Write out the CV exam
…
What causes a waterhammer pulse?
Aortic regurg
When auscultating, what should you comment on?
Can you hear 1st HS, 2nd HS or any added sounds
What causes splinter haemorrhages?
Bacterial endocarditis
What causes these different characters of apex beat?
1) Heaving
2) Thrusting
3) Tapping
4) Diffuse
1) Heaving- aortic stenosis, systemic HTN
2) Thrusting- mitral/aortic incompetance
3) Tapping- mitral stenosis
4) Diffuse- LV failure, dilated cardiomyopathy
What causes these different characters of radial pulse?
1) Bounding
2) Small volume
3) Collapsing
4) Slow rising
5) Bisferien
6) Pulsus alternans (alternating weak and strong)
7) Jerky
8) Pulsus paradoxus
Bounding- CO2 retention, liver failure, sepsis
Small vol.- aortic stenosis, shock, pericardial effusion
Collapsing- aortic incompetence, AV malformation, PDA
Slow rising- aortic stenosis
Bisferien- combined aortic stenosis + regurg
Pulsus alternans- LVF, cardiomyopathy
Jerky- hypertrophic cardiomyopathy
Pulsus paradoxus- severe asthma, cardiac tamponade
What are the symptoms of angina?
Central, crushing retrosternal chest pain
- worse on exertion, cold weather, emotion
- relieved by rest
- may radiate to arms and neck
Dyspnoea
Nausea
Sweatiness
What causes angina?
Ischaemia (mostly due to atheroma)
Which tests should be done on a patient with angina?
ECG
Exercise ECG
What are the differential diagnoses for angina?
Gastro oesophageal reflux
Chest wall pain
What is the management plan for angina?
Risk factors- smoking, obesity, sedentary lifestyle, poor
glycaemic control, HTN
- GIVE ASPIRIN AND STATINS to all patients
Symptoms- beta blockers (1st line)
- long acting calcium antagonist (amlodipine,
diltiazem, nifedipine)
- nitrates (isosorbide mononitrate)
- K+ channel activator (nicorandil)
- Na+ channel blocker (ranolazine)
- inhibitor of pacemaker current (ivabradine)
Acute attack: GTN spray
What are the indications for non-pharmacological treatment of angina?
Angina of sudden onset
Worsening angina (not controlleed by drugs)
Previous MI or CABG
What are the non-pharmacological treatments for angina?
Percutaneous Transluminal Coronary Angioplasty (PCTA) +stenting
CABG
How is unstable angina managed?
Aspirin
Beta blockers
Antithrombotics (fondaparinux, LMWH)
GpIIB/IIIa antagonist (tirofiban)
What does ST depression on an exercise ECG suggest?
Myocardial ischaemia on exertion
What does a sustained fall in BP on an exercise ECG suggest?
Severe coronary artery disease
What are the causes of sinus bradycardia?
EXTRINSIC: drugs (beta blockers, digitalis, antiarrhythmics) Hypothyroidism Hypothermia Cholestatic jaundice Raised ICP
INTRINSIC:
Acute ischaemia (e.g MI)
Fibrosis of atrium and sinus node (sick sinus syndrome)
Neurally mediated e.g. Carotid sinus syndrome and vasovagal attacks
What is the treatment for symptomatic bradycardia?
Treat underlying cause
Permanent cardiac pacemaker
Acute: IV atropine (CI: myasthenia, paralytic ileus) Temporary pacing (transcutaneous/transvenous)
What is sick sinus syndrome?
Bradycardia caused by intermittent failure of sinus node depolarisation/failure of impulse to propagate through atria (sinoatrial block)
What does sick sinus syndrome predispose to?
Ectopic pacemaker activity (tachy-brady syndrome)
Thromboembolism (patients are anticoagulated)
What is the nerve supply of the heart?
Beta 1 receptors
M cholinergic receptors
What does the right coronary artery supply? What are its branches?
SAN and AVN
Right marginal= R. ventricle and R. atrium
Posterior descending= posterior part of interventricular septum
What does the left coronary artery supply?
Interventricular septum
LAD= anterior septum and anterior L. ventricular wall
Left circumflex= L. atrium and ventricle
Which coronary artery usually gives rise to the posterior interventricular (descending) artery?
RCA
Where do the cardiac veins drain into?
The right atrium via the coronary sinus
What are the branches of the aorta?
Brachiocephalic trunk
Subclavian artery
Common carotid artery
Which ECG leads look at:
- Anterior LV
- Septum
- Lateral LV
- Inferior
- Posterior
- Right ventricle
- V1-2
- V3-4
- V5-6, I, aVL
- II, III, aVF
- V1-3
- V1-2
In which lead is the P wave best seen?
V1
What is 1st degree heart block?
Delayed atrioventricular conduction (long PR interval)
What is type 2 heart block?
Mobitz 1 (Wenckebach): Progressive elongation of PR interval until a P wave fails to conduct
Mobitz 2:
Dropped QRS complex not preceded by progressive PR prolongation
2:1:
Every 2nd p wave fails to conduct
3:1:
Every 3rd p wave fails to conduct
What is type 3 heart block?
Complete heart block
No association between P waves and QRS complexes
Ventricular contraction maintained by escape rhythms from:
His bundle–> narrow QRS complex
(May not need permanent pacing)
His-Purkinje system–> broad QRS
(needs permanent pacing)
Which types of heart block are treated with a pacemaker?
Mobitz type 2
Complete heart block with escape rhythm arising from His-Purkinje system
When is it more likely that a second degree AV block will progress to complete heart block?
After acute anterior MI
In Mobitz type 2 block
What does a RBBB look like on ECG?
RSR’ in V1
Slurred S wave in V5+6
MORROW: In V1- M shaped QRS
In V6- W shaped QRS
What does a LBBB look like on ECG?
RSR’ in left ventricular leads (1, AVL, V4-6)
WILLIAM: In V1- W shaped QRS
In V6- M shaped QRS
What is a short PR interval and a delta wave on ECG indicative of?
Wolff-Parkinson-White
What is the treatment of WPW syndrome?
If no structural heart abnormality: flecainide
If pt has heart abnormality: sotalol
What are the types of supraventricular tachycardias?
Sinus tachycardia
Atrial tachycardia
Atrial flutter
Atrial fibrillation
Atrioventricular junctional tachycardias:
-atrioventricular nodal re-entry tachycardia (AVNRT)
-atrioventricular re-entry tachycardia (AVRT)e.g. in WPW
What does the ECG look like in
1) AV nodal re-entry tachycardia
2) atrioventricular re-entry tachycardia
1) P waves not visible/seen immediately before or after QRS Narrow QRS (but may be wide if BBB) 2) Shortened PR interval Delta wave Narrow QRS
What are the symptoms of supraventricular tachycardias?
Palpitations- abrupt onset Dizziness Dyspnoea Central chest pain Syncope Exacerbated by: coffee, tea, exercise, alcohol
What is the acute management of supraventricular tachycardias?
UNSTABLE (circulatory collapse- low BP: -emergency cardioversion HAEMODYNAMICALLY STABLE: -Valsalva manoeuvre -Right carotid sinus massage -Amiodarone -Sotalol (if pt has structural heart problem)
What is the long term treatment of WPW?
Radiofrequency ablation
What is the definition of pulmonary hypertension?
Mean pul. artery pressure >25 mmHg at rest
Secondary right ventricular failure
What are the causes of pulmonary hypertension?
INCREASED PULMONARY BLOOD FLOW/PULMONARY VASCULAR RESISTANCE
- hereditary, idiopathic
- SLE, RA
- ASD,VSD
- portal hypertension
- pulmonary veno-occlusive disease
- cocaine and amphetamines
Secondary to:
- Left heart disease
- COPD
- OSA
- lung fibrosis
What are the clinical features of pulmonary hypertension?
Exertional dyspnoea, lethargy, fatigue RV failure- peripheral oedema, hepatic pain (from congestion) Signs: -Loud pulmonary second sound -Right parasternal heave -Cor pulmonale - Raised JVP
What is cor pulmonale?
Right heart failure secondary to pulmonary disease leading to increased pulmonary vascular resistance.
RHF occurs if pulmonary artery pressure is >40 mmHg
Signs: cyanosis, tachycardia, raised JVP, RV heave, loud P2, pan-systolic murmur (tricuspid regurg), early diastolic Graham-Steell murmur, hepatomegaly, oedema
Hypoxia with/without hypercapnia
Symptoms: Dyspnoea, fatigue, syncope
What can be seen on a CXR that suggests pulmonary hypertension?
Enlarged pulmonary arteries
What is seen on an echo that suggests pulmonary hypertension?
RV hypertrophy
P pulmonale
What is the management of pulmonary hypertension?
Oxygen
Warfarin
Diuretics
Calcium channel blockers
Endothelin receptor antagonists (bosenten, sitaxentam)
Prostanoid analogues (iloprost, sildenafil)
What are the risk factors for a PE?
Surgery Thrombophilia (antiphospholipid syndrome) Leg fracture Prolonged bed rest Malignancy Pregnancy Pill/HRT Previous PE
What are the signs and symptoms of a PE?
Small-medium PE:
SOB, pleuritic chest pain, haemoptysis, tachypnoea, pleural rub, exudative pleural effusion
Massive PE:
severe central chest pain, pale, sweaty, tachypnoea, tachycardia, raised JVP, RV heave, gallop rhythm, wide split S2
Which investigations are done in suspected PE?
ABG- decreased pO2 and pCO2
CXR- decreased markings
CTPA
What are the causes of a raised JVP?
‘PQRST’
Pericardial effusion/PE/Pericardial constriction
Quantity of fluid increased (iatrogenic fluid overload)
Right heart failure/congestive heart failure
SVC obstruction
Tricuspid regurg/Tricuspid stenosis/Tamponade
What are the causes of left axis deviation?
Left anterior hemi-block
Inferior MI
WPW syndrome
What are the causes of right axis deviation?
Right ventricular hypertrophy
PE
Anterolateral MI
What is the most common cause of cyanotic heart disease?
Tetralogy of Fallot
What are the features of tetralogy of Fallot?
RV hypertrophy
Overriding aorta
Pulmonary stenosis
VSD
What is the most common type of bronchial carcinoma?
Squamous
What are the features of squamous cell carcinoma?
Most common type of cavitating lung tumour Central location Hypercalcaemia Local spread common Widespread metastases often occur late
Where does lung cancer most commonly metastasise to?
Bone
Brain
Spread within the chest–> pleura and ribs
–> brachial plexus (Pancoast)
–> sympathetic ganglion (causes Horner’s syndrome)
–> left recurrent laryngeal nerve (causes hoarse voice+cough)
What are the types of non-small cell carcinoma?
Squamous (40%)
Large cell (25%)
Adenocarcinoma (10%
What is the most common lung cancer associated with asbestos exposure?
Adenocarcinoma
Which type of non-small cell carcinoma is poorly differentiated?
Large cell
Which type of non-small cell carcinoma usually occurs peripherally?
Adenocarcinoma
What are the characteristics of small cell bronchial carcinomas?
Arises from endocrine cells (Kulchitsky cells)
Early widespread metastases
Poor prognosis
Responds to chemo
Secrete polypeptide hormones
(gynaecomastia/Cushing’s/hypercalcaemia/hyponatraemia)
What is the management of non-small cell lung cancer?
Surgical excision
Radiotherapy
Chemotherapy
What is the management of small cell carcinoma?
Limited disease: Chemotherapy + Radiotherapy
(25% survival at 5 years)
Extensive disease: Chemotherapy (20% survival at 2 yrs)
Symptomatic treatment:
-Pleural drainage
-IV opiates for pain
-Endoscopic laser, endobronchial irradiation, transbronchial stenting for airway narrowing
What are the signs and symptoms of pericarditis?
Sharp central/left sided chest pain Relieved by leaning forwards Worsened by coughing/laying flat/breathing in Signs of infection: fever, tachycardia Pericardial rub 3rd heart sound
What are the causes of pericarditis?
Viral (flu, HIV, EBV...) Fungal Bacerial MI Uraemia Autoimmune conditions
What may pericarditis lead to?
Pericardial effusion
Cardiac tamponade
What is the management of pericarditis?
Treat underlying condition
NSAIDs
What may be present on an ECG in pericarditis?
Saddle shaped ST elevation
What are the main clinical features associated with mitral stenosis?
palpitations
haemoptysis
dyspnoea (due to pulmonary oedema)
What may be found on examination in a patient with mitral stenosis?
Tapping, undisplaced apex beat
Rumbling mid-diastolic murmur
Opening snap after S2
Loud S1
What may be found on examination in a patient with pulmonary hypertension?
Loud S2
Palpable RV heave
What is the management of mitral stenosis?
Surgery- if valve is 1cm squared
AF- beta blockers/digoxin
Pulmonary oedema- diuretics and anticoagulation
What are the types of acute coronary syndrome?
STEMI, NSTEMI, unstable angina
Which investigations should be done in patients presenting with symptoms suggestive of acute coronary syndrome?
Troponin- measured on arrival and 12 hours after onset of symptoms
ECG
CXR
What are the typical features of an ACS?
Patient with known angina
Worsening pain on minimal exertion
Chest pain at rest/unrelieved by nitrates and rest
How is an acute coronary syndrome immediately managed?
GTN spray Diamorphine/morphine Metoclopramide (antiemetic) Oxygen Aspirin Clopidogrel
Which scoring system is used to assess the risk of STEMI and death in patients with angina/NSTEMI?
TIMI score
GRACE score
What are the symptoms of STEMI?
Acute central chest pain >20mins Nausea Sweats Dyspnoea Palpitations
Silent MI: Syncope Pulmonary oedema Epigastric pain and vomiting Oliguria Stroke Acute confusion
What is the appearance of the ECG
1) minutes after STEMI
2) hours after STEMI
3) days/weeks after STEMI
1)T waves become tall and pointed ST elevation New LBBB 2)T wave inversion Pathological Q waves 3) ST elevation and T wave inversion return to normal Pathological Q waves remain
Where is the infarct?
1) ST elevation in II, III and AvF
2) ST elevation in I, II and AvL
3) ST elevation in V2-V6
1) inferior
2) lateral
3) anterior
Which enzymes are released by dead heart tissue?
Troponin
Creatine kinase
What is the immediate management of a STEMI?
Primary angioplasty/thrombolysis
Metoprolol
ACEI
Clopidogrel
What are the signs and symptoms of a PE?
Symptoms:
- dyspnoea
- haemoptysis
- pleuritic chest pain
Signs:
- Tachypnoea
- Tachycardia
- Crackles
What are the risk factors for a PE?
Venous stasis: long flight, hospital, pregnancy, varicose veins
Endothelial injury: trauma, inflammation
Hypercoagulability: Malignancy, Thrombolysis, Smoking, OCP/HRT, obesity, old age
What is the treatment for a PE?
LMWH/fondaparinux
What are the classic ECG changes seen in a PE?
S1Q3T3:
large S wave in lead I
large Q wave in lead III
inverted T wave in lead III
RBBB
Right axis deviation
Sinus tachycardia
What is the management of aortic stenosis?
Aortic valve replacement if symptomatic
If asymptomatic: cut off= gradient of 50mmHg
What are the ECG features of hypokalaemia?
U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
What are the 2 types of ventricular tachycardia?
monomorphic VT: most commonly caused by myocardial infarction
polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval.
What is the treatment for ventricular tachycardia?
If systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min: IMMEDIATE CARDIOVERSION
Otherwise:
- amiodarone (through central line)
- lidocaine
What are some cardiac and non-cardiac causes of AF?
Cardiac: Congestive HF Rheumatic heart disease HTN Myocarditis Pericarditis
Non-cardiac:
- Alcohol
- Thyrotoxicosis
What are the signs and symptoms of AF?
Rapid palpitations Irregularly irregular heartbeat Dyspnoea Chest pain Fatigue, light-headedness
What are the 3 types of AF?
Paroxysmal
Persistent
Permanent
What is the treatment for acute AF?
Treat underlying cause
Heparin
Cardioversion or IV amiodarone/flecainide
Rate control: Bisoprolol/verapamil
What is the treatment for chronic AF?
–> Warfarin
–>Rate control (for over 65s/IHD)
1st line: Beta blocker (not sotalol)
Calcium channel blocker (verapamil/diltiazem
N.B.: don’t give calcium blocker+beta blocker together
2nd line: +digoxin
3rd line: amiodarone
–> Rhythm control (for young patients)
Cardioversion: Pre-treat with sotalol/amiodarone
Pharm: -flecainide (if no structural heart disease)
- amiodarone (if structural heart disease)
What is the treatment for paroxysmal AF?
Pill in pocket sotalol/flecainide
Anticoagulation
What may be used to unmask flutter waves?
Carotid sinus massage
IV adenosine
What is the treatment for atrial flutter?
Cardioversion (anticoagulate)
Amiodarone to restore sinus rhythm
Sotalol to maintain sinus rhythm
Beta blocker for rate control
What is the CHA2DS2-VASc score used for ?
Measures stroke risk in AF
1 point each: Heart failure, diabetes, HTN, vascular disease, age>65, female
2 points each: age>75, previous TIA, stroke/thromboembolism
Score of 1+: consider oral anticoagulation
Which conditions require temporary pacing?
Symptomatic bradycardia (unresponsive to atropine) After anterior MI in type 2 or complete heart block Drug resistant VT/VF
Which conditions require permanent pacing?
Complete AV block Mobitz type 2 AV block Persistent AV block after anterior MI Symptomatic bradycardias Heart failure Drug-resistant tachyarrhythmias
What is cardiac resynchronisation therapy?
Biventricular pacing and an atrial lead May also have defibrillator Improves synchronisation of contraction Reduces mortality with EF<35% and long QRS Used in heart failure
What is the difference between AVRT and AVNRT?
In AVRT, there is an accessory pathway (e.g. ,Bundle of Kent in WPW syndrome). In AVNRT there is no accessory pathway (the AVN is split, and one half conducts faster than the other).
The circuit between the AVN and the accessory pathway in AVRT and between the two halves of the AVN in AVNRT is triggered by an ectopic beat
What is the acute management of SVTs?
Valsalva manoeuvre
Adenosine, flecainide
Synchronised DC cardioversion
What is the 1st line treatment for hypertension in patients
1) younger than 55
2) older than 55/black patients of any age?
What are the 2nd and 3rd line treatments?
1st line:
1) ACCE inhibitor
2) calcium channel blockers
2nd line: ACE inhibitor + calcium channel blocker
3rd line: add thiazide diuretic
What is the first line treatment to revascularise the myocardium after an MI?
Percutaneous coronary intervention (primary angioplasty)
What are the causes of RBBB?
normal variant - more common with increasing age
right ventricular hypertrophy
chronically increased right ventricular pressure - e.g. cor pulmonale
pulmonary embolism
myocardial infarction
atrial septal defect
cardiomyopathy or myocarditis
What treatment is used to prevent SVTs?
beta blockers
radiofrequency ablation