Cardiology (Antiplatelets and murmurs)

Question 1

antiplatelet drugs

Answer 1

Antiplatelet drugs decrease platelet aggregation and inhibit the formation of thrombi in the arterial circulation.

e.g. arterial clots such as MI

Question 2

anticoagulation

Answer 2

Venous and intracardiac thrombosis driven largely by coagulation cascade and fibrin compared to arterial thrombus - mainly platelet rich

Question 3

Antiplatelets: Acute coronary syndrome (ACS) treated medically

Answer 3

First line Lifelong aspirin + 12 months ticagrelor

Second line If aspirin is contraindicated, give lifelong clopidogrel

Question 4

Antiplatelets: Acute coronary syndrome (ACS) treated with PCI

Answer 4

First line Lifelong aspirin + 12 months prasugrel or ticagrelor

Second line If aspirin is contraindicated, give lifelong clopidogrel

Question 5

Antiplatelets: PAD

Answer 5

First line Lifelong clopidogrel

Second line Aspirin

Question 6

Antiplatelet: ischaemic attack

Answer 6

Start aspirin 300mg daily immediatley

Prevention

First line Lifelong clopidogrel

Second line Aspirin + lifelong modified-release dipyridamole

Question 7

Antiplatelet: Stroke

Answer 7

Start aspirin 300mg daily immediatley for 2 weeks

Prevention

First line Lifelong clopidogrel

Second line Aspirin + lifelong modified-release dipyridamole

Question 8

normal heart sounds are

Answer 8

S1 (first heart sound) and S2 (second heart sound).

I + II + 0

Question 9

S1

Answer 9

the closure of the mitral and triscuspid valve

Question 10

S2

Answer 10

due to the closure of the aortic and pulmonary valves

Question 11

heart murmurs basics

Answer 11

Heart murmurs are additional sounds as a result of turbulent blood flow.

• Ideally, blood flow should be laminar and silent.
• A thrill is a murmur significant enough to be palpable.
• Systolic murmurs are mostly pathological but can be benign in children or pregnant women.
• Diastolic murmurs are always pathological.

Question 12

ejection systolic murmus

Answer 12

• Aortic stenosis (louder on expiration)
• Pulmonary stenosis (louder on inspiration)
• Coarctation of the aorta

Question 13

late systolic murmur

Answer 13

• Coarctation of the aorta – loudest below the left scapula
• Mitral valve prolapse

Question 14

Pansystolic murmur

Answer 14

• Mitral regurgitation (louder on expiration)
• Tricuspid regurgitation (Louder on inspiration)
• Ventricular septal defect – loudest at the left lower sternal border

Question 15

early diastolic murmur

Answer 15

• aortic regurgitation (expiration)
• pulmonary regurgitation
  (inspiration)

Question 16

.

mid-late diastolic murmur

Answer 16

• Mitral stenosis
• Severe aortic regurgitation

Question 17

Continuous machinery murmur in the left upper sternal border:

Answer 17

patent ductus arteriosus

Question 18

Pulsus paradoxus

Answer 18

Pulsus paradoxus describes an abnormally large decrease in systolic blood pressure (>10 mmHg) and a decrease in pulse strength during inspiration. It is seen in cardiac tamponade and severe asthma.

Question 20

Collapsing pulse

Answer 20

Also known as Corrigan’s pulse, a collapsing pulse is a sign of aortic regurgitation characterised by a pulse that is bounding and forceful that rapidly increases then collapses. This is felt by raising the patient’s arm vertically upwards and holding the patient’s forearm. Gravity causes an increased flow of blood to the arm and a resultant collapsing pulse.

Question 21

De Musset’s sign

Answer 21

De Musset’s sign describes rhythmic bobbing of the head in sync with the heart and is a sign of aortic regurgitation. The nodding occurs due to an increase in pulse pressure as a result of aortic insufficiency.

Question 22

Quincke’s sign

Answer 22

Quincke’s sign describes pulsations of the capillaries in the nailbeds that occur with each heart beat. This is a sign of aortic regurgitation.

Question 23

Roth’s spots

Answer 23

These are red spots with white centres seen on the retina due to haemorrhage of retinal capillaries. This is a sign of infective endocarditis.

Question 24

Janeway lesions

Answer 24

Janeway lesions are erythematous, non-tender, macular lesions on the palms and soles of the hands associated with infective endocarditis. They occur due to immune complex deposition.

Question 25

Osler’s nodes

Answer 25

Osler’s nodes are painful, erythematous, and raised lesions on the hands and feet associated with infective endocarditis. They occur due to immune complex deposition.

Question 26

Beck’s triad

Answer 26

This is a sign of cardiac tamponade.

• Hypotension
• Muffled/quiet heart sounds
• Elevated jugular venous pressure

Question 27

Jugular venous pressure

Answer 27

The jugular venous pressure (JVP) is assessed by looking at the jugular vein and can be used to assess cardiorespiratory disorders. It can be difficult to differentiate the JVP from the carotid artery. Some distinguishing features include:

• The JVP is biphasic (‘beats twice’) whereas the carotid artery beats once
• The JVP is non-palpable. If a pulse is felt, it is the carotid artery
• The JVP is occludable. Lightly pressing on it occludes the jugular vein which then fills from above the occlusion.

An elevated JVP suggests venous
congestion (such as heart failure).

Question 28

Parasternal heaves

Answer 28

Heaves are palpable heart impulses felt when the hand is rested just lateral to the left sternal edge. This is a sign of right ventricular hypertrophy.

Question 29

Thrills

Answer 29

Thrills are palpable heart murmurs that are felt over the areas on the chest corresponding to the valves of the heart. They feel like a cat purring under the hand.

Question 30

define syncope

Answer 30

Syncope describes a transient loss of consciousness due to a decrease in blood flow to the brain. This is rapid in onset, lasts for a short period of time (mostly up to around 30 seconds), and people resolve spontaneously and completely recover.

This definition excludes other causes of a loss of consciousness, such as epilepsy, which may last longer and have a post-ictal period and more prolonged recovery.

Question 31

classification of syncope

Answer 31

1. Reflex
2. Orthostatic
3. Cardiac

Question 32

reflex syncope

Answer 32

• Vasovagal
• Situational
• Carotid sinus syncope

Question 33

vasovagal syncope

Answer 33

‘fainting’
* Exposure to blood or unpleasant sight
* Strong emotion
* Pain
* Stress

Question 34

Situational syncope

Answer 34

syncope caused by specific behaviours:
* Coughing
* Urination
* Defecation
* Vomiting
* Swallowing

Question 35

Carotid sinus syncope:

Answer 35

Pressure on the carotid sinus can cause syncope in some individuals

Question 36

Orthostatic syncope

Answer 36

This is syncope that occurs due to an excessive drop in blood pressure when standing up from sitting or lying down. Its causes include:

• Primary autonomic failure: causes include Parkinson’s disease, dementia with Lewy bodies, multiple system atrophy, other Parkinson’s plus syndromes
• Secondary autonomic failure: causes include diabetes mellitus, uraemia, spinal cord injuries, amyloidosis
• Drug-induced orthostatic hypotension: causes include diuretics, vasodilators, alcohol, antidepressants
• Volume depletion: causes include haemorrhage, diarrhoea, vomiting

Question 37

cardiac syncope

Answer 37

Cardiac syncope occurs due to arrhythmia, valvular heart disease, muscular heart disease, or vascular heart disease.

Question 38

cardiac syncope: arrhtmia

Answer 38

Bradycardia:
* Sinus node dysfunction
* Atrioventricular (AV) conduction disorders
* Implanted device malfunction
Tachycardia:
* Supraventricular
* Ventricular

Question 39

cardiac syncope: structural disease

Answer 39

Causes include: valvular disease, myocardial ischaemia/infarction, hypertrophic cardiomyopathy, cardiac masses (e.g. myxomas or other tumours), pericardial disease and cardiac tamponade, congenital heart disease, prosthetic valve dysfunction