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Cardio Flashcards

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1
Q

Really generally why does aortic regurg occur?

A

Disease of the aortic valve or distortion/dilation of the aortic root and ascending aorta

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2
Q

What are the causes of aortic regurgitation?

A

Chronic - valve disease:
- rheumatic fever
- calcific valve disease
- connective tissue disease
- bicuspid aortic valve

Chronic - aortic root:
- bicuspid aortic valve
- spondyloathropathies
- hypertension
- syphilis
- marfans, ehler danlos

Acute - valve
- infective endocarditis

Acute aortic root
- aortic dissection

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3
Q

Features of aortic regurgitation

A
  • early diastolic murmur
  • collapsing pulse
  • wide pulse pressure
  • quincke’s sign (nailbed pulsation)
  • De musset’s sign (head bobbing)
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4
Q

Quincke’s sign

A

Nail bed pulsation

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5
Q

De musset’s sign

A

Head bobbing

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6
Q

Investigation aortic regurgitation

A

echocardiography

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7
Q

What are the indications for valve replacement in patients with AR

A
  • symptomatic AR
  • asymptomatic AR with LV systolic dysfunction
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8
Q

Symptoms aortic stenosis

A
  • chest pain
  • dyspnoea
  • syncope/presyncope
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9
Q

Murmur aortic stenosis

A

Ejection systolic murmur, radiating to the carotids

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10
Q

Features of aortic stenosis

A
  • narrow pulse pressure
  • slow rising pulse
  • soft/absent S2
  • S4
  • thrill
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11
Q

What are the causes of aortic stenosis

A
  • degnerative calcificaiton
  • bicuspid aortic valve
  • willilams syndrome
  • post rheumatic disease
  • HOCM
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12
Q

Management of aortic stenosis

A
  • asymptomatic then observe
  • symptomatic then valve replacement
  • asymptomatic but valvular gradient >40mmHg and features such as left ventricular systolic dysfunction then consider surgery
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13
Q

What are the options for aortic stenosis surgery?

A
  • surgical aortic valve replacement (low/med risk pts)
  • transcatheter AVR (high risk patients)
  • balloon valvuloplasty: children with no aortic valve calcification, critical aortic stenosis but not fit for valve replacement
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14
Q

Mitral valve regurgitation risk factors

A
  • female
  • lower body mass
  • age
  • renal dysfunction
  • prior MI
  • prior mitral stenosis or valve prolapse
  • collagen disorders
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15
Q

What are the causes of mitral regurgitation

A
  • Post MI/coronary artery disease: papillary muscles or chordae tendinae affected
  • mitral valve prolaspe: leaflet of valve deformed
  • infective endocarditis: vegetations stop valve closing properly
  • rheumatic fever (inflamed valve)
  • congenital
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16
Q

Features of mitral regurgitation

A
  • pansystolic murmur
  • apex, radiates to the axilla
  • S1 may be quiet, in severe cases may have widely split S2
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17
Q

Management of mitral regurgitation

A
  • medical management: nitrates, diuretics, positive inotropes, intra-aortic balloon pump to increase output
  • if in heart failure: ACEi, beta blockers, spironolactone
  • acute severe regurg: surgery
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18
Q

Narrow QRS tachycardia management (stable)

A
  • vagal manoeuvres
  • adenosine 6mg rapid IV bolus, then 12, then 18
  • if ineffective then verampamil or beta blocker
  • if ineffective then synchronised DC shock up to 3 times
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19
Q

Broad complex tachycardia stable management

A
  • amiodarone 300mg IV over 10-60 minutes
  • if ineffective then synchronised DC shock up to 3 times
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20
Q

What are the causes of mitral stenosis?

A

Rheumatic fever

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21
Q

Features of mitral stenosis

A
  • dyspnoea
  • haemoptysis
  • mid-late diastolic murmur
  • loud S1
  • opening snap
  • low volume pulse
  • malar flush
  • atrial fibrillation
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22
Q

What is the management of mitral stenosis?

A
  • if they have associated AF then anti-coagulate with warfarin
  • asymtpomatic: regular echo
  • symptomatic: percutaneous mitral balloon valvotomy or mitral valve surgery
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23
Q

What are the causes of ejection systolic murmur?

A

Louder on expiration:
- aortic stenosis
- hypertrophic obstrucive cardiomyopathy

Louder on inspiration
- pulmonary stenosis
- atrial septal defect

  • teratology of fallot
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24
Q

What are the causes of a holosystolic (pansystolic murmur)

A
  • mitral/tricuspid regurgitation
  • ventricular septal defect
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25
Early diastolic murmur
- aortic regurgitation - graham- steel murmur
26
Mid-late diastolic murmur
- mitral stenosis
27
Coronary artery anterior STEMI
Left anterior descending
28
Coronary artery inferior STEMI
Right coronary
29
Coronary artery lateral STEMI
Left circumflex
30
Initial drug therapy in ACS
- aspirin 300mg - oxygen if SATs<94% - morphine if severe pain - nitrates (caution if hypotensive)
31
What is the STEMI criteria?
- clinical symptoms consistent with ACS for ≥20 minutes with persistent ECG features in ≥2 continguous leads of: - 2.5mm ST elevation in leads V2-3 in men under 40 or ≥2mm elevation in men over 40 - 1.5mm ST elevation in V2-3 in women - 1mm ST elevation in other leads - new LBBB
32
In a confirmed STEMI, when should PCI be offered?
- if the presentation is within 12 hours of symptom onset and PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given - in a patient who has received fibrinolysis whose ECG fails to show resolution of the ST elevation
33
What kind of stent for PCI
Drug eluting
34
Access for PCI
Radial is preferred to femoral
35
When should a patient be offered fibrinolysis?
- should be offered within 12 hours of symptom onset if primary PCI cant be delivered within 120 minutes of the time fibrinolysis could have been given
36
Further antiplatelet prior to PCI
- aspirin + - prasugrel if not taking an oral anticoagulant - if taking an oral anticoagulant then clopidogrel
37
What should patients undergoing fibrinolysis be given
Antithrombin drug
38
Coronary artery anterolateral stemi
Left coronary artery
39
What are the types of myocardial infarction?
- Type 1: traditional MI due to ACS - Type 2: increased demand or reduced supply of oxygen - Type 3: sudden cardiac death or cardiac arrest suggestive of an ischaemic event - Type 4: MI associated with PCI, coronary stenting and CABG
40
Secondary prevention for ACS
- aspirin 75mg once daily - another antiplatelet (ticagrelor or clopidogrel) for 12 months - atorvastatin - ace inhibitor - atenolol - aldosterone antagonist
41
Management of NSTEMI
- GRACE score to decide on PCI or angiography - Aspirin 300mg stat dose - Ticagrelor 180mg - Morphine - antithrombin (fondaparinux) - Nitrate (GTN) Oxygen if sats less than 94
42
Which patients with NSTEMI or unstable angina should have coronary angiography
- immediate: if clinically unstable (hypotensive) - within 72 hours: patients with a GRACE score of >3%
43
Killlip class 1
No clinical signs of heart failure
44
Killip class 2
Lung crackles, S3
45
Killip class 3
Frank pulmonary oedema
46
Killip class 4
Cardiogenic shock
47
What are the poor prognostic factors following ACS
- age - development or history of heart failure - peripheral vascular disease - reduced systolic blood pressure - killip class - initial serum creatinine concentration - elevated initial cardiac markers - cardiac arrest on admission - ST segment deviation
48
What is acute pericarditis?
inflammation of the pericardial sac, lasting less than 4-6 weeks
49
Causes of acute pericarditis
- viral infection - tuberculosis - uraemia - post myocardial infarct - radiotherapy - connective tissue disease - hypothyroidism - malignancy (lung cancer, breast cancer) - trauma
50
Features of acute pericarditis
- chest pain: pleuritic, relieved by sitting forwards - non productive cough - dyspnoea - flu like symptoms - pericardial rub
51
ECG pericarditis
- widespread ECG changes - saddle shaped ST elevation - PR depression (most specific ECG marker)
52
Investigation for suspected pericarditis
- ECG - Transthoracic echo - bloods: inflammatory markers, troponin
53
Management of pericarditis
- majority outpatient - if fever >38 or elevated troponin then inpatient - treat any underlying cuase - advise avoiding any stenuous physical activity until symptom resolution and normalisation of inflammatory markers - NSAID and colchinine if acute idiopathic or viral pericarditis until symptom resolution and normalisaton of inflammatory markers
54
Medical management of angina
- Aspirin - statin - beta blocker or calcium channel blocker (if remains symptomatic add the other but never verapamil and beta blocker due to risk of complete heart block)
55
What do NICE adivse regarding nitrate tolerance
If experiencing tolerance then use asymmetric dosing regime to maintain a daily nitrate free time of 10-14 hours
56
TIA antiplatelets
- clopidogrel lifelong
57
Associations of aortic dissection
- hypertension - trauma - bicuspid aortic valve - marfans/ehlers-danlos - turners/noonans - pregnancy - syphilis
58
Features of aortic dissection
- chest/back pain typically maximal at onset - pulse deficit (weak or absent, or difference in BP >20mmHg systolic between the arms) - aortic regurg - hypertension
59
What are the classifications of aortic dissection?
- type A: ascending aorta, 2/3 of cases - Type B: descending aorta, distal to the left subclavian origin
60
Investigation for aortic dissection
- Chest X ray shows widened mediastinum - CT angiography of the chest abdomen and pelvis (investigation of choice) : false lumen= key finding - Transoesophageal echocardiography if unstable
61
Management of type A dissection
- surgical - BP target 100-120 systolic
62
Management of a type B dissection
- conservative management - bed rest - reduce the blood pressure with IV labetalol to prevent progression
63
How to assess features of a murmur
- site - character - radiation - intensity / grade - pitch - timing
64
Murmur grades
- Grade I: difficult to hear - Grade II: quiet - Grade III: Easy to hear - Grade IV: easy to hear with a palpable thrill - Grade V: audible with a stethoscope barely touching the chest - Grade VI: audible with stethoscope off the chest
65
What are the three major complications for mechanical heart valves?
- thrombus formation - infective endocarditis - haemolysis causing anaemia
66
CHADSVASC
- congestive heart failure - hypertension - Age ≥75 (2), 65-74 (1) - Diabetes - Stroke or TIA - Vascular disease - Sex - woman
67
Anticoagulation for cardioversion in AF
- if onset is less than 48 hours then heparin - if greater than 48 hours then anticoagulate for at least 3 weeks
68
Chemical cardioversion
- amiodarone - flecainide if no structural heart disease
69
Which patients should get rhythm control for AF?
- reversible cause of AF - new onset AF (within 48 hours) - heart failure caused by AF - symptoms ongoing despite rate control
70
Immediate cardioversion for AF
- AF present for less than 48 hours - life threatening haemodynamic instability
71
Cardioversion choice when delayed cardioversion
Electrical is recommended
72
Score for risk of bleeding in AF for those on anticoagulation
ORBIT O- older age (75+) R- renal impairment (GFR<60) B- Bleeding previously I- Iron T- taking antiplatelet medication
73
First degree heart block
PR interval >0.2 seconds
74
Second Degree heart block
- Mobitz type 1: progressive prolongation of the PR interval until a dropped beat occurs - Type 2: PR interval is constant but P wave is often not followed by a QRS complex
75
Third degree heart block
No association between P and QRS waves
76
What can raise levels of BNP?
- heart failure - myocardial ischaemia - valvular disease - chronic kidney disease
77
What are the side effects of beta blockers?
- bronchospasm - cold peripheries - fatigue - sleep disturbance, including nightmares - erectile dysfunctions
78
What are the contraindications to beta blockers?
- uncontrolled heart failure - asthma - sick sinus syndrome - concurrent verapamil use: may precipitate severe bradycardia
79
Buergers disease features
- Extremity ischaemia - superficial thrombophlebitis - raynauds
80
Becks triad
Cardiac tamponade - hypotension - raissed JVP - muffled heart sounds
81
What are the features of cardiac tamponade?
- beck's triad - dyspnoea - tachycardia - absent y on JVP - pulsus paradoxus (abnormally large drop in BP during inspiration) - ECG: electrical alternans
82
What is the management of cardiac tamponade?
Urgent pericardiocentesis
83
What decreases BNP levels?
- obesity - diuretics - ACEi - Beta blockers - ARBs - aldosterone antagonists
84
NYHA class 1
- no symptoms - no limitations: ordianry physical exercise does not cause undue fatigue, dyspnoea, or palpitations
85
NYHA class 2
- mild symptoms - slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue/dyspnoea
86
NYHA class III
- moderate symptoms - marked limitation of physical activity, comfortable at rest
87
NYHA class IV
- severe symptoms - unable to carry out any physical activity without discomfort - symptoms at rest
88
What is the mechanism of clopidogrel?
Antagonist of P2Y12 adenosine diphosphate ADP receptor, inhibiting the activation of platelets
89
Features of coarctation of the aorta
- infancy: heart failure - adult: hypertension - radio-femoral delay - mid systolic murmur, maximal over the back - apical click from the aortic valve - notching of the inferior border of the ribs (not seen in young children)
90
Features of complete heart block
- syncope - heart failure - bradycardia - wide pulse pressure - JVP: cannon waves in S1
91
Features of constrictive pericarditis
- dyspnoea - right heart failure - JVP shows prominent x and y descent - pericardial knock: loud s3 - kussmauls sign is positive
92
What are the causes of dilated cardiomyopathy?
- idiopathic - myocarditis - ischaemic heart disease - peripartum - hypertension - iatrogenic - substance abuse - genetic predisposition - infiltrative e.g. haemochromatosis, sarcoidosis
93
Features of dilated cardiomyopathy
- Heart failure - systolic murmur - S3 - balloon appearance of the heart
94
Management of eisenmenger's syndrome
Heart-lung transplant
95
Which valve is most commonly affected in infective endocarditis?
Mitral valve
96
Most common cause of infective endocarditis
Staphylococcus aureus
97
Infective endocarditis associated with dental procedure
Streptococcus viridans
98
Infective endocarditis following valve surgery
- Staph epidermidis - after 2 months, most likely is staph aureus
99
What is the modified duke criteria?
Infective endocarditis can be diagnosied if pathological criteria positive, or 2 major criteria, or 1 major and 3 minor, or 5 minor criteria
100
Duke pathological criteria
Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery
101
Major criteria duke
Blood cultures: - two positive blood cultures showing typical organisms - persistent bacteraemia from two blood cultures taken >12 hours apart or three or more if the pathogen is less specific e.g. staph aurues - positive serology for coxiella, bartonella, chalmydia psittaci - positive molecular assays for specific gene targets Evidence of endocardial involvement - positive echocardiogram - new valvular regurgitation
102
Minor criteria duke
- predisposing heart condition or IVDU - microbiological evidence not meeting major criteria - fever >38 - vascular: major emboli, splenomegaly, clubbing, splinter haemorrhage, janeway lesion, petechia or purpura - immunological: glomerulonephritis, osler nodes, roth spots
103
Vascular phenomena infective endocarditis
major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions (non-tender) , petechiae or purpura
104
Immunological phenomena infective endocarditis
glomerulonephritis, Osler's nodes (tender), Roth spots
105
Initial therapy for infective endocarditis
- amoxicillin if native valve - if penicillin allergic, MRSA or severe sepsis then vancomycin and gent - if prosthetic valve: vancomycin+rifampicin + low dose gent
106
What are the indications for surgery for infective endocarditis
- severe valvular incompetence - aortic abscess - infections resistant to antibiotics/fungal infections - cardiac failure refractory to standard medical treatment - recurrent emboli after antibiotic therapy
107
What are the post MI complications?
- cardiac arrest due to VF - cardiogenic shock - chronic heart failure - tachyarrhythmia, VF/VT - bradyarrhythmia (AV block: more common if inferior MI) - pericarditis: in 1st 48 hours - dresslers: 2-6 weeks post MI , fever, pleuritic pain, pericardial effusion and raised ESR - LV aneurysm: persistent ST elevation and left ventricular failure - Left ventricular free wall rupture (1-2 weeks after) - ventricular septal defect - acute mitral regurgitation
108
How long after MI left ventricular free wall rupture
1-2 weeks
109
Presentation of left ventricular free wall rupture
Acute heart failure secondary to cardiac tamponade: - raised JVP - pulsus paradoxus - diminished heart sounds
110
Presentation of dressler's syndrome
- fever - pleuritic pain - pericardial effusion - raised ESR - 2-6 weeks post MI
111
Presentation of acute mitral regurg post MI
- acute hypotension - pulmonary oedema
112
Features of takayasu arteritis
- systemic features of vasculitis - unequal blood pressure in the upper limbs - carotid bruit and tenderness - absent or weak peripheral pulses - upper and lower limb claudication on exertion - aortic regurg
113
Management of takayasu's arteritis
Steroid
114
Features of takotsubo cardiomyopathy
- chest pain - features of heart failure - ECG: st elevation - normal angiogram
115
Management of takotsubo cardiomyopathy
Majority improve with supportive treatment
116
What is the management of tosades de pointes?
IV magnesium sulphate
117
Causes of a long QT interval
- congenital - antiarrhythmics - tricyclics - antipsychotics - chloroquine - erythromycin - hypothermia - subarachnoid haemorrhage - hypocalcaemia, hypokalaemia, hypomagnesaemia
118
ECG features wolff parkinson white
- short PR interval - wide QRS with slurred upstroke (delta wave) - left axis deviation if right sided accessory pathway
119
When should beta blockers be stopped in heart failure?
- heart rate <50 - second or third degree heart block - shock
120
What is the investigation of choice for suspected aortic dissection?
CT aortic angiogram
121
Warfarin target mechanical aortic valve
3
122
Warfarin target mechanical mitral valve
3.5
123
What is an early sign of LVF?
Gallop rhythm with S3
124
Posterior MI on ECG
tall, broad R waves, ST depression and tall upright T waves
125
Cardiac tamponade on ECG
Electrical alternans (alternating QRS amplitude)
126

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