Cardiology — 5-min cram sheet

Cardiology — 5-min cram sheet

_Built from the cardio disease index. Deck-faithful._

Buzzword → answer (the vignette reflex)

• Epsilon wave (small notch at end of QRS) → ARVC (pathognomonic; fibro-fatty replacement of RV free wall)
• Delta wave + short PR <120 ms + wide QRS >120 ms → WPW
• Beck's triad + pulsus paradoxus + electrical alternans → cardiac tamponade (pathognomonic combo)
• Widespread saddle-shaped (concave) ST elevation + PR depression, no reciprocal ST depression → acute pericarditis
• Pulsus parvus et tardus (small-volume, slow-rising carotid) → aortic stenosis
• Water-hammer / collapsing pulse + Corrigan's, Quincke's, De Musset's, Duroziez's → aortic regurgitation
• Loud S1 + opening snap + mid-diastolic rumble at apex + malar (mitral) flush → mitral stenosis (almost always rheumatic)
• Tearing/ripping chest pain maximal at onset + "cobweb" sign on TOE (100% specific for false lumen) → aortic dissection
• S1Q3T3 + new RBBB → PE (classic but uncommon)
• Osler's nodes / Janeway lesions / Roth spots / splinter haemorrhages + fever + new murmur → infective endocarditis
• Apical ballooning + unobstructed coronaries, older woman after stress → Tako-tsubo cardiomyopathy
• Voltage-mass mismatch (low ECG voltage + thickened walls) + speckled/ground-glass myocardium → cardiac amyloidosis
• Fibrinoid necrosis of arterioles + flea-bitten kidney + papilloedema → malignant HTN
• Asymmetric septal hypertrophy (ASH) + systolic anterior motion (SAM); murmur ↑ with Valsalva/standing → HCM

Murmur / heart sound → lesion

Criteria / staging / scores at a glance

Diagnostic criteria

• Modified Duke (IE): Major = +blood cultures/histology, echo vegetation. Definite = 2 major, or 1 major + 3 minor, or 5 minor; Possible = 1 major + 1–2 minor, or 3–4 minor.
• 2023 ESC IE: Definite = 2 major, 1 major + ≥3 minor, or 5 minor; Possible = 1 major + 1–2 minor, or 3–4 minor; else Rejected.
• Dutch Lipid Clinic (FH): Definite >8, Probable 6–8, Possible 3–5 (tendinous xanthomata 6 pts, arcus <45 yr 4 pts, LDL-C ≥325 = 8 pts, LDLR/ApoB/PCSK9 mutation 8 pts; one score per group).
• Task Force (ARVC): 5 categories — structural, tissue biopsy, ECG, Holter, family history.

Risk scores

• CHA₂DS₂-VA: C(HF)1, H(HTN)1, A₂(≥75)2, D(diabetes)1, S₂(prior stroke/TIA)2, V(vascular)1, A(65–74)1, Sc(female)1 → ≥2 OAC recommended, =1 consider, =0 none.
• HAS-BLED: 9 components (HTN SBP ≥160, abnormal renal, abnormal liver, stroke, bleeding, labile INR, elderly ≥65, drugs, alcohol) → score 0 ≈1%/yr, ≥3 >5%/yr (high) — modify factors, do NOT withhold OAC.
• ACS risk: GRACE (age, HR, SBP, creatinine, HF, arrest, ST deviation, troponin); HEART (History, EKG, Age, Risk factors, Troponin); TIMI.
• SCORE2 (40–69) / SCORE2-OP (≥70): 10-yr fatal + non-fatal CV events; ≥10% = high, 5–<10% = borderline.
• HCM SCD: ICD if ≥2 of — LVH >30 mm, FHx SCD <50 yr, NSVT, unexplained syncope, abnormal (flat/hypotensive) BP response to exercise; <2 → amiodarone.

Anatomical classifications

• Aortic dissection: Stanford A = ascending (= DeBakey I/II) → surgery; Stanford B = descending only (= DeBakey III) → medical. DeBakey I 60%, II 10–15%, III 25–30%.
• MI universal: Type 1 = plaque rupture + thrombus; Type 2 = supply–demand imbalance (2a vasospasm, 2b fixed atherosclerosis, 2c severe anaemia/hypotension).
• ACS: UA = troponin−, ST depression/T-changes or normal; NSTEMI = troponin+, no ST elevation; STEMI = troponin+ + ST elevation. NSTE-ACS = UA + NSTEMI.
• AF clinical: paroxysmal <7 days, persistent >7 days, longstanding persistent >1 year, permanent (agreed to stop rhythm control).
• Fredrickson: I chylomicrons; IIa LDL (= FH, commonest); IIb LDL+VLDL; III IDL; IV VLDL; V VLDL+chylomicrons.

Severity classifications

• NYHA: I no limitation; II slight (ordinary activity → symptoms); III marked (less-than-ordinary → symptoms); IV symptoms at rest.
• HF by LVEF: HFrEF ≤40%, HFmrEF 41–49%, HFpEF ≥50% (HFpEF/HFmrEF also need raised filling pressures).
• ACC/AHA stages: A at-risk → B pre-HF (structural/biomarker) → C symptomatic → D refractory. Maps: A→none, B→NYHA I, C→NYHA II–IV, D→NYHA IV (structural progression is one-way).
• HTN BP cutoffs: office non-elevated <120/70, elevated 120–139/70–89, HTN ≥140/90; ABPM 24-h ≥130/80, daytime ≥135/85, night ≥120/70; HBPM ≥135/85.
• HTN primary vs secondary: primary 90% (>40 yr, gradual), secondary 10% (<40 yr, abrupt, potentially curable).
• HTN benign vs malignant: benign = hyaline arteriolosclerosis; malignant = hyperplastic arteriolosclerosis ("onion-skinning") + fibrinoid necrosis + papilloedema + MAHA.
• Cardiomyopathies: HCM, DCM, RCM, ARVC, + other (LVNC, Tako-tsubo, peripartum, tachycardia-induced, obliterative/EMF).

ECG criteria

• Chamberlain's 10 rules = normal ECG (PR 120–200 ms, QRS <110 ms, aVR all-negative, R grows V1→V4, etc.).
• LBBB: QRS ≥120 ms, V1–V2 QS/rS, V5–V6/I monophasic R → cannot diagnose MI, ischaemia, enlargement, hemiblock.
• RBBB: QRS ≥120 ms, rsR' "rabbit ears" V1–V2, slurred S in I/V5/V6 → cannot diagnose ischaemia or enlargement (MI still diagnosable).
• LVH: Sokolow-Lyon S V1 + R V5 >35 mm; Cornell S V3 + R aVL >28 mm (♂)/>20 mm (♀); R aVL ≥11 mm.
• RVH: V1 tall R >7 mm or R/S ≥1; deep S in V6; V1–V2 strain.
• WPW: short PR <120 ms, wide QRS >120 ms, delta wave; Type A dominant R V1, Type B dominant S V1; pre-excited AF ~300 bpm.
• HCM ECG: LVH, ST/T changes, abnormal Q waves inferolateral leads.

Surgical / procedural indications

• AS → AVR: all symptomatic severe; asymptomatic if EF <50%, peak velocity >5.5 m/s, PA pressure >60 mmHg, velocity ↑ >0.3 m/s/yr, or exercise symptoms; bicuspid + ascending aorta >50 mm or expanding >5 mm/yr.
• AR → surgery: symptomatic severe; asymptomatic if EF ≤50%, end-diastolic >70 mm or end-systolic >50 mm.
• MR → surgery: symptomatic severe; asymptomatic if end-systolic >40 mm, EF <60%, or AF/pulmonary HTN (stricter than aortic — LV unloads into LA).
• MS → BMV: MVA ≤1.5 cm² + symptoms/PHTN + pliable valve; contraindicated if heavy calcification, more than mild MR, or LA thrombus (TOE mandatory pre-BMV).
• IE → V-HEART: Valve dysfunction→HF, Heart failure, Embolism (recurrent), Abscess (paravalvular), Resistant organism, large vegeTation >10 mm; post-stroke delay surgery 1 month.

ECG fundamentals (numbers worth having)

• Paper: small square 0.04 s (0.1 mV), big square 0.2 s; 25 mm/s; 10 mm = 1 mV.
• Leads → artery: II/III/aVF inferior (RCA); I/aVL high lateral + V5/V6 low lateral (LCx); V1/V2 septal + V3/V4 anterior (LAD).
• Rate: regular = 300 ÷ big squares (or 1500 ÷ small); irregular = QRS in 30 big squares × 10.
• Axis: normal −30 to +90 (I+, III+); LAD −30 to −90 (I+, III−); RAD +90 to +180 (I−, III+); extreme both negative.
• Normal values: PR 120–200 ms; QRS <110–120 ms; QTc prolonged >440 (♂)/>460 ms (♀), >500 = torsades risk.
• Acute ischaemia: new STE ≥1 mm (V2–V3: ≥2 mm ♂≥40, ≥2.5 ♂<40, ≥1.5 ♀) in 2 contiguous leads; STD ≥0.5 mm; ischaemic T inversion symmetrical.
• Pathological Q: >1 mm wide (>0.04 s) AND >2 mm deep, OR >25% of following R, in 2 contiguous leads.
• Atrial enlargement: RAE (P pulmonale) tall peaked P >2.5 mm in II; LAE (P mitrale) broad >3 mm/notched P.
• Low voltage: QRS <5 mm all limb and/or <10 mm all chest leads (sum I+II+III <15 mm); + electrical alternans → tamponade.
• STEMI evolution: hyperacute T (0–6 h) → ST elevation + Q begins 8–12 h → T inversion (24 h–3 wk) → ST normalises, Q persists; persistent ST elevation >3 wk = LV aneurysm.

Discriminators that decide questions

1. UA vs NSTEMI — identical clinically and on ECG (ST depression/T-changes); the troponin is the only feature — negative = UA, positive = NSTEMI.
2. Mobitz I (Wenckebach) vs Mobitz II — Mobitz I = progressive PR lengthening then dropped beat, block at AV node, benign (observe/atropine); Mobitz II = PR fixed with dropped beats + wide QRS, infranodal (His), unreliable escape → permanent pacemaker.
3. HCM vs AS — same angina + syncope + dyspnoea triad, but HCM murmur increases with Valsalva/standing (↓ afterload) while AS decreases; HCM murmur ↓ on squatting.
4. LBBB vs RBBB (what's masked) — LBBB masks MI, ischaemia, ventricular enlargement AND hemiblock; RBBB masks only ischaemia and enlargement — MI is still diagnosable in RBBB. New LBBB + chest pain = treat as STEMI.
5. RCM/amyloid vs constrictive pericarditis — both show Kussmaul's + raised JVP + right-HF picture; constrictive shows thickened/calcified pericardium (egg-shell) on CT/MRI + pericardial knock, and cardiac catheterisation distinguishes them.