Cardiology Flashcards
(238 cards)
1
Q
CARDIAC PHARMACOLOGY
What is the main aim when treating hypertension
A
Control peripheral resistance! This involves controlling the RAAS and SNS
2
Q
CARDIAC PHARMACOLOGY
what are the functions of Angiotensin II?
A
- Vasoconstrictor
- Increase peripheral resistance
- increase CO
- encourage release of noradrenaline- increased sympathetic activity
- water retention through encouragement of aldosterone release
- tubular Na+, Cl- reabsorption, K+ excretion
- ADH secretion so increase water absorption
3
Q
CARDIAC PHARMACOLOGY
Name some examples of ACE inhibitors
A
- Ramipril
- enalapril
- Perindopril
4
Q
CARDIAC PHARMACOLOGY
Name some side effects of ACE inhibitors
A
- Hypotension
- Chronic cough
- Acute renal failure
- Hyperkalaemia
- foetus abnormalities
5
Q
CARDIAC PHARMACOLOGY
Angiotensin II receptor blockers (ARB’s) act on what receptor?
A
AT-1 receptor
6
Q
CARDIAC PHARMACOLOGY
Name some examples of ARB’s
A
- Candesartan
- Losartan
- Valsartan
7
Q
CARDIAC PHARMACOLOGY
Name some examples of calcium channel blockers (CCB’s)
A
- Amlodipine
- Nifedipine
- Verapamil
- Diltiazem
8
Q
CARDIAC PHARMACOLOGY
Amlodipine and nifedipine are Dihydropyridines, what is their function
A
Peripheral arterial vasodilators
9
Q
CARDIAC PHARMACOLOGY
Verapamil is a phenylalkylamine, what is its function
A
Negatively chronotropic/ Inotropic
10
Q
CARDIAC PHARMACOLOGY
Diltiazem is a benzothiazepine, what is its function
A
intermediate heart and peripheral effects, ( bit of both)
11
Q
CARDIAC PHARMACOLOGY
Common side of effect Verapamil?
A
- constipation
12
Q
CARDIAC PHARMACOLOGY
Negatively chronotropic and inotropic effects can cause what?
A
- ve chronotropic= Bradycardia and AV block
- ve inotropic= worsening of HF
13
Q
CARDIAC PHARMACOLOGY
Name examples of Beta- adrenoceptor blockers (BB’s)
A
- Bisoprolol (B1 selective)
- Metoprolol
- Atenolol
- Propranolol (B1/B2 non selective)
in order of selectivity
14
Q
CARDIAC PHARMACOLOGY
Name the types of Diuretics
A
- Thiazides ( work on DCT and are long acting)
- Loop diuretics ( work on Loop of Henle and are POWERFUL)
- aldosterone antagonists (K+ sparing diuretics)
15
Q
CARDIAC PHARMACOLOGY
Name some examples of Thiazides
A
- Bendroflumethiazide
- Hydrochlorothiazide
16
Q
CARDIAC PHARMACOLOGY
Name some examples of loop diuretics
A
- Furosemide
- Bumetanide
17
Q
CARDIAC PHARMACOLOGY
Name some examples of K+ sparing diuretics
A
- Spironolactone
- Eplerenone
18
Q
CARDIAC PHARMACOLOGY
What is a common side effect of spironolactone
A
It has oestrogenic effects so can increase breast tissue
19
Q
CARDIAC PHARMACOLOGY
1st line treatment for HTN for an under 55?
A
- ACE-I or ARB
20
Q
CARDIAC PHARMACOLOGY
1st line treatment for HTN for an over 55 or afro-Caribbean?
A
CCB
21
Q
CARDIAC PHARMACOLOGY
2nd line treatment for HTN?
A
Both ACE-1/ARB and CCB
22
Q
CARDIAC PHARMACOLOGY
What is the 3rd line treatment for HTN?
A
Add a Thiazide
23
Q
CARDIAC PHARMACOLOGY
what is the 4th line treatment for HTN?
A
add spironolactone/ alpha/ beta- blocker
24
Q
CARDIAC PHARMACOLOGY
1st line treatment for heart failure?
A
ACE-I and beta blocker ( low dose and slow uptitration)
25
CARDIAC PHARMACOLOGY
2nd line treatment for HF?
aldosterone antagonist
26
CARDIAC PHARMACOLOGY
if a patient has an intolerance for ACE-I what do you give them instead?
If ACE-I intolerant use ARB
27
CARDIAC PHARMACOLOGY
If a patient is ACE-1 and ARB intolerant what do you give them?
Hydralazine/ nitrate combo
28
CARDIAC PHARMACOLOGY
| What do you try as a 4th option if all HF treatments fail?
consider digoxin
29
CARDIAC PHARMACOLOGY
What peptides do the atria and ventricles naturally release?
atria- atrial natriuretic peptide (ANP)
| ventricle- brain natriuretic peptide (BNP)
30
CARDIAC PHARMACOLOGY
In what circumstances are ANP and BNP released?
- Increased atrial/ ventricle pressure
- stretch of heart tissue
- volume overload
31
CARDIAC PHARMACOLOGY
What is the function of ANP ands BNP?
1) increase renal excretion of sodium and water (natriuresis and diuresis)
2) relax vascular smooth muscle
3) increase vascular permeability
32
CARDIAC PHARMACOLOGY
What does ANP and BNP inhibit the release of?
1) Aldosterone
2) AG-II
3) Endothelin
4) ADH
(vasoconstrictors!)
33
CARDIAC PHARMACOLOGY
Neutral Endopeptidases metabolise what?
ANP/BNP
34
CARDIAC PHARMACOLOGY
Name a nitrate and say its functions
- Isosorbide mononitrate, GTN spray
1) reduction of preload/afterload
2) Lower BP
3) Arterial/ venous dilator
35
ANGINA
What is Angina?
Angina is the descriptive pain caused by myocardial ischaemia
36
ANGINA
What are the different types of angina and when do they occur?
- Stable (effort)
- Unstable (random)
- Nocturnal (night)
- Decubitis (lying down)
- Variant (no provocation)
37
ANGINA
What is Levine's Sign?
Clenched fist over chest to deal with pain
38
ANGINA
Why does angina happen?
There is a rupture of a fibrous cap of a plaque due to inflammation. Constant rupture and healing over time occludes more of the artery each time which causes ANGINA.
39
ANGINA
Main cause of angina?
ATHEROMA
40
ANGINA
What is the diagnostic criteria?
- Central crushing chest pain radiating to arm/jaw
- Exacerbated by exercise
- Relieved by rest/ GTN spray
41
ANGINA
What is the differential diagnosis of Angina? (also has central chest pain)
- ACS
- Pericarditis
- Myocarditis
- PE
- GORD
- Aortic Dissection
42
ANGINA
What would you investigate if a patient is suspected to have Angina?
- ECG and stress ECG (ST segment depression and inverted T wave)
- Cardiac MRI
- CT coronary Angiogram
43
ANGINA
What is the first line treatment?
- GTN spray
- Beta Blocker ( atenolol, metoprolol)
- Calcium Channel Blocker ( Diltiazem, Amlodipine)
44
ANGINA
What is the secondary prevention for Angina?
Aspirin/ clopidogrel and statin
45
ANGINA
If 1st line treatment is not enough, what are the next stages?
2nd- Add nitrate (isosorbide mononitrate), to reduce pressure and dilate, or K+ channel activator (Nicorandil)
46
ANGINA
what surgical interventions can be done?
- Percutaneous coronary intervention (PCI)
| - Coronary artery bypass graft (CABG)
47
ACUTE CORONARY SYNDROMES
What are the different types of ACS?
- Unstable Angina
- Non ST elevation MI (NSTEMI)
- ST elevation MI (STEMI)
48
ACUTE CORONARY SYNDROMES
| What are the blood markers for an NSTEMI?
- Raised troponin and creatine kinase ( this shows myocardial damage)
(STEMI is the same but also there is ST elevation)
49
ACUTE CORONARY SYNDROMES
Symptoms of an ACS?
- same as angina ( central crushing pain)
- Not relieved by GTN
- 4th heart sound- Sweats and Palpitations
- Dyspnoea ( difficulty breathing)
50
ACUTE CORONARY SYNDROMES
What tests would you do?
- Bloods ( raised troponin)
| - ECG ( LBBB, tall T-waves, ST elevation/ depression)
51
ACUTE CORONARY SYNDROMES
Treatment?
```
M- Morphine
O- Oxygen
N- Nitrate
A- Aspirin
T- Clopidogrel/ Ticragelor
```
(A and T are both antiplatelet)
52
ACUTE CORONARY SYNDROMES
How would you assess someone with Angina?
- Assess using the GRACE score
- If high, start GPIIb/IIIa infusion and do angiography
- If low repeat troponin and investigate for ischaemia with angiography
53
ATHEROGENESIS
Name some non modifiable and modifiable risk factors of atherogenesis
Non Modifiable
- Age
- Gender
- Family History
Modifiable
- smoking
- HTN
- Obesity
- Hyperlipidaemia (high LDL's)
- Sedentary lifestyle
- High alcohol intake
54
ATHEROGENESIS
Name the cause of atherogenesis
- Injury to endothelium means lymphocytes migrate into vessel migrate into the vessel walls and the vessel begins to narrow.
55
ATHEROGENESIS
| What are the stages of atherogenesis?
1) Fatty Streaks (the beginning, T cells and macrophages)
2) Intermediate Lesions
3) Fibrous Plaques
4) Rupture of fibrous cap
5) Erosion
56
ATHEROGENESIS
| What happens after the lymphocytes enter the vessel walls?
- Foam cell production
- Smooth muscle and T- lymphocyte proliferation
- platelet adhesion
57
ATHEROGENESIS
What is myocardial Ischaemia?
Imbalance between myocardial oxygen demand and supply
58
ATHEROGENESIS
What is the QRISK2?
QRISK2 is a prediction algorithm for cardiovascular disease (CVD).
If there is >10% risk over 10 years, then this is an indication for primary prevention. e.g- lifestyle changes and begin statin.
59
ACUTE STEMI
What are the ECG changes of an acute STEMI
mins-hrs: Hyperacute T waves and ST elevation
hrs: T waves invert and broad deep Q waves
weeks: T returns. Q remains. STEMI can present with a new LBBB.
60
ACUTE STEMI
What is the treatment?
1) Primary PCl in under 120 mins and Thrombolysis
2) Start GPIIb/IIIa antagonist (abciximab)
Long-Term: statin, aspirin, clopidogrel, B blocker, ACE-I, (for 12 months)
61
HEART FAILURE
What is the definition of heart failure?
When the cardiac output is inadequate for the bodies requirements
62
HEART FAILURE
Causes?
- IHD
- Valvular HD
- Congenital HD
- Pericardial disease
- Cardiomyopathies
- Hyperthyroidism, pregnancy, obesity
63
HEART FAILURE
In detail, describe the pathology of HF?
1) HF= Compensatory mechanisms (maintain CO)
2) HF progresses = Overwhelmed mechanisms
3) Activation of SNS, increased HR, contractility, vasoconstriction
4) SNS stimulation leads to arteriolar constriction, increased after load, fall in renal perfusion activates RAAS- water and salt retention - oedema. AG-II- more arteriolar constriction/ work of heart
5) Myocardial failure -> increase in ESV
o Increased volume =stretch of myocardium
o Eventually leads to pulmonary and peripheral oedema, and increased oxygen requirements of the myocardium
```
6) Ventricular remodelling
o Hypertrophy
o Loss of myocytes
o Increased interstitial fibrosis
= irreversible contractile failure
```
64
HEART FAILURE
What is systolic failure?
- Inability to contract normally
65
HEART FAILURE
What is diastolic failure?
- Inability to fill normally
66
HEART FAILURE
Symptoms of left ventricular failure?
- Exertional dyspnoea
- Fatigue
- Cyanosis
- Paroxysmal nocturnal dyspnoea
- Tired, wheeze, weight loss
67
HEART FAILURE
Symptoms of right ventricular failure?
- Peripheral Oedema
- Dyspnoea and Fatigue
- Increased weight
- Ascites
- Nausea
68
HEART FAILURE
What do you call it if someone has left and right ventricular failure?
Congestive Cardiac Failure (CCF)
69
HEART FAILURE
What are the signs and symptoms of CCF?
- Ascites
- 3rd and 4th heart sounds
- Cardiomegaly
- Displaced apex beat
- Hepatomegaly
- Tachycardia
- Elevated JVP
70
HEART FAILURE
What are pleural effusions?
- Bibisal coarse crackles (crackles at base of both lungs)
| - Bibisal decreased breath sounds (both lungs)
71
HEART FAILURE
What are the different classes of HF?
Class 1- No dyspnoea at rest
Class 2- Comfortable at rest but fatigue/ palpitations/ dyspnoea after regular exercise
Class 3- Mild exercise causes fatigue/ palpitations/ dyspnoea
Class 4- Fatigue/ palpitations/ dyspnoea at rest
72
HEART FAILURE
Name the major criteria for HF
```
S- S3 heart sound (gallop)
A- Acute pulmonary oedema
W- Weight loss >4.5kg in 5 days
P- Paroxysmal nocturnal dyspnoea
A- Abdominojugular reflex (hepatojugular)
N- Neck vein distension
I- Increased cardiac shadow on XR (cardiomegaly)
C- Crackles in lungs
```
73
HEART FAILURE
| Name the minor criteria for HF?
```
H- Hepatomegaly
E- Effusions (pleural)
A- Ankle Oedema
exeR- tional dyspnoea
T- Tachycardia
V- Vital capacity decreased by 1/3
N- Nocturnal cough
```
74
HEART FAILURE
What tests would be carried out to check for HF?
- Bloods (anaemia, high BNP)
- Echo (systolic/diastolic function)
- Calculate eject fraction <35% is severe
- Chest X-ray
75
HEART FAILURE
What do we look for on a chest X-ray when looking for heart failure?
```
A- alveolar oedema
B- kerley B lines
C- Cardiomegaly
D Dilated upper lobe vessels
E - pleural effusions
```
76
HEART FAILURE
When would you give a patient O2?
Only give patient oxygen if they're hypoxic.
77
HYPERTENSION
| Causes?
(90%)- Obesity, genetics, high salt, diabetes, alcohol
(8%)- Kidney Disease
rare- endocrine, the pill
78
HYPERTENSION
To measure hypertension we carry out 24 hour ambulatory blood pressure monitoring. At what BP would this be offered?
over 140/90
79
HYPERTENSION
What is End Organ Damage?
- Retinopathy
- Renal Failure
- Stroke/ TIA
- MI/Angina
- LV Hypertrophy
- HF
- Peripheral vascular disease
80
HYPERTENSION
Treatment of hypertension
1st- <55= ACE-I
>55 or afro-Caribbean= CCB
2nd- Both
3rd- Add thiazide
4th- Add extra diuretic/alpha/ beta blocker
81
ARRHYTHMIAS
Symptoms?
- Palpitations
- Syncope
- Dyspnoea
- Dizziness
OR asymptomatic
82
ARRHYTHMIAS
| How are cardiac arrhythmias diagnosed?
24 hour ambulatory ECG -> Loop recorder
83
ARRHYTHMIAS
Causes of heart block?
- CAD
- Cardiomyopathies
- Fibrosis of conducting pathways (in the elderly)
84
ARRHYTHMIAS
Name the different types of AV block
1) First degree AV Block
2) Second degree AV Block
3) Third degree AV Block
85
ARRHYTHMIAS
Name the different types of second degree AV Block
- Mobitz Type 1
- Mobitz Type 2
- 2:1 or 3:1 Block
86
ARRHYTHMIAS
What is 1st degree AV Block and what does it look like on an ECG?
- 1st degree AV Block is delayed AV conduction and on an ECG it has:
A prolonged PR interval >0.22s
87
ARRHYTHMIAS
What happens in 2nd degree AV block?
Some impulses fail to reach the ventricles
88
ARRHYTHMIAS
What does an ECG look like for a patient with Mobitz Type 1 AV block?
- Progressively longer PR interval until the P wave fails to conduct. It then resets and occurs again
89
ARRHYTHMIAS
What does an ECG look like for a patient with Mobitz Type 2 AV block?
Random dropping of QRS complexes due to failed conduction of P. On an ECG there is:
-Wide QRS complexes
90
ARRHYTHMIAS
What does an ECG look like for a patient with 2:1 or 3:1 AV Block and what is it?
It is when there are 2 or 3 P waves for every QRS complex due to failed conductions.
(e.g- 3:1 AV block has 3 P waves for every QRS.)
91
ARRHYTHMIAS
What is the treatment for each of the different types of AV block?
1st: No Rx
2nd- Mobitz 1- Monitor
Mobitz 2, 2:1/3:1, 3rd: Pacemaker
92
ARRHYTHMIAS
What is 3rd degree AV block and what does an ECG look like?
- Complete heart block
- No association between atrial and ventricular activity.
- Contractions occur due to an escape rhythm.
ECG: P and QRS occur independently
93
ARRHYTHMIAS
What are the causes of an Right Bundle Branch Block? (RBBB)
- IHD
- PE
- Cardiomyopathies
- Congenital heart disease
94
ARRHYTHMIAS
What are the ECG changes for someone with a RBBB?
- wide QRS
- secondary R wave in V1 (RSR)
- QRS in V6- slurred S
(MARRoW)
95
ARRHYTHMIAS
Pathologically, what occurs if someone has an LBBB?
- LBB fails to conduct
- Depolarisation spreads across LV via cell to cell
- Therefore, RV contracts BEFORE LV
96
ARRHYTHMIAS
Pathologically, what occurs if someone has an RBBB?
- RBB fails to conduct
- Depolarisation spreads across RV via cell to cell
- Therefore, LV contracts BEFORE RV
97
ARRHYTHMIAS
What are the causes of a Left Bundle Branch Block? (LBBB)
- IHD
- HTN
- LVH
- aortic valve disease
- Fibrosis of conducting pathways
98
ARRHYTHMIAS
What ECG changes can be found for someone with an LBBB?
- Wide QRS
- Secondary R wave in LV leads ( 1, aVL, V4-V6)
- QRS in V1 (W)
- RSR in V6 (M)
(WiLLiaM)
99
ARRHYTHMIAS
In a normal ECG in leads 1 and 2, QRS is positive, what changes in:
- Left Axis Deviation?
- Right Axis Deviation?
LAD: Lead 1- positive Lead 2- negative
RAD: Lead 1- negative Lead 2- positive
100
ARRHYTHMIAS
What is Sinus Tachycardia?
Physiological response to exercise and excitement
101
ARRHYTHMIAS
what happens to someone's ECG if they have Supraventricular Tachycardia?
- P wave is absent or inverted after QRS
102
ARRHYTHMIAS
What are the signs of a supraventricular tachycardia?
- Rapid palpitations
- Dizziness
- Dyspnoea
- Central chest pain
103
ARRHYTHMIAS
How are supraventricular tachycardias managed?
1) Vagal Manoeuvres (carotid massage)
2) Adenosine
If fails Verapamil or (atenolol/ sotalol)
LONG TERM= ABLATION
104
ARRHYTHMIAS
What is a ventricular tachycardia and how is it treated?
It is a rapid ventricular rhythm with broad abnormal QRS complexes
Treatment: Amiodarone IV + Defib
105
ARRHYTHMIAS
What is a Ventricular Ectopic and how is it treated?
Premature beats and abnormal P wave.
Ectopic electrical activity is not conducted through normal tissue
Treatment: beta blockers
106
ARRHYTHMIAS
Prolonged QT syndrome is when what is prolonged?
Ventricular repolarisation
107
ARRHYTHMIAS
What are the causes of prolonged QT syndrome?
- Congenital ( mutation to Na/ Mg channel genes)
- Electrolyte disturbances (hyper/hypo)
- Drugs ( TCA's, phenothiazines)
108
ARRHYTHMIAS
| What are the symptoms of prolonged QT syndrome?
- Palpitations
- Syncope
- Torsade de pointes (polymorphic VT)
(rapid irregular QRS, changing from upright to inverted)
109
ARRHYTHMIAS
Treatment for prolonged QT syndrome?
- IV isoprenaline and treat underlying causes
110
ARRHYTHMIAS
What is Wolff- Parkinson White?
Congenital accessory conduction pathway between the atria and ventricles (Bundle of Kent)
Patient presents with Supraventricular Tachycardia
111
ARRHYTHMIAS
WPW is a type of Atrioventricular re-entry Tachycardia (AVRT), but what is an AVRT?
It is when an impulse can travel down 1 route but back up another.
112
ARRHYTHMIAS
What are the ECG changes for someone with an AVRT
- Short PR due to speed of accessory pathway
| - Slurred QRS, 'pre-excitation'
113
ARRHYTHMIAS
How is AVRT and AVNRT managed?
1st- Electrical cardioversion or carotid massage
2nd- Adenosine
3rd- Verapamil
Long Term- Ablation
114
ARRHYTHMIAS
What is AF?
Atrial Fibrillation is chaotic atrial rhythm at a rate of 300-600bpm
115
ARRHYTHMIAS
What are some causes of AF?
- HF
- HTN
- Mitral Valve Disease
- Hyperthyroidism
- Alcohol
- MI
- PE
116
ARRHYTHMIAS
Symptoms of AF?
- Asymptomatic, palpitations, fatigue
It is IRREGULARLY IRREGULAR
117
ARRHYTHMIAS
Investigations for AF?
ECG and bloods (U+E, thyroid function, cardiac enzymes)
Absent P waves
118
ARRHYTHMIAS
Management of acute AF?
1st- Cardioversion or IV amiodarone
02 and U+E's
Verapamil or bisoprolol
119
ARRHYTHMIAS
Management of chronic AF?
- Beta blocker (rate control)
- Warfarin
- Add digoxin then amiodarone
120
ARRHYTHMIAS
How is an atrial flutter found on an ECG?
- Sawtooth baseline
121
ARRHYTHMIAS
What is an atrial flutter?
Atrial Tachycardia, atria beats at 300bpm and ventricles only conduct every second beat/ e.g it is regular so 150bpm
122
ARRHYTHMIAS
How is an atrial flutter treated?
- Anticoagulate and cardioversion
| - Amiodarone (restore sinus rhythm)
123
ARRHYTHMIAS
| What is a sinus arrest?
When the SAN fails to discharge on time, P wave stops
124
ARRHYTHMIAS
What is a SA block?
When an impulse doesn't reach the atria
125
There are 10 basic ECG rules. Try name a few
1) PR interval- 120-200ms
2) QRS < 110ms
3) Leads I and II predominantly upright
4) QRS and T same direction
5) All negative in aVR!
6) R grows V1-V4
7) S grows V1-V3 and goes at V6
8) P wave is upright in leads (I, II, V2-V6)
9) no/small Q <0.04ms in leads ( I, II V2-V6)
10) T wave upright in leads ( I, II, V2-V6)
126
What does a statin do?
statins inhibit HMG-CoA reductase and reduce cholesterol synthesis
127
what does clopidogrel/ ticagrelor do?
inhibitors of P2Y12 ADP receptor
128
What does aspirin do?
unlike other NSAIDs, aspirin action is IRREVERSIBLE inhibitor of COX enzyme. (cyclo- oxygenase)
129
What is a foam cell?
macrophage that localises to fatty deposits in BV walls (ingest LDL's).
130
What is electrocardiography?
summation of the hearts electrical activity
131
At what rate does the dominant SAN beat?
60-100bpm
132
what are the two back-up pacemakers of the heart?
AVN- 40-60bpm
| Ventricular cells- 20-45bpm
133
On an ECG what does a small box represent horizontally?
0.2 seconds
134
On an ECG what does a small box represent vertically?
0.5mV
135
Lead I is said to be at 0 degrees. At what angles are the other leads in relation to lead I
```
Lead II +60
aVF +90
Lead III +120
aVR -150
aVL -30
```
136
What is Einthoven's triangle?
Einthoven's triangle is an imaginary formation of three limb leads in a triangle used in electrocardiography, formed by the two shoulders and the pubis.
RA - + LA
- -
+ LL +
137
AORTIC STENOSIS
Causes?
- Degeneration and calcification of a normal valve (elderly)
- Calcification of congenital bicuspid valve (middle-aged)
- Rheumatic heart disease
138
AORTIC STENOSIS
Pathology?
1) obstruction to LV emptying (LV Hypertrophy)
2) increased myocardial demand = ischaemia of myocardium
3) This leads to Angina, arrhythmias and left heart failure
139
AORTIC STENOSIS
Symptoms?
Classic Triad
1) angina
2) syncope
3) heart failure and congestive HF
also, dyspnoea, dizzy, fatigue
140
AORTIC STENOSIS
Tests?
- CXR (dilated aorta and enlarged heart)
- ECG Tall R waves in aVL and V4-V6
- Doppler Ultrasound - assess pressure gradient across valve
Echo- Would find LVH
141
AORTIC STENOSIS
Treatment?
Valve replacement/ repair
142
AORTIC STENOSIS
Signs?
1) systolic ejection murmur
2) ejection click- sudden opening
3) soft S2 heart sound
4) Slow rising pulse with narrow pulse pressure
5) LVH signs- heaving, displaced apex beat
6) pulsus parvus et tardos
143
MITRAL REGURGITATION
| Cause?
Prolapsing mitral valve
Rheumatic HD
Infective Endocarditis
144
MITRAL REGURGITATION
What happens in chronic MR?
LA and LV dilation (time to adjust)= exertional dyspnoea
145
MITRAL REGURGITATION
What happens in acute MR?
1) LA pressure increases
| 2) backs up into lungs = Pulmonary Oedema + exertional dyspnoea
146
MITRAL REGURGITATION
Signs?
- AF
- pansystolic murmur (heart murmur that occurs over the entire systole, from the 1st to the 2nd heart sounds)
- displaced apex beat
- weak S1
5) RV heave
147
AORTIC REGURGITATION
Causes?
- Infective Endocarditis
- Rheumatic Heart disease
- Bicuspid Aortic Valve
148
AORTIC REGURGITATION
What happens in chronic AR?
1) Blood backs up into LV= LV hypertrophy and dilation
2) Stroke volume and pulse pressure increased
3) results in LV failure and dyspnoea
149
AORTIC REGURGITATION
What happens in acute AR?
there is no adaptations as there is not enough time therefore:
Pulmonary oedema and decreased stroke volume
150
AORTIC REGURGITATION
Signs?
- High pitched early diastolic murmur
- wide pulse pressure
- collapsing pulse
- displaced apex
- Breathless when lying down
151
AORTIC REGURGITATION
Tests and treatment?
ALL VERY SIMILAR
1) beta blockers (control rate)
2) ACE-I (reduce LV hypertension)
3) Surgery- valve replacement
4) anticoagulants
152
MITRAL STENOSIS
Tests?
CXR- enlarged LV, dilation of AA
| ECG- LVH, P Mitrale (bifid P waves, bit like a curly M)
153
MITRAL STENOSIS
Causes?
1) Thickening of valves leads to obstruction between LA and LV, thus, increasing LA pressure
2) this leads to pulmonary oedema, HTN and right heart dysfunction
also, rheumatic HD
154
MITRAL STENOSIS
very simply, describe the pathology
- increased LA pressure and dilation= LA dysfunction= AF= dyspnoea
155
MITRAL STENOSIS
Signs?
- mitral facies (pink/ purple patches on cheeks due to low CO)
- Mid diastolic murmur
- Loud S1
- Opening snap when mitral valve opens
more severe: longer murmur and snap is closer to S2
156
MITRAL STENOSIS
Treatment?
ALL VERY SIMILAR
1) beta blockers (control rate)
2) ACE-I (reduce LV hypertension)
3) Surgery- valve replacement
4) anticoagulants
also diuretics
157
AORTIC ANEURYSM
Causes?
- Atheroma
| - Marfan's Syndrome
158
AORTIC ANEURYSM
Symtpoms?
- Epigastric pain radiating to back
- Expansible abdominal mass
- Unruptured may be asymptomatic
159
AORTIC ANEURYSM
Tests?
Ultrasound + CT
160
AORTIC ANEURYSM
Treatment?
- Immediate surgery if symptomatic or >5.5cm
161
AORTIC DISSECTION
What is it?
- Tear in the intima of the aorta, leading to blood flowing in and creating a false lumen in the diseased media
162
AORTIC DISSECTION
Symptoms?
- Sudden severe tearing chest pain- radiating through back
163
AORTIC DISSECTION
Tests?
- CXR
- CT
- TOE
- MRI
164
AORTIC DISSECTION
Treatment?
- BP control- (IV Labetalol and immediate surgery)
| - Hypotensive to keep systolic BP at 100-110mmHg
165
ENDOCARDITIS
what is it?
Destruction of valve due to fibrin, platelets and infective organisms forming vegetation on the valve
166
ENDOCARDITIS
Risk Groups?
- Intravenous Drug Users
- Prosthetics
- Structural Heart Defects
167
ENDOCARDITIS
| Causes?
- S. viridans
- S. aureus
- coliforms
- enterococci
- s. epidermis
168
ENDOCARDITIS
Features?
- Fever
- Night sweats
- Weight loss
- Malaise
- Anaemia
- NEW HEART MURMURS
- Haematoma occurs in 70%
169
ENDOCARDITIS
Signs of Left Emboli?
Brain - Stroke
Kidney- Haematuria
Bone- Osteomyelitis
Skin- Janeway's Lesions
170
ENDOCARDITIS
Signs of Right Emboli?
- Pulmonary Infraction
| - Pneumonia
171
ENDOCARDITIS
Signs of causation by immune complex deposition?
- Osler's Nodes (painful lesions on hand/feet)
- Splinter haemorrhages under nails
- Roth spots on retina
- Joints = arthralgia
172
ENDOCARDITIS
Tests?
- Transoesophageal echocardiography (TOE)
| - Blood cultures ( 3 from different sites over 24hrs)
173
ENDOCARDITIS
Major Criteria for Endocarditis?
1) Positive blood cultures (typical organisms in 2/3)
2) Endocardial involvement
3) Positive echo
4) New regurgitation murmur
174
ENDOCARDITIS
Minor criteria for Endocarditis?
1) fever >38C
2) vascular phenomena
3) Immunological phenomena
4) Cardiac lesion
175
ENDOCARDITIS
Treatment?
- IV benzylpenicillin & gentamycin for 6 weeks
| - If staph suspected- vancomycin instead of penicillin
176
PERICARDITIS
Viral Causes?
- Coxsackie B
- HIV
- Varicella
- Mumps
- Influenza
- Echovirus
177
PERICARDITIS
Bacterial Causes?
- Staphs/ Streps
178
PERICARDITIS
Symptoms?
- Sharp retrosternal chest pain
- Pain worse on inspiration, lying flat
- Leaning forward relieves!!!!!!!!
179
PERICARDITIS
Cardinal Signs?
Pericardial Rub
180
PERICARDITIS
ECG changes?
- Concave ST elevation in ALL leads
181
PERICARDITIS
Bloods?
increased CRP, WCC, troponin
182
PERICARDITIS
Treatment?
- treat underlying causes + NSAIDs
183
CONSTRICTIVE PERICARDITIS
What is it?
when the heart is enclosed in a rigid, fibrotic pericardium, preventing diastolic filling of ventricles
184
CONSTRICTIVE PERICARDITIS
Symptoms?
Symptoms of right HF:
- Ascites
- Lower limb oedema
- increased JVP
185
CONSTRICTIVE PERICARDITIS?
Tests and treatment?
CXR shows calcification
Treated with pericardiectomy
186
PERIPHERAL ARTERIAL DISEASE
| Risk Groups?
- CAD
- Atherosclerosis
- General CVS problems
187
PERIPHERAL ARTERIAL DISEASE
Symptoms?
- Intermittent Claudication
(cramp felt in calf, buttock or thigh after walking a certain distances- relieved by rest)
- burning or numbness
- Differences between limbs in relation to colour and/or warmth
- Decreased rate of hair and nail growth on the impacted limb
188
PERIPHERAL ARTERIAL DISEASE
Stages of PAD?
1) Asymptomatic
2) Intermittent Claudication
3) Ischaemia rest pain
4) 3+ gangrene/ ulceration (critical ischaemia)
189
PERIPHERAL ARTERIAL DISEASE
A normal Ankle Brachial Pressure Index is 1-1.2, what would somebody's ABPI be if they had PAD?
0.5-0.9
190
PERIPHERAL ARTERIAL DISEASE
Signs?
- Absent lower limb pulses
- cold, white legs
- ulcers
- atrophic skin
- slow growth of nails and hair
191
PERIPHERAL ARTERIAL DISEASE
Investigations?
- Colour duplex ultrasound
- FBC- anaemia
- ABPI
192
PERIPHERAL ARTERIAL DISEASE
Treatment?
1) risk factor modification (e.g. smoking, control BP/cholesterol, antoiplatelet- clopidogrel)
2) Manage claudication
- exercise programmes- increase collateral blood flow
- exercise to point of maximum pain
3) Revascularisation
- percutaneous transluminal angioplasty (PTA)- balloon in narrowed segment
4) Surgical Reconstruction - arterial bypass graft
193
CARDIOMYOPATHY
What is it?
Disease of the myocardium
194
HYPERTROPHIC CARDIOMYOPATHY
Causes?
Autosomal dominant Mutations
Hypertrophic non-compliant ventricles impair diastolic filling and reduce SV so results in HEART FAILURE
195
HYPERTROPHIC CARDIOMYOPATHY
Symptoms?
- Asymptomatic
- Breathless, angina, syncope
- jerky carotid pulse
- ejection systolic murmur
- pansystolic murmur
196
HYPERTROPHIC CARDIOMYOPATHY
Investigations?
ECG- LVH and progressive T wave inversion
Cardiac Imaging:
- Ventricular Hypertrophy (echo and MRI)
- fibrosis (MRI)
197
HYPERTROPHIC CARDIOMYOPATHY
Treatment?
- b- blockers or verapamil (CCB)
- amiodarone for arrhythmias
- anticoagulate to avoid emboli
- consider implantable defib if HIGH RISK
198
DILATED CARDIOMYOPATHY
Features? (same as HF)
- Dyspnoea
- Emboli or arrhythmia
- Progressive HF
- increased JVP, HTN
199
DILATED CARDIOMYOPATHY
Investigations
- CXR
- ECG
- Echo
200
DILATED CARDIOMYOPATHY
treatment?
- bed rest
- diuretics
- digoxin
- ACE inhibitors
- anti- coagulate
implantable defib
201
ATRIAL SEPTAL DEFECT
What is it?
a hole that connects the atria
202
Which cardiac drugs:
Control rate?
Restore sinus rhythm?
Reduce Hypertrophy?
beta blockers (control rate)
Amiodarone (restore sinus rhythm)
ACE-I (reduce LV hypertension)
203
ATRIAL SEPTAL DEFECT
Investigations?
- ECG ( RBBB with LAD and prolonged PR interval)
| - CXR- small aortic knuckle and pulmonary plethora
204
ATRIAL SEPTAL DEFECT
Treatment?
transcatheter closure> surgery
205
What is an Atrioventricular Septal Defect (AVSD) and what disease often causes AVSD?
A hole in the centre of the heart seen often in Down's syndrome.
206
What is a Patent ductus Arteriosus and what does it require?
Persistent communication between proximal left PA and descending aorta- continuous left to right shunt that requires a heart transplant
207
What is restrictive cardiomyopathy identical to clinically?
Restrictive pericarditis (R sided failure)
208
How is diagnosis of restrictive cardiomyopathy made, and what is the treatment?
Diagnosis by cardiac catheterisation showing characteristic pressure changes. No treatment.
209
SHOCK
What is it?
Circulatory failure resulting from inadequate organ perfusion
210
SHOCK
Give 6 signs
```
anuria,
low GCS,
tachycardia,
tachypnoea,
agitation,
confusion,
pallor (unhealthy, pale appearance)
```
211
SHOCK
What are the types of shock?
Hypovolaemic: bleeding, trauma, burns, dehydration.
Cardiogenic: acute coronary syndromes, arryhthmias, cardiac tamponade, PE.
Septic: systemic inflammatory response syndrome
sepsis: SIRS occurring with an infection.
Septic shock: sepsis with organ hypoperfusion.
Anaphylactic: mast cell degranulation.
Neurogenic: attributed to the autonomic pathways in spinal cord. Surgery, trauma.
212
SHOCK
What is the definition of SIRS, and when does this become sepsis? How is sepsis managed?
SIRS: systemic inflammatory response syndrome
(Temp <36 or >38, tachypnoea>20, tachycardia>90, white cells > 12,000/L, hyperglycaemia. I like my TTT white with sugar.).
Sepsis is SIRS + Infection.
BUFALO: blood cultures, urine output, fluids, antibiotics (don’t delay past 1 hour. Good cover is IV co-amoxiclav + IV gentamicin + IV metronidazole), lactate, oxygen.
213
SHOCK
How is sepsis managed?
```
BUFALO:
blood cultures,
urine output,
fluids,
antibiotics (don’t delay past 1 hour. Good cover is IV co-amoxiclav + IV gentamicin + IV metronidazole),
lactate,
oxygen.
```
214
SHOCK
Management of anaphylaxis?
Secure airway. Remove cause. 0.5ml of 1/1000 adrenaline IM, repeating every 5 mins, IV hydrocortisone, chlorphenamine.
anti-histamines
215
SHOCK
What cells are involved in anaphylaxis?
It is a Type 1 IgE- mediated hypersensitivity and involves the degranulation of MAST CELLS that release histamine
216
SHOCK
What are the stages (in terms of blood loss) of hypovolaemic shock, and how is it managed?
1: 0-15%.
2: 15-30%.
3: 30-40%.
4: >40%.
Treat by identifying the cause and stopping it and giving fluids.
217
When are congenital heart defects particularly dangerous?
During pregnancy
218
What are the 4 things in tetralogy of Fallot?
1) Ventricular septal defect,
2) overriding of the aorta of the VSD into LV and RV,
3) pulmonary stenosis,
4) right ventricular hypertrophy.
219
Tetralogy of Fallot
What pressure differences are there between the R and L and what does this cause?
Pulmonary stenosis causes RV pressure to be higher than LV pressure, so blood goes right to left. Causes cyanosis of patient.
220
Tetralogy of Fallot
What does CXR show and how is it managed?
Boot shaped heart. Managed with surgery before age of 1.
221
What pressure changes occur in Ventricular Septal Defect?
LV higher than RV, so blood flows from left to right.
222
What can a large Ventricular Septal Defect cause? Why is this bad?
High pressure into pulmonary vasculature = damage. This resists flow and RV pressure increases, becoming higher than the left and the shunt is reversed – Eisenmenger’s syndrome.
Bad as there is a really poor prognosis.
223
ATRIAL SEPTAL DEFECTS
What causes atrial septal defects?
Ostium secundum defects.
224
ATRIAL SEPTAL DEFECTS
Which way is blood shunted?
LA to RA
225
ATRIAL SEPTAL DEFECTS
Give 2 clinical features.
Dyspnoea at 40-60, pulmonary flow murmur.
226
What 3 shunts can there be?
Intra-atrial, intra-ventricular, or both combined
227
When is a patent ductus arteriosus more likely, and what does it cause in terms of blood flow?
In premature babies. Causes torrential bloodflow to lungs in infancy causing dyspnoea.
228
At what point are most cases of coarctation of the aorta?
Just distal to L subclavian artery
229
What murmur is heard in patent ductus arteriosus?
A continuous machinery murmur (throughout the whole cycle)
230
What will a mild coarctation present with, and what is the classic sign?
Hypertension in the 20’s. sign is radiofemoral delay.
231
What murmur would be heard in a mild coarctation?
Systolic murmur over scapulae due to collaterals being formed.
232
How is mild coarctation diagnosed and treated?
Diagnosed with CT, treated with surgery.
233
What is the inevitable fate of a bicuspid aortic valve?
Aortic stenosis
234
Give 3 things that severe pulmonary stenosis causes.
Pulmonary hypertension, dyspnoea, RV failure, collapsing
235
How is pulmonary stenosis treated?
Balloon valvuloplasty
236
What is arryhthmogenic cardiomyopathy caused by?
Desmosome mutations affecting gap junctions
237
What does arrhythmogenic cardiomyopathy present with on ECG?
epsilon waves after QRS
238
What is Eisenmenger's syndrome?
1) Ventricular septal defect causes increased blood flow to pulmonary arteries.
2) Eisenmenger syndrome occurs when the pressure in the pulmonary arteries becomes so high that it causes oxygen-poor (blue) blood to flow from the right to left ventricle (shunt reversal)
3) This goes to the body, causing cyanosis. The high pressure also causes the wall of your heart's right ventricle to thicken (hypertrophy).
