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Cardiology Flashcards

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1
Q

What is this murmur?

A
  • crescendo-decrescendo
  • early in systole
  • Most likely Aortic Stenosis
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2
Q

Atrial Fibrillation

What are the causes?

  • 6 cardiac
  • 5 respiratory
  • 2 endocrine
A

Cardiac

  • hypertension (esp + LVH)
  • atherosclerosis/coronary artery disease
  • valve disease (esp mitral stenosis)
  • congenital heart disease, ASD
  • cardiomyopathy (dilated and hypertrophic)
  • pericarditis, myocarditis
  • cardiac surgery
  • atrial myxoma
  • sick sinus syndrome
  • WPW

Respiratory

  • pneumonia
  • bronchial Ca
  • asthma/COPD
  • lung Ca
  • PE
  • carbon monoxide poisoning
  • pleural effusion
  • pulmonary hypertension
  • pneumothorax

Endocrine/metabolic

  • diabetes
  • thyrotoxicosis
  • alcohol (acute or chronic)
  • Idiopathic
  • Obesity
  • sleep apnoea
  • haemochromatosis
  • sarcoid
  • narcotics
  • Genetic: autosomal dominant
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3
Q

Ejection Systolic Murmur

What are the causes?

A
  • narrowed outlet
    • aortic stenosis or sclerosis
    • pulmonary stenosis
    • HOCM
  • increased stroke volume (flow murmur)
    • pregnancy
    • fever
    • severe anaemia
    • bradycardia (athletes)
    • aortic regurgitation (+ EDM)
  • Atrial Septal Defect (pulmonary flow murmur)
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4
Q

Atrial Fibrillation

What are the complications?

A
  • Clotting, esp stroke

turbulent flow –> atrial clot –> embolises

  • Bowel ischaemia (same mechanism)

Rarer:

  • heart failure
  • cardiomyopathy
  • worsening angina
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5
Q

Aortic Stenosis

What is seen on the chest radiograph?

A
  • valve calcification
  • cardiomegaly (LVH)
  • dilated descending aorta
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6
Q

Aortic Stenosis

What is seen on the ECG?

A
  • P mitrale (m-shaped P wave = bulky L atrium)
  • LVH + left strain pattern
  • LBBB
  • complete AV block
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7
Q

Atrial Fibrillation

Rate Control

A
  • slow heart rate to ensure adequate filling
  • rhythm remains abnormal
    • anti-coagulate to avoid thromboemobolism

1st line = BB or rate-limiting CCB

  • atenolol
  • propranolol
  • verapamil
  • diltiazem

Target: 90bpm resting

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7
Q

Aortic Stenosis

European Society of Cardiology Classification

A
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9
Q

Signs of Aortic Stenosis

A
  • slow rising pulse
  • narrow pulse pressure
  • LV and apical heave (non-displaced)
    • LV pressure overload –> LV hypertrophy
  • aortic thrill
  • ejection systolic murmur
    • harsh, high-pitched, musical
    • crescendo-decrescendo
    • aortic area radiating to carotids
  • normal S1
  • quiet S2 +/- reverse splitting (softens as stenosis worsens)
  • +/- ejection click
  • +/- S4

contracting ventricle gradually pushes blood over stiff valve then relaxes

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10
Q

Symptoms of Aortic Stenosis

(HAS 4 Ds)

A

Triad of exertional:

  1. dyspnoea (heart failure)
  2. angina
  3. syncope

Plus:

  • dyspnoea
  • dizziness
  • death (sudden)
  • distant emboli (if due to endocarditis)
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11
Q

What is this murmur?

A
  • murmur throughout diastole
  • loudest in the early phase (EDM)
  • associated systolic flow murmur (due to increased stroke volume because blood is recycled)
  • most likely to be Aortic Regurgitation
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12
Q

What is this murmur?

A
  • murmur throughout systole
  • (loud and blowing character)
  • covering both heart sounds
  • most likely to be Mitral Regurgitation
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13
Q

What is this murmur?

A
  • murmur starts mid-diastole
  • (low-pitched, rumbling)
  • pre-systolic extenuation
  • may start with opening snap
  • covers S2
  • most likely to be Mitral Stenosis
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14
Q

What is an Austin Flint murmur?

A
  • mid-diastolic murmur
  • accompanies aortic regurgitation (EDM)
  • regurgitant jet of blood hits anterior leaflet of mitral valve as it descends
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15
Q

Causes of a Pansystolic Murmur

A
  • mitral regurgitation
  • tricuspid regurgitation
  • VSD (including post-MI septal rupture)
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16
Q

Grades of Murmur

(1 - 6)

A
  1. heard by an expert in optimum conditions
  2. heard by a non-expert in optimum conditions
  3. easily heard
  4. with thrill
  5. heard over a wide area with thrill
  6. heard without stethoscope
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17
Q

Cardiac Enzymes

  • time to peak
  • amount increase
  • time to normalising
A

Myoglobin - earliest rise, doubles, normalises within 24h

CK-MB - peaks at 24h, quadruples, normalises on day 5

Cardiac Troponin - peaks at 12h, rises 50x, normalises on day 7

  • 12h troponin is sensitive and specific
  • I is better than T

Out-dated enzymes:

  • AST - d1 - 2
  • LDH - d2
  • CK
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18
Q

Diagnosis of Acute MI

A
  1. Troponin or CK-MB rise
  2. Ischaemic symptoms
  3. ECG ischaemia - ST depression, elevation or pathological Q waves
  4. Coronary artery intervention
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19
Q

Diagnosis of STEMI

A
  1. ST elevation > 2 small squares in chest leads (V1 - V3)
  2. ST elevation > 1 small square anywhere else
  3. new LBBB
  4. (posterior MI appearance)
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20
Q

Diagnosis of NSTEMI

A
  1. ST depression > 1/2 small square
  2. symmetrical T wave inversion > 2 small squares
  3. normal ECG BUT raised 12h troponin
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21
Q

Causes of a raised troponin

A
  • myocardial necrosis -
    • MI
    • myocarditis
    • arrhythmia
  • right ventricular strain during PE
  • sepsis
  • subarachnoid (NB. these occasionally also cause chest pain! Consider if the patient is vomiting)
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22
Q

Heart Failure

Chest XR Findings

A
  • cardiomegaly
  • pulmonary oedema
  • kerley B lines
  • upper lobe diversion
  • pleural effusion
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23
Q

Heart Failure

New York Heart Association Classification

A
  1. no symptoms, even during physical activity
  2. slight limitation of physical activity
  3. mild exertion causes symptoms
  4. symptoms at rest, unable to exert at all
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24
Q

Heart Failure

Ejection Fraction Cut-offs

A
  • over 55% = normal (up to 70%)
  • 40 - 55% = reduced
  • < 40% = heart failure
  • < 35% = risk of arrhythmias and death - ICD recommended

NB. EF may be normal in diastolic failure

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25
What is S1?
* closure of mitral and tricuspid (atroventricular) valves * start of ventricular systole * may have normal inspiratory splitting
26
What is S2?
* closure of the aortic and pulmonary (semilunar) valves * normal splitting = A before P on inspiration, no split on expiration
27
Causes of a quiet S2
* quiet A2 * aortic stenosis * aortic regurgitation * quiet P2 * pulmonary stenosis
28
Causes of a loud S2
* loud A2 * hypertension * tachycardia * loud P2 * pulmonary hypertension
29
Fixed Splitting of S2
* ASD pressure eualises between the two atria --\> AV valves close together
30
Increased (Wide) Splitting of S2
* RH contraction delayed = RBBB * RH volume overloaded = VSD * RH trying to empty against ++ resistance * pulmonary hypertension * pulmonary stenosis * mitral regurgitation emptying of the R heart is delayed --\> P2 delayed further after A2 than normal --\> increased split
31
Reverse Splitting of S2
* LH contraction delayed = LBBB * LH trying to overcome ++ resistance * left outflow obstruction and aortic stenosis * PDA * RV pacing left heart emptying delayed --\> A2 delayed --\> moves after P2
32
What is S3?
rapid early filling of ventricles --\> sound of blood bouncing of walls **Kentucky** **low pitched sound** **early diastole** * physiological * young (\< 30y) * athletes * pregnancy * fever * rapid filling * mitral regurgitation * VSD * insufficient emptying (**heart failure**) (+ soft S1 and S2 and tachycardia) * post-MI * dilated cardiomyopathy * pericarditis
33
Aortic Stenosis Causes
* degenerative (calcification) * \> 60y or \> 40y if underlying bicuspid valve * congenital * bicuspid valve * subaortic membrane * William's syndrome = supravalvular aortic stenosis * rheumatic * subvalvular narrowing (HOCM)
34
ECG features of hypokalaemia
* U waves * small/absent T waves (sometimes inverted) * prolonged PR interval * ST depression * long QT *In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT*
35
Causes of long QT
Congenital * Jervell-Lange-Nielsen syndrome (deafness, abnormal K channel) * Romano-Ward (no deafness) Drugs * amiodarone * stoalol * class 1a anti-arrythmics * tricyclic ADs * fluoxetine * chloroquine * terfenadine * erythromycin Other * electrolytes * low Ca * low K * low Mg * acute MI, myocarditis * hypothermia * subarachnoid
36
Contrainidications to Warfarin
* bleeding disorders * hypertension (+ Warfarin = brain haemorrhage) * adherence * falls history Can use aspirin 300mg
37
Causes of a loud S1
* mitral stenosis (valve not closing much) * with tapping apex beat * short filling time (SVT)
38
Causes of a soft S1
* prolonged filling * long PR interval * mitral regurgitation
39
Single S2
* tetralogy of Fallot * severe AS and PS * large VSD * hypertension
40
What is a pericardial knock?
high pitched sound early diastole * restrictive pericarditis * cardiomyopathy
41
What is S4?
atrial contraction against a stiff valve or hypertrophic ventricle **Tennessee** **before S1** **bell at apex** * ventricular hypertrophy * hypertension * aortic stenosis * ventricular fibrosis * MI
42
**Thrombolysis** Contraindications
* already bleeding problem * internal or heavy PV bleeding * haemorrhagic stroke * recent trauma or surgery * vulnerable vessels * aortic dissection * oesophageal varcies * BP \> 200/120 * acute pancreatitis * liver disease * lung pathology with cavitation * allergy * cerebral cancer
43
Aortic Regurgitation Causes
* aortic root dilation * syphilitic aortitis * aortic dissection * rheumatic fever * bicuspid * calcification * endocarditis Associated with Ankylosing Spondylitis & Marfan's
44
Aortic Regurgitation Signs
when the ventricle relaxes, the pressure is higher in the aorta so blood falls back in through the incompetent valve - large changes in carotids --\> bobbing, collapsing * collapsing pulse * hyperdynamic apex beat * laterally displaced * L volume overload --\> dilation * low diastolic BP --\> wide pulse pressure * Corrigan's carotid pulsations * de Musset's head bob * Quinke's nail pulsations * Traube's pistol shot femorals * Duroziez's femoral murmurs * early diastolic decrescendo murmur * mid-diastolic rumble = Austin-Flint murmur
45
What is an Austin-Flint murmur?
regurgitant blood hitting the anterior leaflet of the mitral valve causes a mid-diastolic murmur
46
Pan-Systolic Murmur Causes
* Mitral regurgitation - apex radiating to axilla, blowing * Tricuspid regurgitation - lower L sternum, pulsatile liver, v wave in JVP * VSD - loud, L sternal border radiating to R, thrill * harsh = ruptured septum post-MI
47
Mitral Stenosis Causes
* malar flush * heart failure - JVP, oedema * atrial fibrillation * tapping apex beat * low rumbling mid-diastolic murmur (as filling passes stiff valve) * accentuated by exercise * pre-systolic extenuation * opening snap (after S1) = stiff valve opening * loud S1 (elevated LA pressure and stiff valve closing) left atrial pressure overload --\> left atrial dilation and pulmonary hypertension, left atrial thrombus Causes pulmonary hypertension * R ventricular heave * pulmonary haemosiderosis (iron deposits, visible on chest xray)
48
Mitral Regurgitation Signs
* displaced, diffuse apex beat * irregularly irregular pulse * congestion * raised JVP * parasternal heave (R) * loud pansystolic murmur radiating to axilla * radiates up the left sternum (outflow tract) * loud, blowing * soft S1 * S2 hidden in PSM * S3 high pressure in ventricle and aorta pushes blood back over incompetent mitral valve **heart failure**
49
Left Axis Deviation Causes
increase left ventricular mass * hypertension * aortic stenosis * ischaemic heart disease * intraventricular conduction defect * inferior MI * WPW
50
Right Axis Deviation Causes
51
52
Jervell & Lange-Nielsen Syndrome
* autosomal recessive congenital heart disease * long QT * sensorineural deafness less than 10% long QT cases
53
Lenegre-Lev Syndrome Lev's disease
* fibrosis and calcification of electrical tissue --\> complete heart block ?senile degeneration can --\> Stokes-Adams attacks
54
Romano-Ward Syndrome
* autosomal dominant long QT syndrome * normal hearing
55
Stokes-Adams Attack
* pale, skip a beat --\> collapse * 30s syncope +/- 20s seizure * recovery --\> flushing non-positional due to decreased cardiac output after a short period of asystole
56
Sick Sinus Syndrome
* slowed firing in SAN or sinoatrial block * (may have AVN escape beats) * usually due to SAN fibrosis Managed with pacemaker
57
Sinus Bradycardia Causes
* Cadiac * disease of the sinoatrial node: ischaemia, infarct, degeneration, fibrosis, vagal stimulation, myocarditis * IHD (60% people have SAN supplied by RCA) * anti-arrhythmis drugs * raised intracranial pressure * hypoxia * hypothermia * underactive thyroid * sepsis * cervical or mediastinal tumours
58
Long QT Causes
* Congenital * Jervell & Lange-Nielsen * Romano-Ward * Electrolytes * low K * low Mg * low Ca * Drugs * IA * III * tricyclics * phenothiazines (chlopromazine) * terfenadine * CNS disease * Organophosphates * Mitral valve prolapse * Acute MI
59
Atrial Flutter Causes
60
Pacemaker Syndrome
* single chamber RV pacemaker * retrograde conduction into the atrium * causes cannon waves, high pulmonary arterial pressure and decreased cardiac output management: replace with a dual chamber device
61
Mitral Stenosis Causes
* rheumatic * congenital * severe calcification
62
Mitral Regurgitation Causes
* rheumatic * degeneration, calcification * ischaemia, infarct * prolapse
63
Endocarditis Signs
* fever * new murmur * 1/3 if right-sided * commonest is AR * petechiae: conjuntiva, hands and feet, chest and abdo, oral mucosa and soft palate * splinter haemorrhages * osler's nodes (nodules in digital pulps) * clubbing * Roth's spots - retinal haemorrhaes with pale centres * Janeway's lesions (irregular macules) * arthritis (asymmetric, sterile fluid or septic monoarthritis) * splenomegaly * meningism/itis
64
Rheumatic Fever Diagnosis **Jones Criteria**
* evidence of recent strep (scarlet fever, throat swab, ASOT, DNAase B titre) + 1 major or 2 minor **MAJOR** * arthritis - migratory, large joint, ++inflammed * carditis - affecting the whole heart and sometimes the valves, tachycardia beyond what is expected for the temperature * AR * pericardial rub * mitral valve most affected * Carey Coombs murmur - diastolic filling * Austin Flint * Sydenham's chorea (St Vitus' Dance) * Paediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (PANDAS) * Subcutaneous nodules - firm, painless, over extensor surfaces * Aschoff bodies found in heart * Erythema marginatum (annulare) MINOR * fever * raised ESR and CRP * arthralgia * prolonged PR interval
65
Right-Sided Endocarditis
Staph aureus often infects right side because it is more virulent and can infect healthy valves -- needs an entry port therefore seen in IVDU -- needs urgent valve surgery as antibiotics won't be fast enough Strep viridans only infects damaged valves so tends to affect left sided valves in the elderly
66
What is the management of complete heart block?
1. Basic resus 2. Pacing * pacing wire * temporary external pacemaker - because 3rd degree heart block reflects dysfunction of the AV node so it won't respond to atropine. If ischaemic (post-MI), the node may recover.
67
Complications of an MI
* Re-infarct or extension of infarct * Arrhythmia - especially VF * Heart failure * mitral regurg * Embolism * stroke * PE * Rupture, aneurysmal dilation * Pericarditis * early (day after, common) * later (6 weeks, Dresslers')
68
Pericarditis
Positional chest pain, imrpvoes sitting forward Managed with NSAIDs **Early** - common occurence the day after full thickness infarct **Late** = Dressler's syndrome - immune response 6 weeks after MI
69
Heart Failure Signs
* Tachycardia * S3 * Tachypnoea * Cardiac asthma, wheeze * Bilateral creps * Raised JVP * Peripheral oedema ... in approx order of onset When venous pressure is higher than oncotic pressure --\> flash pulmonary oedema
70
Acute Pulmonary Oedema Management
1. sit up 2. high flow oxygen 3. 40mg frusemide (vasodilation --\> sudden relief) 4. ACEi for remodelling and blocking fluid retention
71
Cardiogenic Shock Definition
insufficient cardiac output to meet the circulatory demands of the body to the extent that the myocardium and brain and not perfused
72
Subendocardial MI
* infarct in the wall, septum or papillary muscles but not full thickness * common after blood loss in surgery * ST depression on ECG * new T wave inversion likely * abnormal cardiac enzymes * risk of arrhythmia
73
Aortic Stenosis Velocity Cut-offs European Society of Cardiology
mild \< 3 m/s moderate 3 - 4 severe \> 4m/s
74
Aortic Stenosis Area Cut-offs European Society of Cardiology
mild \> 1.5 cm2 moderate 1 - 1.5 cm2 severe \< 1 cm2
75
Aortic Stenosis Gradient Cut-offs European Society of Cardiology
mild \< 30 mmHg moderate 30 - 50 mmHg severe \> 50mmHg

Medicine (12 decks)

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