Cardiology Flashcards
(214 cards)
1
Q
Murmur and signs in mitral stenosis
A
Mid diastolic murmur
Loud and palpable S1
AF
Opening snap
2
Q
Complication of mitral stenosis
A
Pulmonary hypertension
3
Q
Murmur and signs in mitral regurgitation
A
Pansystolic murmur, radiating to axilla, ‘blowing’.
Soft S1
S3 sound
4
Q
Murmur and signs in mitral prolapse
A
Late systolic murmur
Mid-systolic click
5
Q
Murmur and signs in aortic stenosis
A
Harsh, ejection systolic murmur
Delayed and diminished carotid pulse = parvus et tardus
LV heave
Aortic thrill
6
Q
Management of aortic valve pathology
A
Transcatheter aortic valve implantation
Valve replacement
7
Q
Murmur and signs in aortic regurgitation
A
High pitch diastolic murmur
Waterhammer/collapsing pulse
Austin flint murmur if severe
Hyperdynamic apex beat
8
Q
Most common cause of tricuspid stenosis
A
Rheumatic fever
9
Q
Most common cause of tricuspid regurgitation
A
Functional e.g. LV failure.
10
Q
Murmur in tricuspid stenosis
A
Diastolic murmur on inspiration
11
Q
Murmur in tricuspid regurgitation
A
Parasternal pansystolic murmur.
12
Q
Most common cause of pulmonary stenosis
A
Congenital e.g. Noonan’s, Turner’s.
13
Q
Murmur in pulmonary stenosis
A
Ejection systolic murmur radiation to back/shoulder.
14
Q
Most common cause of pulmonary regurgitation
A
PULMONARY HTN AND ITS CAUSES
15
Q
Murmur in pulmonary reurgitation
A
Crescendo diastolic murmur.
Graham-Steell murmur
16
Q
Kussmaul sign
A
Rise in JVP on inspiration, or lack of fall when inspiring due to right side of heart unable to hold venous return. e.g. constrictive pericarditis, cardiac tamponade
17
Q
Pathophysiology triad for ACS symptoms
A
Virchow’s triad. Hypercoagulability + endothelial damage + blood flow stasis
18
Q
Differences between unstable angina, STEMI and NSTEMI
A
Biochemical and and clinically:
UA = can have no ECG changes. No rise in troponin.
STEMI = ST elevation in leads anatomically correlated to infarct. Rise in troponin.
NSTEMI = no ST elevation. Troponin elevation.
19
Q
Initial management of ACS
A
MONA = (oxygen), GTN, aspirin, morphine.
ECG!!!!!
Anti-platelet: Aspirin 300mg and ticagrelol 180mg (or clopidogrel)
Anticoagulation: Fondaparinux
20
Q
Long term management of ACS and beneficial pharmacology effect
A
Beta blockers (Bisprolol) - decrease HR, decrease contractility, ACE inhibitor (ramipril) - vasodilator to decrease preload, block sympathetic activity, inhibit remodelling. Statin - lower cholesterol. Lifelong aspirin, continue ticagrelol for 1yr - prevent clots. Definitive treatment = percutaneous coronary intervention.
21
Q
Driving after ACS
A
4 weeks
22
Q
Sex after ACS
A
2 weeks
23
Q
Working after ACS
A
6 weeks
24
Q
Name of a non-pathological arrhythmia seen in young people
A
Sinus arrhythmia. Respiration cycle causes change in P-R interval.
25
Causes of sick sinus syndrome
```
Amyloidosis, Sarcoidosis.
Idiopathic degeneration and fibrosis of sinus node.
Surgical injury
Digoxin, CCBs, beta-blockers.
Cardiomyopathies
```
26
Name for alternating bradycardia and paroxysmal tachycardia
Bradycardia-tachycardia syndrome. Can get syncope in transition as node recovers.
27
Drugs causing sinus bradycardia
Opiates, beta-blockers, CCB, digoxin.
28
Drugs causing sinus tachycardia
Caffeine, salbutamol, atropine, cocaine, carbamazepine, adrenaline.
29
'Camel hump' T waves
Sinus tachycardia as P waves morphed into T waves.
30
3 categories and examples for supra-ventricular tachycardias
1) Regular and originate from atria e.g. atrial flutter, sinus tachycardia.
2) Irregular and originate form atria e.g. atrial fibrillation, multifocal atrial tachycardia.
3) Regular and AV origin e.g. AV nodal re-entry tachycardia and AV re-entry tachycardia.
31
ECG in atrial flutter
Re-entrant circuit.
ECG =
'saw tooth' flutter/F waves, best seen in leads 2,3 and aVF.
rate >300bpm.
atria to ventricular activity ratio = AV block e.g. 2:1 (most common) or 3:1.
32
ECG in atrial fibrillation
No P waves
Oscillating baseline
Narrow QRS
33
Assessing risk of AF in patients
HAS-BLED - risk of major bleed for AF patients on anticoagulation.
CHA2DS2VASc - risk of an AF patient having a stroke.
34
Slow AF
<60bpm
| Seen in hypothermia and digoxin toxicity.
35
4 categories and examples of AF treatment
1) Anticoagulate e.g. Apixaban.
2) Rate control e.g. cardioselective beta-blocker (bisoprolol) or CCB.
3) Rhythm control e.g. amiodarone or cardioversion.
4) Definitive e.g atrial ablation and pacemaker.
36
ECG in multifocal atrial tachycardia
3 distinct P wave morphologies in a single lead.
37
Patients at higher risk of multifocal atrial tachycardia
COPD and CHF
38
Typical patient and presentation of AVNRT
Female.
| Paroxysmal but can be triggered by exertion, caffeine, alcohol.
39
2 circuits in AVNRT
alpha/slow
beta/fast
Subtype depends on which pathway has retrograde activity.
40
Idiopathic disease for heart block
Lev's Disease
41
1st degree heart block ECG
Long PR interval
42
2nd degree, type 1 heart block ECG
Progressively longer PR interval and then a dropped beat/no QRS.
43
2nd degree heart, type 2 block ECG
Random dropped beats but no changes in PR interval.
44
3rd degree heart block ECG
No conduction to ventricles results in random QRS complexes (via escape beats) with no relation to P waves.
45
Management of 3rd degreee heart block
Atropine to increase HR
| Transcutaneous pacing
46
Causes of bundle branch block
```
Both = MI, myocarditis, cardiomyopathy.
Right = PE
Left = HTN, digoxin toxicity.
```
47
ECG of LBBB
Small R wave and deep S wave in V1 (W)
Upgoing broad R wave in V6, can be notched (M)
Impulses are travelling towards V6 away from V1 as travels from RV to LV.
48
ECG of RBBB
Tall and late terminal R wave in V1, RSR configuration (M)
| Wide and deep, slurred S wave in V6 (W)
49
Life threatening ventricular TC
| Which arrhythmias can you shock?
Life threatening = Sustained VT and VF
| Shockable = pulseless VT and all VF
50
ECG of VT
```
Wide QRS.
Absent PR interval, can have P waves but they are no associated with QRS pattern.
Fast rate (over 100bpm can be 250bpm).
```
51
Management of VT
- If haemo-dynamically unstable (shock, MI, HF or syncope) 3 attempts at synchronised DC shock + 300mg IV Amiodarone over 20mins.
- If haemo-dynamically stable give 300mg IV Amiodarone
- Correct any electrolyte imbalances.
- Sedation / muscle relaxant (benzodiazepines)
52
Causes of sustained VT
Sustained = HR >100bpm with broad complex QRS lasting for at least 30 seconds.
Ischaemic heart disease
Coronary artery disease
Cardiomyopathy
53
ECG of VF
No QRS complexes, no P waves.
No HR
Chaotic, rapid oscillating baseline.
54
Symptoms and signs in VF
Pulseless and unconscious.
55
Management of VF
- Will most likely be haemo-dynamically unstable (shock, MI, HF or syncope) so give 3 attempts at synchronised DC shock + 300mg IV Amiodarone over 20mins.
- Correct any electrolyte imbalances.
- Consider analgesia or muscle relaxant (benzodiazepines)
56
Causes of VF
```
Coronary artery disease
Hypoxia
Ischaemic
Post DC shock
Anti-arrythmic drugs
```
57
Torsades de Pointes ECG
Fast HR
Prolonged QT interval
Twisting QRS complexes rotating around the isoelectric line.
58
Torsades de Pointes description, Ix and Mx
Polymorphic ventricular tachycardia, QRS amplitude varies and complexes appear to twist on isoelectric baseline.
Ix: U+E, cardiac enzymes, ECG = tachycardia, twisting of QRS complexes, prolonged QT interval.
Mx: A to E
IV Magnesium
Isoprenaline (beta1-agonist, decrease QT interval but accelerates HR)
Cardioversion if VF or VT develop.
59
Causes of long QT interval
```
Congenital = Jervell-Lange-Nielson
Drugs = Tricyclic antidepressants, sotalol
Electrolytes = Hypokalaemia, hypomagnesia, hypocalcaemia.
Acquired = Acute MI
```
60
Treatment in HF which improves prognosis (NOT symptomatic)
Beta-blockers
ACE inhibitor or ARB
Aldosterone antagonist e.g. spironolactone.
61
Complication of acute HF
Cardiogenic shock
62
Signs and symptoms of cardiogenic shock
```
Patient sat upright, pale, clay and coughing (can bring up frothy pulmonary oedema)
Chest pain
Altered consciousness
Low BP
High HR
High respiratory rate
Low PaO2 sats
Cold extremities and prolonged cap refill.
```
63
Management of cardiogenic shock
A to E
Close monitor and investigations (ABG, FBC, U and E)
IV glyceryl trinitrate
Morpcine
Consider IV fluids, IV dobutamine (inotropic).
64
Angina
Constricting discomfort in front of chest, shoulders, jaw and arms.
Precipitated by physical exercise.
Relieved by rest to GTN spray
65
Investigations for angina
FBC - anaemia
ECG
Fasting lipid profile
CT coronary angiogram
66
What percentage of stenosis can cause angina?
70%
67
4 modifiable and 4 non-modifiable risk factors for unstable angina
```
Modifiable = obesity, smoking, high cholesterol, hypertension, anaemia.
Non-modifiable = male, DM, Fx, advancing age.
```
68
Management of angina
REFER TO RAPID ACCESS CHEST PAIN CLINIC!!
1) Lifestyle = stop smoking, dietary advice, optimise co-morbidities treatment.
2) PRN = Short-acting nitrate spray e.g. glyceryl-trinitrate.
3) Stable angina Rx = 1st line is beta-blocker or CCB e.g. atenolol/amlodipine. 2nd line add long-acting nitrate (isosorbide mononitrate), Ivabradine or Nicorandil.
4) Secondary CVD prevention = aspirin, ACE inhibitor if diabetic.
5) Not satisfactory control with medical therapy = CABG or PCI.
69
Complications of an MI
```
Cariogenic shock
Mitral regurgiation
Arrythmias
Cardiac arrest
RVF
Dressler's syndrome - recurrent pericarditis
```
70
Investigations in hospital wit ?ACS
```
DO ECG!
Give 300mg aspirin, morphine and GTN.
Troponin I and T (better than CK-MB in first 6hrs).
FBC
Blood glucose
Coronary angiography
```
71
Discuss the cardiac biomarkers ❤️
```
Troponin = Marker of cardiac cell necrosis but can also be raised in skeletal muscle injury. Raised 4-6hrs after injury and stay high for 10 days with peak at 12-24hrs. Test at admission, 6 and 12hrs after pain onset.
CK-MB = more specific than Troponins.
```
72
Treatment for STEMI
- Immediate = morphine, glyceryl trinitrate, aspirin, ECG.
- Assess eligibility for re-perfusion therapy - Can they get to Cath lab within 120 mins = PIC, if no = fibrinolysis.
Percutaneous coronary intervention = +angiography. Within 120mins of time of onset.
Fibrinolysis = present after 120min, use alteplase/reteplase/streptokinase/tenecteplase.
- Fondaparinux until discharge!
- Long term management and secondary prevention = lifestyle advice, aspirin + ticagrelol, beta-blocker, atorvastatin.
73
Scores for risk after ACS
```
GRACE rise score - Global Registry for Acute Cardiac Events (6 month mortality)
Components =
Age
Heart rate
Systolic BP
Creatinine/Renal function
Cardiac arrest on admission?
ST changes on ECG
Abnormal cardiac enzymes (tropI+T)
Signs of congestive HF
```
74
Management of NSTEMI or unstable angina
1) Drugs = Aspirin 300mg and Fondaparinux.
2) Assess risk using GRACE risk score.
3) Low and high risk give Clopidogrel. High risk also give glycoprotein inhibitor e.g. tirofiban.
4) Assess appropriateness for revascularisation. Offer coronary angiography within 96hrs of admission if mod-high risk
5) Long term CVD prevention e.g. beta-blocker, aspirin + clopidogrel, atorvastatin.
75
ECG in STEMI
STEMI = ST elevation, tall T waves, Over hours T wave inversion and pathological Q waves.
76
Modifiable and non-modifiable risk factors for ACS
```
Modifiable = smoking, cocaine use, hypertension, hyperlipidaemia, sedentary lifestyle, obesity.
Non-modifiable = age, male, FHx, DM
```
77
3 common pathophysiological processes in all ACS
Plaque rupture
Thrombus
Inflammation
78
S+S of ACS
```
Acute onset, central, crushing chest pain, radiate down arm or up jaw.
Nausea
Sweating
Palpitations
Light-headedness
```
O/E:
Tachycardia
Pallor
Added heart sounds
79
Differentials for acute onset chest pain
```
ACS
Aortic dissection
Pneumothorax
Pulmonary embolism
Pericarditis
Panic attack
```
80
Aortic stenosis signs and symptoms
Elderly patient.
Symptoms = Chest pain, syncope, HF (exertional dyspnoea).
Signs = ejection systolic murmur which can radiate to carotid, delayed and diminished carotid upstroke (parvus and tardus), LV and apex heave.
81
Ix and Mx for aortic stenosis
```
Ix = ECG, CXR. Diagnostic = echocardiogram.
Mx = valve replacement/TAVI and longterm anticoagulant (warfarin)
```
82
Most common cause of aortic stenosis
Senile calcification.
83
What valve pathology has lots of associated diseases and what are the associated diseases?
Aortic regurgitation.
| Associated with: SLE, Marfan's syndrome, Ehler-Danlos, Turner's syndrome, ankylosing spondylitis
84
Signs and symptoms for aortic regurgitation
Can be acute cardiovascular collapse.
Symptoms = exertional dyspnoea, palpitations, paroxysmal nocturnal dyspnoea.
O/E:
High-pitch diastolic murmur (expiration, patient sat forward), collapsing water-hammer pulse, wide pulse pressure, Austin-flint murmur (rumbling diastolic murmur at apex).
85
Ix and Mx for aortic regurgiation
```
Ix = ECG, CXR, diagnose with echocardiogram.
Mx = reduce HTN with ACE inhibitor, valve replacement + anticoagulation.
```
86
What valve is most susceptible to injury from venous pathogens
Tricuspid e.g IVDU, carcinoid 5-HT tumours.
87
Causes of mitral valve prolapse.
Mitral valve prolapse.
| Seen with atrial septal defect, cardiomyopathy, Turner's syndrome, Marfan's syndrome.
88
Presentation, Ix, Mx and Complications for mitral valve prolapse
Asymptomatic, chest pain, palpitations. Signs = mid-systolic click, late systolic murmur.
Ix = echocardiogram.
Mx = beta-blocker to aid symptoms, surgical valve repair.
Cx = mitral regurgitation, cerebral emboli, arrhythmias, death.
89
Mitral regurgitation causes, presentation, Ix and Mx
```
Causes = LV dilation and functional, calcification, valve prolapse.
Symptoms = dyspnoea, palpitations.
Signs = pan systolic murmur at apex radiating to axilla, displaced apex beat, soft S1 and split S2.
Ix = ECG, CXR, diagnose with echocardiogram.
Mx = manage AF, diuretics may help symptoms, surgical valve repair.
```
90
Mitral stenosis causes, presentation, Ix and Mx
```
Causes = rheumatic fever.
Symptoms = pulmonary HTN (dyspnoea, haemoptysis), palpitations, chest pain.
Signs = mid-diastolic murmur, malar flush on cheeks, loud S1, opening snap/pliable valve.
Ix = ECG, CXR and diagnostic echocardiogram.
Mx = control AF, diuretics may help symptoms, balloon valvuloplasty or replacement.
```
91
Risk factors for hypertension
```
Obesity
High alcohol intake
Diabetes mellitus
Black ethnicity
Fhx
```
92
Stages of hypertension
Stage 1 = clinic BP greater than 140/90 mmHg or average ABPM over 135/85 mmHg
Stage 2 = clinic BP greater than 160.100 mmHg or average ABPM over 150/95 mmHg.
Severe = clinic SBP over 180 mmHg or DBP over 110 mmHg.
Accelerated = clinic BP over 180/110 mmHg + signs of papilloma +/- retinal haemorrhage.
93
Advice for using ABPM or HBPM
- ABPM = record BP twice during every waking hour. Average value of 14 measurements = overall reading.
HBPM = 2 consecutive recordings at least 1 min apart, twice daily, average from days (don't include first day readings).
94
Causes of secondary hypertension
Renal disease e.g. Glomerulonephritis.
Endocrine disease e.g. Cushing's, pheochromocytoma.
Pregnancy
Drugs = COCP, cocaine, steroids, MAOI.
95
Signs and symptoms of hypertension
Asymptomatic.
Headache
Visual changes, retinopathy.
Proteinuria
96
Ix for HTN
Clinic BP and then ambulatory or home blood pressure monitoring.
Quantify risk = serum lipid profile, blood sugar/HbA1c, ECG, urine dipstick, estimate GFR.
97
Mx for hypertension
- Lifestyle advice = increase exercise, healthy diet, reduce alcohol consumption, reduce caffeine intake, stop smoking.
- Medical management for patients with stage 2 HTN (clinic >160/100mmHg or ABPM >150/95mmHg) or above.
- Medical management for patients with stage 1 HTN if they are under 80yrs and have target organ damage or CVD, renal disease, DM, QRisk > 10%.
- Medical management =
1st line: CCB (nifedipine) for over 55yrs or Afro-carribean or ACEi (ramipril) or ARB (losartan) for under 55yrs or a T2DM.
2nd line: if on CCB add ACEi/ARB. If on ACEi/ARB add CCB or thiazide diuretic (indapamide).
3rd line: ACEi/ARB + CCB + thiazide diuretic.
4th line: RESISTANT HTN, add spironolactone or alpha-blocker (tamsulosin).
- Monitoring = BP, drug side effects, eGFR/creatinine, Qrisk.
98
Target BP for HTN patients
If under 80yrs target < 140/90mmHg
If over 80yrs target <150/90mmHg
If diabetic less than 130/80.
99
Mx for malignant HTN
```
A-E
IV Labetalol (beta-blocker)
IV Nicardipine (CCB)
```
100
Use of digoxin
Fast AF
101
Describe narrow complex tachycardias
HR >100bpm, QRS complex <120ms.
| e.g. Atrial fibrillation, atrial flutter.
102
Management of AV nodal re-entry tachycardia and AV re-entry tachycardia.
Vagal manoeuvres e.g. carotid sinus massage, Valsalva manoeuvre.
IV adenosine
103
Describe broad complex tachycardia
HR >100bpm, QRS complex >120ms.
May have no clear QRS complexes.
e.g. VF, VT, Torsades de Pointes.
104
Management of narrow complex tachycardia
If HR regular (NOT AF) - Vagal maneourvers + IV. adenosine. Do ECG to assess whether atrial flutter or re-entry.
If HR irregular (AF) - beta-blocker + digoxin or Amiodarone
105
Long term management for VF
beta-blocker
| Implantable cardioverter defibrillators
106
Brugada Syndrome
Genetic disease - autosomal dominant. Mutation in sodium channels.
Increased risk of sudden death.
ECG = coved ST segment elevation (>2mm in at least one of V1, V2 or V3), inverted T waves.
Mx = implantable cardioverter defibrillator, screen family!!
107
Treatment of a bradycardia
Review drugs
IV atropine
Transcutaneous pacing
108
What arrythmia is seen in Wolff-Parkinson-White syndrome. Describe the condition, the ECG and the management.
Atrial impulses can by-pass AV node and cause premature ventricular activity via Bundle of Kent structure.
Type of supraventricular TC --> atrioventricular re-entrant tachycardia.
ECG = delta waves (slurred upstroke), short PR, wide QRS complexes.
Mx = Amiodarine, flecainaide, DC shock if unstable. Curative = radio frequency ablation.
109
Symptoms and signs in a patient with a supraventricualr tachy
Palpitations, fatigue, light-headedness, chest discomfort, syncope.
110
Ix for atrial flutter
Thyroid function (hyperthyroid can cause flutter)
FBC (anaemia)
U+E
Renal function
111
Define atrial fibrillation
An irregularly irregular pulse.
Supraventricular tachyarrhythmia due to an irregular, disorganized electrical activity and ineffective contraction of the atria.
112
Causes and risk factors for AF
```
Cardiac = CHF, sick-sinus syndrome, myocarditis.
Non-cardiac = sepsis, PE, thyrotoxicosis.
Lifestyle = obesity, excess caffeine, high alcohol intake, smoking.
Drugs = thyroxine.
```
113
Complications of AF
Increased risk of stroke, thromboembolism.
| Heart failure
114
S+S of AF
Symptoms = breathless, palpitations, chest discomfort, syncope or dizziness, reduced exercise tolerance.
O/E = pulse palpation feels irregular.
115
Ix and expected results for AF
ECG = no P waves, irregular and fast ventricular rate, chaotic baseline.
Is ?paroxysmal AF do 24-hr ambulatory ECG.
Echocardiogram not routine but may be used in potential cardio version, functional heart disease etc.
Bloods = thyroid function, U+E, FBC, BM
116
Mx for AF
1) Prevent stroke/thrombi = assess risk with CHA2DS2VASc and HAS-BLED. Anticoagulants to be used include apixaban, rivaroxaban, warfarin (vit K antagonist).
2) Rate control = 1st line is beta-blocker e.g. atenolol or CCB e.g. amlodipine. Can combine two or add diltiazem/digoxin.
3) Rhythm control = cardioversion +amiodarone
4) Advise = can still fly, need to inform DVLA (responsibility of patient), annual review
117
Describe the 'pill in pocket stratgey'
Paroxysmal AF patients have an anti-arrythmic drug prescribed to them but do not take it regularly. Take it PRN when an episode of AF is starting.
118
CHA2DS2VaSc
```
Assess an AF patient's risk of a stroke.
C = congestive heart failure.
H = HTN
A = age (over 75yrs =2, 65-74 =1)
D = DM
S = stroke
Va = vascular disease e.g. Hx of MI or VTE
S = sex
```
119
HAS-BLED
Assess an AF patient's risk of a bleed when on anti-coagulants.
```
Labile INR
Over 65yrs
Meds which increase risk of bleeding e.g. NSAIDs
Alcohol abuse
Uncontrolled HTN
Hx of predisposition to bleeding
Abnormal renal function
Abnormal liver function
Stroke Hx
```
120
Pros and Cons of DOAC and warfarin
Warfarin - need to monitor INR, longer half-life so missing a dose not as drastic.
DOACs - fast onset of action, increased GI bleed, decreased CNS bleed.
121
What is a cardiac tamponade
Pericardial effusion.
| Increase in intrapericardial pressure reduces ability for ventricles to fill and thus lowers cardiac output.
122
Presentation of a cardiac tamponade. Ix and Mx
Sudden cardiac arrest.
O/E = BECK'S TRIAD: FALLING BP, RAISED JVP AND MUFFLED HEART SOUNDS. tachycardia, pulses paradoxus (decrease in stroke volume on inspiration), Kassmaul's sign.
```
Ix = diagnose with echocardiogram. Also consider CXR, ECG.
Mx = urgent drainage from specialist = pericardiocentesis. Send drained fluid for culture, acid-fast stain/TB culture and cytology.
```
123
Causes of pericardial effusions
```
with infection - TB, fungi
Malignancy
Trauma
Ruptured aortic aneurysms
Post-cardiac surgery
Acute MI
```
124
S+S of pericardial effusion
```
Depend on size and onset.
Chest discomfort relieved by sitting up and leaning forward, worsened by lying down.
Syncope or light-headedness.
Palpitations
Signs of compression - nausea, hiccups.
```
O/E: Beck's triad for a cardiac tamponade.
Ix and Mx similar for cardiac tamponade.
125
Complications of HTN
```
Macrovascular = atherosclerosis, stroke, MI and peripheral vascular disease.
Microscopic = nephropathy, retinopathy and neuropathy.
```
126
Which HTN patients would you not give an ACE inhibitor to ?
Renal artery stenosis and BP will increase.
127
Systolic V Diastolic heart failure
```
Systolic = unable for ventricles to maintain adequate cardiac output. Causes = cardiomyopathy, MI, IHD.
Diastolic= unable to relax and fill with required volume, have preserved ejection fraction. Causes = constrictive pericarditis, HTN, tamponade.
```
128
Left v Right heart failure
Left HF symptoms = dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea (how many pillows they sleep with??), cough.
Right HF symptoms = peripheral oedema, nausea, raised JVP/Kassmaul's sign, hepatomegaly, ascites.
129
Ix for ?Heart failure and expected results
Bloods = Renal function profile, thyroid function profile, liver function profile, lipid profile, HbA1c, FBC, NT-proBNP
Other primary care Ix = ECG, Urine dipstick analysis, Spirometry and peak flow.
CXR = alveolar oedema, Kerley B lines for interstitial oedema, cardiomegaly, dilated prominent upper lobe vessels, pleural effusion.
Doppler 2D transthoracic echocardiogram to exclude structural defects.
130
Symptoms and signs for congestive heart failure and how are they used?
```
Framingham criteria (2 major or 1 major + 2 minor =∆).
MAJOR = Paroxysmal nocturnal dyspnoea, crepitations, cardiomegaly, S3 gallop, increased central venous pressure, neck vein distention, acute pulmonary oedema, hepatojugular reflux.
```
MINOR = Bilateral ankle oedema, dyspnoea, tachycardia, nocturnal cough, hepatomegaly, pleural effusion.
131
Causes of false high and false low NT-proBNP
is also high in = diabetes, COPD, sepsis, under 70yrs, liver failure.
is also low in = beta-blockers, spironolactone, ACEi, obesity, diuretics.
132
Classification for heart failure
New York Heart Association Classification of Heart Failure.
133
Management of heart failure with reduced ejection fraction (systolic failure)
1) Lifestyle advice - reduce fluid and salt consumption, stop smoking, reduce alcohol intake. Annual influenza flu vaccine.
2) ACE inhibitor (ramipril) or beta-blocker (atenolol) to Rx and loop diuretic to improve symptoms (furosemide)
3) add mineralocorticoid receptor antagonist (spironolactone).
4) Specialist referral and consider Ivabradine or digoxin.
134
Management of heart failure with preserved ejection fraction (diastolic failure)
Review medications
Loop diuretic to alleviate symptoms
Annual influenza vaccine
135
Acute decompensation of chronic heart failure
Caused by = MI, papillary muscle rupture, new-onset mitral regurgitation, arrhythmias, PE, infection, AKI etc etc.
Leads to = Pulmonary oedema, cardiogenic shock.
136
Acute heart failure Ix and Mx
```
Ix = ECG, NT-proBNP, U+E
Mx = A-E resuscitation, supplementary oxygen, loop diuretic (furosemide), beta-blocker (bisprolol), ACEi/ARB, may need Spironolactone too.
```
137
In hospital management of a cardiac arrest
- Call resuscitations team (2222 or 999).
- CPR 30 compressions to 2 rescue breathes.
- Maintain airway and administer oxygen.
- Gain vascular access.
- Attach defibrillator and assess if rhythm shockable --> if it is then shock + adrenaline every 3-5mins.
- IV Amiodarone after 3 shocks.
138
Reversible causes of cardiac arrest
```
Hypoxia
Hypovolaemia
Hypo/hyper-kalaemia
Hypothermia
Thrombus (coronary or pulmonary emboli)
Tension pneumothorax
Cardiac Tamponade
Toxins
```
139
Definitive values for postural/orthostatic hypotension
Take BP while sitting and then take again after 3 minute of standing.
Reduction in systolic BP by 20mmHg or diastolic BP by 10mmHg.
140
Causes of postural/orthostatic hypotension
Old age, Parkinson's disease, dehydration, antihypertensive drugs.
141
Rheumatic fever pathophysiology and presentation
Autoimmune disease post LANCEFIELD GROUP A BETA-HAEMOLYTIC STREPTOCOCCAL THROAT INFECTION.
Attack on joints, heart, brain and skin. 2 week latent period from throat infection to rheumatic fever.
Peak incidence in 5-15yrs.
REVISED JONES CRITEIA ∆:
- evidence of a group A strep infection (+ve throat swab, antigen +ve, raised strep antibody titre, recent Scarlet fever).
- Carditis = tachycardia, cardiomegaly, murmur, chest pain, pericardial rub etc.
- Arthritis = 'flitting' polyarthritis of larger joints.
- Erythema marginatum = small, painless mobile nodules on extensor surfaces of joints and spine.
- Sydenham's chorea = late sign.
- Other = fever, raised CRP, arthralgia, prolonged QT, Hx of rheumatic fever.
142
Ix and Mx for rheumatic fever
FBC - raised WCC.
Inflammatory markers - raised ESR and CRP.
Blood cultures.
Throat swab, rapid antigen test for group A strep, anti-streptococcal serology.
CXR, ECG + echocardiogram.
Mx = Bed rest. Benzylpenicillin, analgesia (NSAIDs/PCM). Consider secondary prophylaxis with BenPen.
143
Fever and new heart murmur ...?
INFECTIVE ENDOCARDITIS UNTIL PROVEN OTHERWISE 🦠
144
Common pathogens to cause infective endocarditis
```
Streptococcus viridians
Staph aureus (IVDU, tricuspid valve, RH signs)
Staphylococcus epidermidis (prosthetic valves)
```
145
Presentation of infective endocarditis
Fever, malaise, night sweats, weight loss, myalgia.
Shortness of breath
Roth's sports - retinal haemorrhage with pale centre (due to vasculitis)
Osler's nodes - red, painful blister on phalanges (due to vasculitis).
Murmur
Janeway lesions - painless red maculae on palms and soles from micro-emboli.
Anaemia
Arthritis
Splinter nail haemorrhage
Clubbing
146
Ix and diagnostic criteria for infective endocarditis
Modified Duke Criteria (2 major or 1 major + 3minor):
- Major = Positive blood culture and Endocardium involvement (echocardiogram/CT).
- Minor = Predisposition/at risk, fever, vascular stigmata (Janeway), immunological stigmata (Osler's).
Ix = 3xblood cultures, FBC, inflammatory markers, U+E, LFT, urinalysis, CXR, echocardiogram/CT.
147
Management of infection endocarditis
Broad-spec empirical ABx e.g. flucloxacillin/amoxicillin + gentamicin.
148
Myocarditis pathophysiology and causes
Inflammation of the myocardium without Ischaemia.
Causes (only some examples, there are lots and lots and lots and lots):
- Viral e.g. Enteroviruses, CMV, EBV, mumps, hepatits, influenza, Coxsackie, herpes simplex.
- Bacterial e.g. Staph, Strep, Mycoplasma pneumoniae, TB.
- Spirochaetes e.g. Lyme disease.
- Protozoea e.g. toxoplasmosis.
- Drugs e.g. cyclophosphamide, spironolactone, carbamazepine
- Immunological e.g SLE, Kawasaki's.
IDIOPATHIC
149
Symptoms + signs, Ix and Mx for myocarditis
```
Presentation = Similar to ACS - central, crushing chest pain, FEVER, Palpitations, Fatigue. O/E: Tachycardia, S3 gallop.
Ix = rule out ACS (cardiac enzymes!), ECG, CXR, echocardiogram, gold standard = end-myocardial biopsy.
Mx = supportive Rx e.g. anagelsia and treat underlying cause.
```
150
Complications of myocarditis
Dilated cardiomyopathy
| Atrial fibrillation
151
Areas of the heart correlating to ECG leads and main coronary artery
```
Inferior = II, III, aVF (Right coronary)
Septal = V1 and V2 (Left anterior descending)
Anterior = V3 and V4 (Left anterior descending)
Lateral = I, aVL, V5 and V6 (Circumflex)
```
152
Difference between acute pericarditis and constrictive pericarditis
Acute pericarditis = inflammation of the pericardium, acute onset (<6 weeks).
Constrictive = complication of acute pericarditis which impedes diastolic filling.
153
S+S of acute pericarditis
Sharp, severe retrosternal chest pain. Increased pain on inspiration and lying down, relieved by sitting forward.
O/E:
Low grade fever
Tachypnoea
Tachycardia
Pericardial friction rub on auscultation.
Evidence of pericardial effusion/tamponade (falling BP, rising JVP and muffled heart sounds)
154
Complications of acute pericarditis
Constrictive pericarditis
| Pericardial effusion and cardiac tamponade
155
Ix and Mx for acute pericarditis
- FBC, ESR/CRP, U+E, cardiac enzymes (rule out ACS).
- ECG = saddle shaped/concave ST segment elevation + PR interval depression (can be normal too).
- Echocardiogram
Mx = NSAIDs+PPI, reduce risk of reoccurrence with Colichicine. If effusion do pericardiocentesis. If purulent consider ABx.
156
How can you reduce the risk of pericarditis reoccurrence
Colchicine
157
ECG in pericarditis
Diffuse, concave/saddle-shaped ST elevation.
| PR interval depression.
158
Causes of pericarditis
```
Viral = EBV, CMV, Coxsackie, Mumps.
Bacterial = TB (granulomatous inflammation), Mycoplasma pneumoniae.
Autoimmune = SLE, Rheumatoid arthritis.
Drugs = hydralazine, procainamide.
Other. = trauma, surgery, malignancy, uraemia.
```
159
Constrictive pericarditis: S+S, Ix and Mx
```
S+S = Similar to right heart failure
Raised JVP
+ve Kassmaul's sign
Soft apex beat
Oedema, ascites.
```
```
Ix = CXR (small heart), CT, Echocardiogram.
Mx = surgical excision
```
160
Describe Dressler's Syndrome
Occurs after event such as MI or heart surgery.
Recurrent pericarditis.
S+S = recurrent fever, chest pain, pericardial rub, pericardial effusion..
Can develop cardiac tamponade (avoid anticoagulants).
Rx = aspirin, NSAIDs + PPI, steroids.
161
Good differential for infective endocarditis
Cardiac myxoma - being tumour. Has similar features of fever, weight loss, clubbing, raised ESR. Ix with echo and Mx via excision.
162
Name 3 cardiomyopathies and which is most common
Dilated cardiomyopathy - most common 🥇🥇
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
163
What are some associations/causes of dilated cardiomyopathy
Dilated, flabby heart.
Alcohol, hypertension, haemochromatosis, congenital (x-linked), thyrotoxicosis, viral infections ( Coxsackie, CMV), autoimmune (SLE, RA).
164
S+S of dilated cardiomyopathy
Sudden cardiac death 💀
Presents as CHF.
Symptoms: fatigue, dyspnoea, poor exercise tolerance.
```
O/E:
Tachycardia, hypotension
Raised JVP
S3 gallop
Pedal oedema, ascites, hepatomegaly.
```
165
Ix and Mx for dilated cardiomyopathy.
Ix = NT-proBNP, CXR (cardiomegaly, pulmonary oedema), ECG, echocardiogram (globally dilated heart).
Mx = Improve symptoms with loop diuretic, ACE inhibitors, beta-blockers.
Biventricular pacing
ICD to prevent sudden death
Transplantation
166
Inheritance of hypertrophic cardiomyopathy and basic pathophysiology
Autosomal dominant. Asymmetrical septal hypertrophy causes obstruction to left ventricle outflow, inability to fill during diastole, risk of myocardial ischaemia and tachyarrythmias.
167
S+S fo hypertrophic cardiomyopathy
Sudden death 💀
Symptoms = angina, dyspnoea, palpitations, syncope.
O/E = 'a' wave in JVP, double apex beat, ejection systolic murmur.
168
Ix and Mx for hypertrophic cardiomyopathy
```
Ix = ECG: left ventricular hypertrophic changes, T wave inversion. Echocardiogram and cardiac catheterisation assess severity.
Mx = beta-blockers or CCb for symptomatic management. Anti-coagulate e.g. apixaban. Surgical septal myomectomy.
```
169
Basic pathophysiology of restrictive cardiomyopathy, some random causes and its presentation.
Normal left ventricle size and systolic functionalists. but there is increased myocardial stiffness leading to poor compliance and poor diastolic filling.
Caused by = sarcoidosis, idiopathic, haemachoromatosis.
S+S = fatigue, dyspnoea, raised JVP, loud S3.
Good differential for constrictive pericarditis.
170
An asian kid who has a fever, is irritable, erythema on hands, bilateral conjunctivitis, rash, swollen lips, cervical lymph glands are up... what is the illness and why is it relevant to cardiology....?
- Kawasaki's disease.
- Must do an echocardiogram because heightened risk of coronary artery aneurysm.
- Rx = IV immunoglobulins and aspirin
171
How do statins work and what are some side-effects
HMG-CoA reductase inhibitors. Help reduce serum LDL levels.
| S/E = Myalgia, GI upset, headache. Monitor LFTs
172
Angina which comes on when the person is lying flat
Decubitas angina
173
Angina which comes on at rest and is only short and is due to coronary artery spasms
Vasospastic/Prinzmetal angina.
174
Pathophysiology behind aortic dissection
Separation between aortic wall intima allowing blood to flow between inner and outer aortic media. This creates a false lumen for blood to flow into.
175
Who has aortic dissections?
Men around 50yrs or older. Hx of HTN, high cholesterol and smoking.
RFx also include Marfan's, Ehlers-Danlos and familial thoracic aortic aneurysms type 1 and 2.
176
Presentation of aortic dissection
Sudden, severe, 'ripping/tearing' pain. Pain migrates as dissection advances - initially retrosternal then moves to back and between scapulae.
Syncope
Limb ischaemia
Angina
O/E: poor/absent peripheral pulses, unequal BP between sides.
177
Ix and Mx for aortic dissection
Ix = Rule out ACS = ECG, cardiac enzymes - DO NOT THROMBOLYSE IN AORTIC DISSECTION - YOU WILL KILL THEM!
Imaging =- CXR, USS in resus but best is CT/MRI angiogram.
Mx = A to E resuscitation, supplementary oxygen, IV fluids, analgesia (morphine), consider use of inotropes e.g. adrenaline.
Beta-blockers - labetalol!!!!
Surgery 🔪
178
Size of normal abdominal aorta and want counts as an aneurysm then? Where are aneurysms most common?
Normal = 2cm, aneurysm >50% enlargement so >3cm is aneurysm.
Most below renal artery junction.
Involve all layers of the aortic wall.
179
RFx/causes of abdominal aneurysms
```
FHx, male, increased age.
Atherosclerotic disease
Smoking
HTN
Hyperlipidaemia
Marfan's, Ehler-Danlos
Arteritis e.g. Takyasu's/Bechet's.
```
180
Presentation of a ruptured AAA
```
Pain in back, abdo, loin/groin (∆∆renal calculi).
Pulsatile, expansile abdo mass
Hypotension
Syncope
Vomiting
Sweaty
Bruit on auscultation.
Signs of shock - decrease level of consciousness, hypotensive, tachycardic, prolonged CRT.
```
If retro-peritoneal can get +ve Grey-Turner's sign = bruising colouration on flank areas.
If not ruptured will be asymptomatic, back pain.
181
Screening for AAA
Males over age of 65yrs are invited.
182
Ix and Mx for ruptured AAA
A-E resuscitation - maintain airway, supplemental oxygen, IV access. Avoid fluids pre-op.
Bloods = U+E, FBC, group + save/crossmatch. catheterise.
preoperative ABx e.g co-amoxiclav.
Alert vascular surgeons - tube graft.
Surgical ASAP over more investigations but if not emergency can do AXR, USS, CT angiography.
183
Chest pain like MI but also haemoptyisis?
Thoracic aortic aneurysm rupture.
184
The most common cause of sudden cardiac death in young people / athletes and what kills them?
Hypertrophic cardiomyopathy.
| Arrythmia from LV outflow tract obstruction
185
2 presentations of a patient who has peripheral vascular disease
Intermittent claudication - pain in lower limbs on exercise.
| Critical limb ischaemia - risk of limb loss high.
186
Mechanisms behind of peripheral artery disease and acute limb ischaemia
PAD = atherosclerosis narrows lower limb arteries.
Acute limb ischaemia = thrombi from atherosclerotic plaque occludes blood vessel. Can also be due to fat, amniotic, or air emboli.
187
Risk factors for peripheral arterial disease
```
SMOKING
Diabetes
Hypertension
Hyperlipidaemia
All of the atherosclerosis ones
```
188
Complications of peripheral arterial disease
Gangrene
| Poor wound healing and ulcers
189
Classification of peripheral arterial disease
```
FONTAINE CLASSIFICATION.
1 = asymptomatic
2 = intermittent claudication
3 = ischaemic pain at rest
4 = ulceration/gangrene/critical ischaemia
```
190
S+S of chronic peripheral arterial disease
Cramping pain in thigh, calf, buttock on walking/exercise (given distance = claudication distance).
Relieved by rest.
```
O/E:
Faint femoral/popliteal/pedal pulses
Cold, pale legs
Atrophic skin
Prolonged CRT
Reduced Buerger's angle
```
191
S+S of critical limb ischaemia and how is management different?
```
S+S =
Ulceration - Punched out ulcers
Gangrene
Foot pain at rest e.g. hangs foot out of side of bed.
Absent femoral/popliteal/pedal pulses
CRT >15seconds.
```
Mx = Duplex USS + CT angiography, vascular MDT, analgesia for pain (pcm), consider surgery before conservative interventions e.g. angioplasty and stenting.
192
What us Buerger's angle
The angle which turns the leg pale when raised. Pathological is <20 degrees.
193
Investigating peripheral arterial disease.
Calculate Ankle Brachial Pressure Index using Doppler US - <0.9 = PAD (normal = 1-1.2).
Assess RFx = HbA1c, lipid profile, FBC, U+E, ESR, ECG.
CT angiography.
194
Management of intermittent claudication
- lifestyle advice to reduce risk = stop smoking, control HTN, anti-platelet drug (Clopidogrel), lower cholesterol with statin.
- Claudication management = exercise programmes.
- Naftidrofuryl oxalate if doesn't want surgery and exercise hasn't worked.
- Non-conservative measures = percutaneous transluminal angioplasty, bypass surgery, amputation.
195
Drug which can be used in chronic PAD
Naftidrofuryl oxalate.
196
S+S of acute limb ischamiea
```
Pale
Pulseless
Painful
Paralysed
Paraesthesia
Perishingly cold
```
197
Ix and Mx for acute limb ischaemia
Hand-held doppler US
Urgent angiography.
Heparin
Emergency reascularization within 6hrs to save limb.
198
Emboli V thrombi in PAD
```
Thrombi = formed in the vessel. Ischaemic pain is insidious in onset, less severe (collateral circulation), Hx of claudication symptoms.
Emboli = not formed locally but can be a break-away from a thrombi. Ischaemic pain is acute onset, profound/severe, mottling of skin.
```
199
Deep vein thrombosis
RFx = cancer, pregnancy, COCP, immobilisation, major surgery.
S+S = unilateral calf warmth, tenderness, swelling, erythema, pitting oedema, prominent superficial vessels
Ix = WELL'S SCORE, d-dimer, Duplex USS, PT/INR, U+E, LFTs, FBC.
Rx =
Pharmacological: LMWH/Fondaparinux. Oral anticoagulants e.g. apixaban. Thrombolytic therapy. Mechanical:vena cava filters.
200
Prevention of DVT
Stop COCP 4weeks pre-op.
Mobilise from surgery quickly.
LMWH for high-risk patients
Compression/TED stockings.
201
CVD risk assessment
QRISK = risk of MI in next 10 years.
| Offer statin if >10%
202
Prescribing oral amiodarone
Class 3 anti-arrytmic drug. Blocks potassium channels.
Need to do thyroid function, LFT, U+E and a CXR before starting.
6 monthly TFT and LFT.
203
Ix for AF
```
Holter monitor
ECG
Bloods: FBC, CRP, D-Dimer, U+E, TFT, troponin, metabolic profile.
CXR
Echocardiogram.
```
204
CHA2DS2-VASc scoring
```
CHF
HTN
Age - 65-74 = 1pt, over 75 = 2pts.
DM
Stroke/TIA/VTE Hx = 2pts
Vascular disease
Sex (female = 1pt)
```
Consider anticoagulant if 1pt, >2pts is anticoagulant candidate.
205
HAASBLED scoring
```
HTN
Abnormal renal function
Abnormal liver function
Stroke Hx
Bleeding Hx or predisposition.
Labile INR
Elderly >65yrs
Drugs predisposing to bleed
Alcohol use >8units/week.
```
Consider no anticoagulation of >2.
206
Classification of heart failure
New York Heart Association.
1 = asymptomatic
2 = minor symptoms on modest exertion (on climbing stairs).
3 = moderate symptoms on minro exertion (on dressing/showering).
4 = symptoms at rest.
207
What are capture beats?
Sinoatrial node transiently captures ventricles simultaneous with AV dissociation. (so they are in VT but sudden normal compelex).
208
Adrenaline in anaphylaxis V adrenaline in MI
1: 1000 = anaphylaxis.
1: 10000 = MI.
209
Mechanism of aspirin
Inhibits COX enzyme and this decrease prostaglandin release.
210
Mechanism of apixaban/DOACs
Inhibits Factor Xa. No thrombin generation.
211
Mechanism of warfarin
Inhibits enzyme epoxide reductase preventing the reduction of vitamin K. No Vitamin K dependent clotting factors (II, VII, IX and X)
212
Mechanism of heparin
Bind irreversible to antithrombin III, preventing generation of thrombin and inactivating factors IX, XI, XII and plasmin
213
Mechanism of clopidogrel and ticagrelol
Antagonist to P2Y12 ADP receptors on platelets, preventing aggregation.
214
How to diagnose a posterior MI
no posterior leads, so reciprocal changes in V1 and V2.
- tall R waves
- ST segment depression
- tall T waves
