Cardiology

Criteria for a STEMI?

Symptoms consistent with ACS (generally >20mins) with persistent (>20 mins) ECG features in 2 or more contiguous leads of:

• 2.5mm ST elevation leads V2-3 men under 40 or 2mm ST elevation leads V2-3 men over 40

• 1.5mm ST elevation V2-3 in women

• 1mm ST elevation in other leads

• New LBBB

Initial treatment of STEMI? Duration of anticoagulation?

Aspirin 300mg

PCI within 120 mins if presented within 12 hours of symptom onset or if after 12 hours but still ongoing evidence of ischaemia

Going for PCI and not already anticoagulated = prasugrel

Going for PCI and already anticoagulated = clopidogrel

No PCI = ticagrelor (clopidogrel if high bleeding risk)

Aspirin lifelong, 2nd agent for 12 months

Anticoagulation during PCI?

Radial access – Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor

Femoral access – bivalirudin with bailout GPI

STEMI presented within 12 hours but no access to PCI within 120 mins - what treatment would be given? What needs to be given with this?

Fibrinolysis - if ST elevation not fixed 60-90 mins later, consider PCI

Give fondaparinux

Complications of MI? Signs of LV free wall rupture? Following MI, acute heart failure and pansystolic murmur? Following MI, persistent ST elevation with fatigue. Signs of papillary muscle rupture? Which MI can cause AV block?

1. DREAD - Death, Rupture of papillary muscles, heart failure, Arrhythmia, Aneurysm, Dressler’s syndrome

2. Anterior MI. 10 days later - low BP, raised JVP, muffled heart sounds, crackles, low O2

3. VSD

4. LV aneurysm

5. Dyspnoea, orthopnoea, hypotension, raised JVP, new pansystolic murmur

6. Inferior MI

Management of NSTEMI/unstable angina? Timelines for coronary angiography? What would you give if having PCI?

Aspirin 300mg 

Fondaparinux if no immediate coronary angiography 

If immediate coronary angiography or creatinine >265 - give unfractionated heparin

Coronary angiography (with follow-on PCI if necessary):

• Immediate – clinically unstable

• Within 72hrs if GRACE >3%

• Consider if experience ischaemia subsequently after admission

If having PCI – give unfractionated heparin (regardless of fondaparinux)

Prior to PCI - further antiplatelet prasugrel or ticagrelor (clopidogrel if taking oral anticoagulant)

No PCI – ticagrelor or clopidogrel if high bleeding risk

ACS secondary prevention?

• ACE inhibitor

• Beta blocker

• Statin - primary prevention 20mg, secondary prevention 80mg

• Aspirin 75mg

• STEMI/NSTEMI - anticoagulated for 12 months

ACE inhibitor - U&Es checked in 1-2 weeks, what rise is acceptable?

Rise in creatinine up to 30% from baseline acceptable

Rise in potassium up to 5.5 acceptable

Management of angina? How to reduce nitrate tolerance?

Aspirin and statin

Sublingual GTN

1st line - BB or CCB (verapamil or diltiazem)

If combo, then amlodipine, nifedipine

Poor response to initial treatment – increase to max dose before adding other stuff

On monotherapy and symptomatic and can’t tolerate the other = long-acting nitrate, ivabradine, nicorandil, ranolazine

BB and CCB – only add 3^rd drug if awaiting PCI/CABG assessment

If taking standard release isosorbide mononitrate – asymmetric dosing interval to maintain 10-14 hours nitrate-free time – reduce chances of tolerance

What is persistent AF? When would you rhythm control first?

Persistent AF = greater than 7 days

Rate control unless coexistent heart failure, first onset AF (less than 48 hours), obvious reversible cause

How do you rate control in AF?

1st line - BB or diltiazem

If still uncontrolled, any 2 of:

Beta blocker, diltiazem, digoxin

AF - how do you rhythm control in less than 48 hours onset?

Give heparin

Electrical - DC cardioversion or

Pharmacological - flecainide or amiodarone if structural heart disease 

No need for further anticoag

AF - how do you rhythm control in more than 48 hours onset?

Anticoagulate for at least 3 weeks first (or do TOE – if no left atrial appendage thrombus can give heparin and cardiovert immediately)

Electrical instead of pharmacological

High risk of cardioversion failure – 4 weeks amiodarone or sotalol first

Anticoagulated for 4 weeks following cardioversion. After this, consider individual risk.

Components of CHA2DS2-VASc? When would you anticoagulate? How would you assess bleeding risk?

Congestive heart failure - 1

HTN - 1

Age >75 - 2

Age 65-74 - 1

Diabetes - 1

Stroke/TIA - 2

Vascular disease - 1

Sex female - 1

0 = no treatment

1 = consider anticoagulation only in males

2 or more = consider anticoagulation

Assess bleeding risk with ORBIT

AF and which condition is an absolute indication for anticoagulation?

AF + valvular disease

Choices of anticoagulation after TIA/stroke? When would you start it?

Warfarin or direct thrombin inhibitor (dabigatran) or factor Xa inhibitor (apixaban, rivaroxaban)

After TIA - anticoagulated ASAP after excluding haemorrhage

After stroke – anticoagulated after 2 weeks (antiplatelet in meantime)

Heart failure - when would you refer for specialist assessment?

NT-proBNP – high = specialist assessment +TTE within 2 weeks.

Raised = specialist assessment +TTE within 6 weeks

Management of heart failure - 1st, 2nd, 3rd line?

1^st line – ace inhibitor AND beta blocker – start one at a time (no effect on mortality in HF with pEF)

2^nd line – aldosterone antagonist, SGLT2- inhibitor

3^rd line – ivabradine (heart rate has to be 75), sacubitril-valsartan (for those symptomatic on ACEi/ARBs – start after washout period), hydralazine + nitrate, digoxin (strongly indicated if also have AF)

Heart failure vaccines? When would you give ICD?

Annual influenza and one-off pneumococcal (booster 5 years if asplenic, CKD)

Cardiac resynchronisation therapy – for those with HF (LVEF<35%) and wide QRS (>120) and persistent symptoms despite medical therapy - ICD

Pericarditis causes? ECG changes? Cause of elevated troponin? Management?

Causes – viral (coxsackie), TB, post-MI (early – fibrinous, late – autoimmune/Dressler’s), connective tissue disease, malignancy

PR depression, saddle-shaped ST elevation

Need to have TTE

May have elevated trop – myopericarditis

Athletes should avoid strenuous exercise for a least 3 months until symptoms resolved and investigations have normalised

Acute idiopathic or viral – NSAIDs and colchicine

ECG territories?

ECG changes in 1) STEMI, 2) NSTEMI, 3) posterior MI, 4) pericarditis, 5) Dressler’s syndrome?

1) STEMI - ST elevation, Q waves

2) NSTEMI - ST depression, T wave inversion 

3) Posterior MI - V1-3 horizontal ST depression, tall broad R waves, upright T waves, dominant R wave V2

4) Pericarditis - saddle-shaped widespread ST elevation, PR depression

5) Dressler’s syndrome - ST elevation and PR depression with reciprocal ST depression and PR elevation in aVR

ECG changes in 1) AF, 2) atrial flutter, 3) 1st degree block, 4) 2nd degree Mobitz I block (Wenkebach), 5) 2nd degree Mobitz II block, 6) 3rd degree block?

1. AF – irregularly irregular, absent P waves

2. Atrial flutter - >300bpm, regular, sawtooth waves

3. 1^st degree block – PR interval prolonged

4. 2^nd degree Mobitz I block (Wenkebach) – PR gets longer until QRS dropped

5. 2^nd degree Mobitz II block – steady PR but blocked QRS

6. 3^rd degree block– complete block

ECG changes in 1) LBBB, 2) RBBB, 3) pulmonary HTN, 4) normal axis deviation, 5) L axis deviation, 6) R axis deviation?

1. LBBB – WiLLiaM – deep S V1, broad R V6

2. RBBB – MaRRoW

3. Pulmonary HTN – Peaked P waves, R axis deviation, RVH, RBBB

4. Normal axis deviation – I positive, II most positive, III tiny bit positive

5. Left axis deviation – lead III negative (only significant if lead II negative)

6. Right axis deviation – lead I negative and lead III positive

ECG changes in 1) digoxin, 2) hypokalaemia, 3) hypothermia, 4) hypercalcaemia?

1. Digoxin – down-sloping ST depression

2. Hypokalaemia – U waves, small/absent T waves, ST depression, long QT, long PR

3. Hypothermia – J wave – small hump at end of QRS, bradycardia

4. Hypercalcaemia – short QT

ECG normal variants in athlete?

Sinus brady, junctional rhythm, 1^st degree heart block, Mobitz I (wenkebach)

Aortic stenosis causes? Murmur/heart sounds? Signs?

Causes – degenerative calcification, BAV, William’s syndrome, post-rheumatic disease, HOCM

Ejection-systolic crescendo-decrescendo

Narrow pulse pressure

Soft/absent S2

S4 gallop due to LVH

Pulsus tardus – slow rising carotid

Pulsus parvus – decreased pulse amplitude

Aortic regurgitation causes? Murmur/heart sounds? Signs?

Causes – rheumatic fever, connective tissue disease, BAV, IE, aortic dissection

Early diastolic decrescendo

Wide pulse pressure

Collapsing water hammer pulse

Quincke’s sign – pulsation in nail beds

de Musset’s sign – head nodding with each beat

Pistol shot femoral – sharp bang on auscultation

Mitral stenosis causes? Murmur/heart sounds? Signs?

Causes – Mainly rheumatic fever

Can get haemoptysis

Late diastolic decrescendo crescendo

Loud S1

“a” wave in jugular venous pulsations – pulmonary HTN and RVH

Mitral regurgitation causes? Murmur/heart sounds? Signs?

Causes – post-MI, mitral valve prolapse, IE, rheumatic fever

Pansystolic

Soft S1, prominent S3 in CCF

Tricuspid regurg murmur? Pulmonary stenosis murmur? ASD murmur? PDA murmur?

TR - pansystolic, split S2

PS - ejection-systolic, widely split S2

ASD - fixed split S2

PDA - machinery murmur, bounding pulse

LBBB murmur? RBBB murmur? HCM murmur? RCM murmur?

LBBB - reverse split S2

RBBB - widely split S2

HCM - ejection systolic murmur LLSE, thrill at LLSE, S4

RCM - increased JVP, S3, S4

S1? S2? S3? S4?

S1 – closure of mitral and tricuspid. Soft in MR, loud in MS.

S2 – closure of aortic and pulmonary. Soft in AS.

S3 – normal in under 30. Heard in LVF, constrictive pericarditis, MR.

S4 – AS, HOCM, HTN.

Examples of narrow-complex tachys? WPW ECG changes? Type A vs type B? Management?

Sinus tachy

AF

Atrial flutter

SVT (p waves hidden) - AVNRT, AVRT, atrial tachycardia

AVRT - WPW - type A is L sided pathway (dominant R wave V1) and type B R sided pathway (no dominant R wave V1)

ECG WPW - short PR, wide QRS, delta wave

Management - sotalol (not in AF), amiodarone, flecainide

Definite - radiofrequency ablation

Management of narrow complex tachys? Half life of adenosine?

Shocked = synchronised DC cardioversion

Not shocked = Vagal manoeuvres → adenosine 6mg → adenosine 12mg → adenosine 18mg → verapamil/BB → DC cardioversion (avoid adenosine in asthmatics)

Adenosine half-life 8-10 seconds

Definitive treatment = radiofrequency ablation

Management of broad complex tachys?

Adverse effects = DC cardioversion

No adverse effects = amiodarone

Adult ALS? Half life of amiodarone?

Shockable = VF / pulseless VT

Non-shockable = asystole / PEA

Compressions to ventilation is 30:2

Defib = 1 shock then 2 mins CPR / monitored patients is 3 shocks

Drug delivery = IV to IO

Non-shockable

-          Adrenaline 1mg ASAP

-          Repeat every 3-5 minutes

Shockable

-          After 3 shocks, 300mg amiodarone (half-life 20-100 days)

-          1 min after CPR restarted after shock 3 = adrenaline

-          Further 150mg amiodarone after 5 shocks

-          Alternative to amiodarone – lidocaine

PE suspected – thrombolytic drugs and continue CPR for extended period of 60-90mins

Management of bradycardia?

Atropine 500mcg IV – up to max 3mg → transcutaneous pacing → isoprenaline/adrenaline infusion → transvenous pacing

Cardiac tamponade triad? Signs?

Beck’s triad = raised JVP, low BP, muffled heart sounds

Kussmaul’s sign = raised JVP and neck vein distention on inspiration

Pulsus paradoxus = exaggeration in variation in pulse pressure in inspiration, causing drop in systolic BP

Infective endocarditis - valve most commonly affected? Most common causative organisms? Treatment?

In normal valves, mitral valve most commonly affected

S. aureus = IVDU, diabetes, surgery – tricuspid valve

S. epidermidis if <2months post-valve surgery

S. viridans = dental

Strep bovis = colorectal cancer

Abx – 4 weeks native valve, 6 weeks prosthetic valve

MRSA – IV vanc and rifampicin or IV vanc and rifampicin and gentamicin if prosthetic heart valve

Aortic dissection - classifications? Investigations and findings? Management? Complications of backward and forward tear?

Tear in tunica intima

Stanford classification:

• Type A - ascending aorta - control BP (IV labetalol) + surgery

• Type B - descending aorta - control BP (IV labetalol)

DeBakey classification:

• Type I – originates in ascending can go distal, type II – originates and confined to ascending, type III – originates in descending, extends distal

Investigations:

• CXR – widened mediastinum

• CT angiography CAP – false lumen key finding

• TOE if too unstable for CT

Complications backward tear – inferior MI, aortic incompetence/regurg

Complications forward tear – unequal arm pulses/BP, stroke, renal failure

Hypertrophic Obstructive Cardiomyopathy - inheritance pattern? ECHO findings? Management? What med would you avoid?

Leading cause sudden cardiac death young athletes

Autosomal dominant. Mutation in gene encoding Beta-myosin heavy chain protein

Echo findings – MR SAM ASH – mitral regurg, systolic anterior motion of anterior mitral valve leaflet, asymmetric hypertrophy

ABCDE – amiodarone, BBs/verapamil. Cardioverter defib, dual chamber pacemaker, endocarditis prophylaxis

Avoid ACEi

Arrhythmogenic right ventricular cardiomyopathy - inheritance pattern, ECG finding, management? What is Naxos disease?

2^nd most common cause of sudden cardiac death in young after HCM

Autosomal dominant

Epsilon wave in 50% - terminal notch in QRS

Sotalol, catheter ablation to prevent VT, implantable cardioverter-defib

Naxos disease – autosomal recessive variant – ARVC, palmoplantar keratosis, woolly hair

What is dilated cardiomyopathy? What is restrictive cardiomyopathy? Acquired cardiomyopathies?

Dilated cardiomyopathy

• Most common form of cardiomyopathy 

• Alcohol, coxsackie B

• S3, systolic murmur, ‘balloon’ appearance of heart on CXR

Restrictive cardiomyopathy

• Amyloidosis, post-radiotherapy 

Acquired cardiomyopathies

• Peripartum

• Takotsubo - stress-induced 

Warfarin and high INR management? INR targets?

INR 5-8, no bleeding – omit 1-2 doses, reduce subsequent dose

INR 5-8, minor bleeding – stop warfarin, IV vit K 1-3mg. Restart when <5

INR >8, no bleeding – stop warfarin, 1-5mg vit K oral. Rpt if high after 24hrs. Restart when <5.

INR >8, minor bleeding – stop warfarin, give IV vit K 1-3mg. Rpt if high after 24hrs. Restart when <5.

Major bleeding – stop warfarin, IV vit K 5mg and prothrombin complex concentrate – if not available then FFP.

INR targets:

Mechanical aortic valve – 3

Mechanical mitral valve – 3.5

VTE – 2.5 / Recurrent VTE – 3.5

AF – 2.5

Rheumatic fever organism? Criteria? Signs? Treatment?

S. pyogenes

Jones criteria

Erythema marginatum, polyarthritis, carditis (endo mainly), subcutaneous nodules

Treatment – pen V, NSAIDs, aspirin

What is non-pulsatile JVP a sign of? What is Kussmaul’s sign and when is it seen?

Non-pulsatile – SVC obstruction

Paradoxical rise in JVP during inspiration – Kussmaul’s sign – constrictive pericarditis

HTN in afro-Caribbean with T2DM - 1st line?

A2RB

Management of acquired QT?

IV isoprenaline (CI in congenital)

What is a capture beat?

Normal QRS complex in between VT complexes

Hypokalaemia precipitates ____ toxicity? Symptom?

Digoxin toxicity

Green/yellow tinge to vision

Brugada syndrome - inheritance pattern, ECG changes? Investigation?

Sudden cardiac death, autosomal dominant

Convex ST elevation in V1-3 followed by negative T wave, partial RBBB

ECG changes more apparent after giving flecainide or ajmaline – Ix of choice

Avoid drugs that can precipitate arrhythmias, implantable device

Buerger’s disease - what is it? Signs?

Small and medium vessel vasculitis, strongly associated with smoking

Extremity ischaemia, superficial thrombophlebitis, Raynaud’s

Takayasu’s arteritis - what is it? Signs/symptoms? Investigation? Management?

Large vessel vasculitis – occlusion of aorta

Systemic features vasculitis, unequal BP upper limbs, carotid bruit, absent/weak peripheral pulses, limb claudication on exertion, AR

MRA or CTA

Management – steroids

Management of Torsades de Pointes? What can cause this?

IV magnesium sulphate

Macrolides

Driving advice for 1) elective angioplasty, 2) CABG, 3) ACS, 4) angina, 5) Pacemaker insertion, 6) ICD for sustained arrhythmia, 7) ICD prophylactically, 8) AAA 6.5cm, 9) heart transplant?

1. Elective angioplasty – 1 week off

2. CABG – 4 weeks off

3. ACS – 4 weeks off (1 weeks if successfully treated by angioplasty)

4. Angina – no driving if symptoms occur at rest/wheel

5. Pacemaker insertion – 1 week off

6. ICD for sustained arrhythmia – off for 6 months

7. ICD prophylactically – off for 1 month

8. AAA of 6.5cm – no driving

9. Heart transplant – off for 6 weeks

Which electrolyte abnormalities can cause long QT syndrome? Which med would you avoid in long QT?

Hypokalaemia, hypocalcaemia, hypomagnesemia

Avoid macrolides

Adrenaline dose for cardiac arrest vs anaphylaxis?

Cardiac arrest = 1mg – 10ml 1:10,000 or 1ml 1:1,000

Anaphylaxis = 0.5mg – 0.5ml 1:1,000

What med is CI in people with renovascular disease?

ACE inhibitors

Difference in diastolic murmur in AR vs MS?

AR = early diastolic murmur

MS = Mid-diastolic murmur