Cardiology Flashcards
Pulmonary oedema presentation
Investigations and what they show
- Acute worsening SOB, dyspnoea
- Orthopnoea
- PND – wake up gasping for breath
- Productive cough – pink frothy sputum
- Chest pain
- Collapse, cardiac arrest or shock
On examination • Distressed, pale sweaty • Tachycardic • Tachypnoeic • Tend to be hypertensive • Crackles on auscultation • Raised JVP
Investigations
• CXR – to confirm diagnosis. Look for
- Interstitial shadowing; Enlarged hila; Prominent upper lobe vessels; Pleural effusions; Kerley B lines (thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitial of the lungs); May or may not be cardiomegaly
- Exclude pneumothorax, PE and consolidation
• ECG – check rhythm
- ?any cardiac arrhythmia
- ?Evidence of acute ST changes
- ?Evidence of underlying heart disease (LVH, p mitrale)
• ABG
- low PaO2. PaCO2 may be low (hyperventilation) or high depending on severity
- Pulse oximetry may be inaccurate if peripherally shut down
• Bloods
- FBC: ?Anaemia or leucocytosis indiciating precipitant
- inc. BNP (serial for treatment). BNP <100 rules out acute HF
- U&Es (baseline of renal function)
- +/- trop
- Echo (not immediately but for HF diagnosis)
Pulmonary oedema management
Acute
Follow up
- Sit upright
- High flow O2 – give 100% oxygen if no pre-existing lung disease
- Gain IV access + take bloods
- Monitor ECG – cardiac monitoring
- Treat any arrhythmias if contributing e.g AF
- Do other investigations as above whilst continuing treatment
3.
- Give 40-80mg Furosemide IV – Should act quickly. Monitor BP when giving.
- Give 1.25-5mg Diamorphine IV to aid respiratory distress (careful in liver failure + COPD)
- Give 2 puffs GTN spray – vasodilates to get fluid off (Don’t give if sBP <90)
4.
- If sBP >100 start a GTN infusion – to reduce preload
- If pt worsening, give further dose of furosemide/infusion
- Give NIV e.g. CPAP – to keep airways open that would collapse because of fluid and push fluid off their chest
- If sBP <100, treat as cardiogenic shock and refer to ICU
Once stable and improving:
• Check obs at least QDS
• Daily weights, aim reduction of 0.5kg/day
• Change to oral furosemide or bumetanide
• Consider adding thiazide if on a large dose of loop diuretic bendroflumethiazide or metolazone 2.5–5mg daily
• ACEi if LVEF <40%.
• Consider beta blocker and spironolactone if LVEF <35%
• Is pt suitable for biventricular pacing or cardiac transplantation
• Consider digoxin warfarin, especially if AF
Hypertension end-organ damage
Proteinuria Hypertensive retinopathy 1) Arteriolar narrowing 2) AV nipping 3) Flame haemorrhages + cotton wool spots 4) Papilloedema LVH
Tests
- Urine dip
- Fundoscopy
- ECG + Echo
- Bloods - electrolytes, glucose, lipids, renal function
Raised troponin causes
MI Myocarditis Takotsubo cardiomyopathy Massive PE Critical illness e.g. shock, sepsi
Contraindications to thrombolysis
Previous intracranial haemorrhage or stroke of unknown cause
Recent ischaemic strokeischaemic stroke
HCM
Main symptoms
ECG
Most important test
Syncope
Angina
Dyspnoea
Palpitations
Signs on examination
- Systolic murmur
- Systolic thrill (L lower sternal edge)
- Jerky peripheral pulse
- Double apical beat
- ?bisferens pulse
ECG
- T wave and ST segment abnormalits
- LVH
- Q waves (hypertrophied septum mimics old MI)
Most important test = exercise test
- Lack of normal change in BP = risk factor for sudden death
Management of HCM
High risk individuals need ICD
BB or Verapamil: for symptomatic patients
Amiodarone for arrhythmias
Anti-coagulate for paroxysmal AF or Systemic emboli
Avoid vasodilators
What is cor pulmonale
Causes
Signs
Hypertrophy of the right ventricle and right heart failure that are caused by pulmonary arterial hypertension
Causes
- COPD
Signs Are of R sided HF - Hepatomegaly - Peripheral oedema - Raised JVP
Left sided heart failure features
Orthopnoea, PND, SOB on exertion
Hypothermia results on investigations
ECG
Bloods
ECG: J waves, long qt, bradycardia, 1st degree HB
Bloods: Hb and haematocrit can be elevatved
- Platelets and WBC may be low (sequestration in spleen)
- Hypokalaemia (shift into intracellular space)
Causes of arrhythmia
Cardiac IHD structural changes Cardiomyopathy Pericarditis Myocarditis
Non-cardiac Caffeine Smoking Pneumonia/PE Metabolic in balance: Potassium potassium, calcium, magnesium, hypercapnia, metabolic acidosis, thyroid disease Pheochromocytoma
Investigation of arrhythmia
Bloods FBC You and EV Glucose Magnesium TFT
ECG - signs of IHD - signs of AF - short PR - long QT - U waves Echo
Mitral regurgitation
Causes
Symptoms
Signs
Management
Causes
1) Primary
- Degenerative mitral valve disease (prolapse, calcification, ruptured chordae tendinea)
- Rheumatic fever
- Infective carditis
- Connective tissue disorders
2) Secondary
- CAD, prior MI causing papillary muscle involvement
- DCM and left HF
Symptoms
- Signs of LV failure
- Dyspnoea
- Fatigue
- Palpitations
Signs
- AF - common in chronic MR with a dilated LA
- Raised JVP If pulmonary HTN and R HF or fluid retention
- Dilated Apex beat
- RV heave
- Sodt S1, Split S2
- Pansystolic murmur radiating to axilla
ECG - AF and p mitral
CxR - large LA and LV
Echo - main assessment
MI must be ruled out in patient preenting with severe MR
Management
- control rate if fast AF
- Diuretics improve symptoms
- Surgery if symptoms worsen - repair preferred. Abx for prophylaxis
Mitral valve prolapse
What is it
Symptoms
Signs
Complications
Tests
Management
Most common valvular abnormality 1/20. Occurs alone or with cardiomyopathy, Turner, WPW, PDA
Symptoms
- usually asymptomatic
- may get chest pain, palpitations
Signs
- mid diastolic click and late systolic murmur
Complications
- MR
- Cerebral emboli
- Arrhytmias, sudden death
Echo diagnostic
Treatment
- bb may help palpitations and chest pain
- surgery if severe MR
Mitral stenosis
Causes
Symptoms
Signs
Tests
Management
Causes
- Rheumatic fever - most most common
- IE
- Congenital
- SLE
Symptoms
- Dyspnoea, fatigue, palpitations, chest pain
- systemic emboli, haemoptysis, chronic bronchitis
Signs
- Malta flush (low CO)
- AF due to LA strain
- Tapping NON displaced apex beat
- Loud S1, rumbling mid diastolic murmur
Tests
- ECG - AF, RVH/RAD, p mitrale
- Echo diagnostic
Management
- Rate control and anticoagulation in AF
- Diuretics
- Balloon mitral valvuloplasty to open valve
- Valve replacement
Complications
- AF
- Pulmonary HTN
- Emboli
- Large LA puts prqessude on structures e.g. Laryngeal nerve
Aortic regurgitation
Causes
Symptoms
Signs
Management
Reflux of blood from aorta into LV during diastole
Causes
- Acute: Rheumatic fever, IE, aortic dissection, chest trauma
- Congenital - aortic valve anbnormalitis, connective tissue disorders, Rheumatic fever, RA, SLE, ank spond
Symptoms
- often asymptomatic with only exertional Dyspnoea
- orthopnoea and paroxysmal nocturnal Dyspnoea
- palipiataions, angina, syncope
Signs
- collapsing pulse
- wise pulse pressure
- displaced apex beat
- early diastolic murmur ( sat forward and expiration)
- corrigans sign - carotid pulsitations in neck
- De musset - he’s nodding with each HB
- Quincke signs - capillary pulsation in nail bed
- Austin flint murmur - heard at apex - early diastolic rumbling murmur caused by blood flowing back through the aortic valve and over mitral valve leaflets
Management
- Aim to reduce systolic HTM
- Aim to replace valve before significant dysfunction
- Abx prophylaxis against IE
- Vasodilators: ACEi or Nifedipine
Complications
- LV failure
- pulmonary oedema
Infective endocarditis
Causes
Risk factors
Signs and symptoms
Causes
- bacteraemia - s. Aureus, strep vridans (subacute), staph epidermis, staph bovis (associated with colorectal ca)
- fungal infection - usually in IV drug users, immunocompromised, prosthetic valves
- rarely HaCEk
- SLE
- Maliganncy
Risk factors
1) on normal valves
- Dermatitis
- IV injection
- Renal failure
- immunosuppressed/ organ transplant
- DM
- Post op wound
2) on abnormal valves
- Aortic or mitral valve disease
- Triscupid valves in IVDU
- Coarctation
- PDA
- Prosthetic valves
Signs and Simpson’s
- Sepsis - fevers, rights, night sweats, weight loss, splenomegaly, clubbing
- cardiac - murmur (new or changed),
- immune complex deposition - vascularising, microscopic haematuria, glomeruolonephritis/AKI, Roth spots, splinter haemorrhages, Oslerd nodes
- Emobolic - abscesses in relevant organ e.g. brain, heart, kidney, spleen, gut or skin (Janeway lesions)
Infective endocarditis critieria
Management
Modified dukes criteria. Need 2 major or 1 major + 3 minor or 5 minor
Major - BE
- Blood culture +ve 2 x 12 h apart
- Endocardial involvement from Echo
Minor - FEEVER
- Fever >38
- Echo findings (not major)
- Vascular findings - splenomegaly, clubbing, splinter haemorrhages, janeway lesions, petechiae, major haemorrhage
- EEvidence from micro/immnunology (2 evidences)
- Risk factors e.g. drug abuse, valve disease
Management
- speak to micro and cardio
- give antibiotics
- consider surgery if severe valve incompetency etc.
Tricuspid regurgitation
Causes
Symptoms
Signs
Management
Causes
- RV dilation due to pulmonary HTN induced by LV failure or PE
- Rheumatic fever
- Infective endocarditis
- carcinoid syndrome
- Congenital
- Drugs
Symptoms
- fatigue, SOB, palpitations, hepatic pain on exertion, ascites, oedema and symptoms of cause
Signs
- giant V waves in raised JVP
- Parastermal RV heave
- Pansustolic murmur ( in inspiration)
- Pulsatile hepatomegaly, jaundice, ascites
Management
- Treat cause
- Give diuretics, digoxin and ACEi
- Valve repair if needed
Causes of raised JVP
Cause of absent A waves
Cause of large A waves
Cause of large V waves
Increased RA pressure
1) HF
2) Fluid overload
3) Constrictive pericarditis
4) Cardiac tamponade
Cause of absent A waves
- AF
Cause of large A waves
- RVH due to Pulmonary HTN or PS
- Tricuspid stenosis
Cause of large V waves
- Tricuspid regurgitation
Stages of JVP
A wave = atrial contraction
- blood passed through tricuspid to RA
- Also up so blood in IJV increases
X descent = atrial relaXation
- blood flows into relaxed atria from IJV
- also blood from atria to ventricles
c wave = start of systolic Contraction
- RV contracts squeezing blood to pulmonary artery
- pressure pushes into closed tricuspid - bulges into RA
X descent = end of RV contraction
- RV squeezed small -= space in pericardium = space for atria to fill out and suck in blood
V wave = atrial relaXation
- RA starts to fill with blood (tricuspid closed)
- As fills more, filling occurs higher up
Y descent = tricuspid opens
- Emptying of RA
What is the Leriche’s syndrome
Peripheral artery disease at level of aortic bifurcation or bilateral occlusion of iliac arteries = classic triad
1) Bilateral buttock, hip or thigh claudicatipn
2) Erectile dysfunction
3) Absent/ diminished femoral pulses
What is bifasicular block and trifasicular block
Bifasicular block = RBBB with LAD
Trifasicular block = RBBB with LAD and 1st degree heart block
Who gets statins
Dose for actor OST’s tin
- all with establish CVD ( IHD, Stroke, TIA, PAD)
- all with 10 year Cv risk 10% or more
- AsSess T2 diabetics with QRISK2
- T1DM If dx more than 10 y ago, older than 40 or established nephropThy
Atorvostatin dose
- 20mg for primary prevention
==> increase the dose if non-HDL has not reduced for >= 40%
- 80mg for secondary prevention
Causes of long QT
1) Genetic
2) electrolytes
- hypomagnesaemia
- hypocalcaemia
- hypokalaemia
3) Drugs
- Anti arrhythmic e.g, amiodarone, SOTALOL
- antibiotics e.g. erythromycin, clarithromycin, ciprofloxacin
- psychotropic drugs e.g. SSRI, TCA, Neuroleptic
Causes of sinus bradycardia
Young athletic
Sleep
Chronic degeneration of sinus or AV nodesu or atria
Drugs e.g. Bb, morphing, amiodarone, CCB, lithium, propafenone
Increased Vagal tone - vasovagal attack, N&V, carotid sinus hypersentivify
Hypothyroid
Hypothermia
MI or ischaemia of the sinus node
Raised ICP
Wells score for PE
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
> 4 – CTPA
4 or less – D dimer
AF need for anti-coagulation
C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female) 1
Strategy based on score 0 No treatment 1 Males: Consider anticoagulation Females: No treatment (this is because their score of 1 is only reached due to their gender) 2 or more Offer anticoagulation
Warfarin INR targets
Venous thromboembolism
AF
Mechanical valves
Venous thromboembolism: 2.5, if recurrent 3.5
AF: 2.5
Mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.
beta blocker CIs
Side effects
Uncontrolled HF
Concurrent verapamil: May precipitate severe bradycardia
Asthma
Sick sinus syndrome
Side effects
- Bronchospasm
- Trouble sleeping
- ED
- Fatigue
- Cold peripheries
