Amiodarone (older patients)

2. Fleicanide (younger patients)

3. Sotalol (last option)

AF: What is the CHA2DS2VASc criteria for anti-coagulation?

• Congestive heart failure (1)

• HTN (1)

• Age over 75 (2)

• Diabetes (1)

• Stroke or TIA (2)

• Age 65-74 (1)

• Sex is female (1)

If score is over 1 in males or over 2 in females→ anti-coagulate!!

AF: Which scores assess bleeding risk with anti-coagulates?

HASBLED (HTN, stroke, renal or liver impairment, over 65 y/o, major bleed, drug or alcohol use, labile INR)

ORBIT:

• Old age (75 y/o)

• Renal impairment ( eGFR less than 60)

• Bleeding history

• Iron (low Hb)

• Taking antiplatelets

Atherosclerosis: What are the non-modifiable risk factors?

• Old age

• FH

• Male

Atherosclerosis: What QRISK Score indicates preventative medication?

QRISK less than 10%:

• Atorvastatin 20mg every night (measure LFT at baseline, 3m and 12m)

• Atenolol

• ACEi

Heart Failure: What is the difference between systolic and diastolic heart failure?

• Systolic→ ventricles fill, poor pumping

• Diastolic→ ventricles struggle to fill, good pumping

Heart Failure: What are the signs and symptoms of LEFT sided HF?

• Extertional SOB

• orthopnea

• PND

• nocturnal cough

• pink sputum

• mitral regurgitation

• bibasal crackles

• cyanosis

Heart Failure: What are the signs and symptoms of RIGHT sided HF?

• ankle oedema

• weight gain

• anorexia

• nausea

• › JVP

• pitting peripheral oedema, hepatomegaly

• ascites

• transudative pleural effusions

Heart Failure: What are the investigations?

1. NT-pro BNP → over 2000 do a TTE within 2 weeks

2. 12 lead ECG

3. TTE within 6 weeks if BNP less than 2000

4. CXR

Heart Failure: What is the management?

• Conservative management

• ACEi and beta blocker

• Spironolactone

• SGLT2 inhibitors

Heart Failure: What is the management in black patients?

Hydralazine and nitrates

Heart Failure: What is the management in patients with AF?

Digoxin

HTN: What is the criteria for stage 1 HTN?

• Hospital → 140/90

• Ambulatory or home→ 135/85

HTN: What is the criteria for stage 2 HTN?

• Hospital → 180/100

• Ambulatory or home→ 150/95

HTN: What is the criteria for stage 3 HTN?

> 180/120

HTN: What is the management of HTN?

If black or over 55 y/o:

1. CCB e.g. amlodipine

2. CCB and ACEi

3. CCB and ACEi and thiazide (e.g. indapimide)

If less than 55 y/o or diabetic:

1. ACEi

2. ACEi and CCB

3. ACEi and CCB and thiazide

4. If potassium is less than 4.5 mmol/L → spiranolactone

4. If potassium is more than 4.5 mmol/L → doxazosin (alpha blocker) or a beta blocker

HTN: What type of drug is verapamil and amlodipine?

CCB

HTN: What are the ABPM targets after treatment?

• Less than 80 y/o→ <135/85

• Over 80 y/o→ <145/85

• Patient has T1DM and end-organ damage→ <130/80

HOCM: What is HOCM?

• Autosomal dominant inheritance

• LV hypertrophy and outflow obstruction due to B-myosin heavy chain gene mutation

HOCM: What are the symptoms?

• Exertional syncope ± dyspnoea

• Sudden cardiac death

• Fatigue

• Angina

• FH of sudden cardiac death

HOCM: What are the signs?

• Jerky pulse

• Double apex beat

• Mitral regurgitation

• Harsh ejection systolic murmur

• Young patient

• Apical thrill

• JVP wave

• Biphasic pulse

HOCM: What are the ECG findings?

Deep T wave inversion

LVH

Abnormal Q wave

HOCM: What is the management?

1. Conservative

2. Beta blockers

3. Septal myoectomy

If risk of sudden cardiac death is high, implant a defibrillator (ICD)

IE: What are the risk factors for infective endocarditis?

Over 60 y/o, male, IVDU, poor oral hygiene and valvular disease

IE: What are the signs and symptoms?

• Painless janeway lesions

• Painful osler nodes

• Splinter haemorrhages

• Fever

• Night sweats

• Anorexia/weight loss

• Cough

• Pain

IE: How do you classify acute, subacute and chronic IE?

• Acute→ 0-6 weeks

• Subacute→ 6 weeks - 3 months

• Chronic→ 3+ months

IE: What is the Duke’s criteria for diagnosis?

Major criteria: blood cultures from 2 sites, echo (vegetations)

Minor criteria: fever, immunological signs e.g. janeway lesions, vascular signs e.g. IVDU and echo

IE: What are the investigations?

1. TTE

2. TOE

3. PET CT

IE: What is the management?

• Awaiting results? Give amoxicillin in the meantime

• Native valve disease? Give flucloxacillin, rifampicin and vancomycin

• Prosthetic valve disease? Give flucloxacillin, rifampicin and gentamycin

• Strep viridens infection> Give benzylpenicillin, vancomycin and gentamycin

IE: When does a patient require surgical management?

If patient has IE and prolonged PR interval

IE: What do you do if IE is caused by strep bovis?

Perform a colorectal colonoscopy to rule out colorectal carcinoma

IE: What are the causes of negative blood culture- IE?

‘HACEK’ organisms→ manage via ceftraxione:

• Haemophillus

• Action bacillus

• Cardiobacterium

• Eikenella

• Kingella

Pericarditis: What are the symptoms?

• Usually occurs after infection

• Relieved by sitting up

• Worsens when laying down

• Friction rub

• Pleuritic pain worse on inspiration

• Raised JVP

• Beck’s triad

Pericarditis: What are the investigations?

1. ECG→ widespread ST elevation and PR depression

2. High ESR, CRP and WCC

Pericarditis: What is the management?

1. NSAIDS and PPI for 2 weeks

2. Colchicine for 3 months

3. If bacterial causes, give IV antibiotics and perform pericardiocentesis

SVT: What is the management of SVT in STABLE patients?

1. Vagal manoeuvres

2. IV adenosine 6mg, 12mg, 18mg

3. Beta blocker or verapamil

SVT: What is the management of SVT in UNSTABLE patients?

DC cardioversion (shock)

SVT: What must be considered when giving adenosine?

• Warn patient that it causes impending sense of doom

• Contraindicated in asthmatics

• Only give 3mg if the patient has a central line

Rheumatic Fever: What are the symptoms?

• Occurs 2-4 weeks after lancefield group A beta-haemolytic strep infection

• Typical patient is a child

• Fever

• New murmur

• Arthralgia

Rheumatic Fever: What is the Jone’s criteria for diagnosis?

Major:

• Arthritis

• Pancarditis

Minor:

• Fever

• High ESR/CRP

• Prolonged PR interval

• Arthralgia

Rheumatic Fever: What are the clinical signs?

• Sydenham chorea (muscle weakness and spasms)

• Erythema marginatum (non-itchy pink rash)

Rheumatic Fever: What is the investigation?

Anti-streptolysin O titres

Rheumatic Fever: What is the management?

STAT dose of IV benzylpenicillin and 10 days of phenoxymethylpenicillin

Atrial Flutter: What are the ECG findings?

Saw tooth character of p waves

Regular RR intervals

This is due to aberrant re-enterance in right atrium

Atrial Flutter: What are the symptoms?

• Asymptomatic

• Palpitations

• Light-headed

• Syncope

• Chest pain

Atrial Flutter: What is the management in STABLE patients?

1. Bisoprolol or CCB

2. DC cardioversion

3. Ablation to cure if recurrent

Atrial Flutter: What is the management in UNSTABLE patients?

DC cardioversion ( amiodarone, sotalol or digoxin)

NCT: What is narrow complex tachycardia?

• More than 100 bpm

• QRS less than 120ms

• Regular→ atrial flutter, AVRT, junctional tachycardia

• Irregular→ AF, multifocal atrial tachycardia (COPD patients)

NCT: What are the symptoms?

• Palpitations

• Light-headed

• Dyspnoea

• Chest pain

• Syncope

NCT: What are the investigations?

• ECG

• 24 hour holter monitor

• Cardiac catheterisation

NCT: What is the emergency management?

DC cardioversion with amiodarone

NCT: What is the management for REGULAR rhythm?

1. Vagal manoeuvres

2. Adenosine 6mg, 12mg, 18mg (verapamil if asthmatic)

3. Verapamil or beta blockers

4. DC cardioversion

NCT: What is the management for IRREGULAR rhythm?

1. Beta blockers

2. Digoxin if signs of heart failure are present

Heart Block: What is first degree heart block?

• PR over 200ms

• Due to digoxin, athletes, hyperkalaemia etc

• No management needed

Heart Block: What is second degree, mobitz type 1 heart block?

• “Wenkebach phenomenon”

• PR interval increases progressively until a P waves isn’t followed by a QRS complex but then returns to normal

• No management needed

Heart Block: What is second degree, mobitz type 2 heart block?

• Absence of QRS complexes after every P wave

• Constant PR interval increases progressively

• Manage via permanent pacemaker

Heart Block: What is third degree heart block?

• No relationship between P or QRS

• High risk of Asystole

• Manage via 500mg IV atropine or adrenaline

BBB: What is bundle branch block?

• A delay in impulses to ventricles causing a wide QRS over 120ms

• Seen in leads V1 and V6

• Confirm in leads V2 and V3 too if in doubt

BBB: What is the ‘William Marrow’ mneumonic?

William - LBB (acute)

Marrow- RBB

BBB: What are the causes of BBB?

• LBBB→ aortic stenosis, digoxin toxicity, hyperkalaemia

• RBBB→ PE, ischaemia, congenital heart disease

Aortic Dissection: What is aortic dissection?

Tear in the tunica intima that causes flow of blood inside and outside the aorta:

• Stanford A→ involves ascending aorta

• Stanford B→ involves descending aorta

Aortic Dissection: What are the risk factors?

HTN, marfans, valvular heart disease, cocaine, amphetamine

Aortic Dissection: What are the symptoms?

• Men over 50 y/o

• Sudden chest pain radiating to the back

• Bowel or limb ischaemia

• Syncope

Aortic Dissection: What are the signs?

• R-R delay

• R-F delay

• BP difference across both arms

Aortic Dissection: What are the investigations?

• Gold standard investigation is CT angiogram

• Echo→ pericardial effusion

• CXR→ wide mediastinum

• Blood→ D dimer and raised troponin

Acute Bradycardia: What is the cause?

• Sick sinus syndrome (pacemaker dysfunction)→ common in over 65’s

• Associated with marfans (arched palate and dislocated lens)

Acute Bradycardia: What are the symptoms?

• Light-headed

• Syncope

• SOB

• Fatigue

• <60bpm and shock or heart failure

Acute Bradycardia: What is the management?

1. 500mg IV atropine

2. Transcutaneous pacing or adrenaline or glucagon if suspected beta blocker/CCB overdose

3. Insert pacemaker

Cardiac Tamponade: What is cardiac tamponade?

Compression of IVC and heart chambers due a pericardial effusion, leading to reduced cardiac output. This is a life-threatening emergency.

Cardiac Tamponade: What are the symptoms?

• SOB

• Tachycardia

• Confusion

• Chest pain

• Abdominal pain

• Pulsus paradoxus

• Electrical alterans (ECG)

• Becks triad→ hypotension, muffled heart sounds, raised JVP

Cardiac Tamponade: What is the management?

• Stable? Observe

• Unstable? Pericardiocentesis

Pericardial Effusion: What are the symptoms?

• Dyspnoea

• Chest pain

• Hiccups

• Nausea

• Lower left base bronchial breathing (ewart’s sign)

• Becks triad → hypotension, muffled heart sounds, raised JVP

• Enlarged globular heart on CXR

Digoxin Toxicity: What is the mechanism of drug action?

Inhibits sodium-potassium ATPase pump to slow the heart rate but increase the contractility

Digoxin Toxicity: What are the symptoms?

• Low K

• Low Mg

• High Ca

• Nausea/vomiting

• Diarrhoea

• Blurry yellow/green vision

• Confusion

• Syncope

• Palpitations

Digoxin Toxicity: What is the management?

1. Stop digoxin

2. Correct any electrolyte imbalance

3. Give digifab if life-threatening

Myocarditis: What is the cause?

• UK→ cocksachie B virus

• Globally→ Chagas’ disease

Myocarditis: What are the symptoms?

• Affects young people aged 19-35 y/o

• Sharp chest pain radiating

• Worse laying down

• Light-headed

• Fever

• SOB

• Dull heart sounds

• Pericardial rub on auscultation

• Sudden cardiac death

Myocarditis: What is the investigations?

• Raised troponin

• Raised CK-MB

Myocarditis: What is the management?

Corticosteroids

Malignant HTN: What are the vascular features?

Fibrinoid necrosis of small vessels