Cardiology

Question 1

What are the features of MS?

Answer 1

Mitral facies (rosy cheeks not crossing nose, blue cyanosed face)

Mid-diastolic, pre-systolic murmur, with opening snap
Loud S1
Loud P2 
Low-pitched
Evident after exercise

Question 2

What are the features of AR?

Answer 2

Decrescendo early diastolic blowing murmur
Best heard over aortic areas sitting up in held expiration
AR causing premature closure or mitral valve –> Austin flint murmur (mid diastolic)
Widened pulse pressure
Waterhammer pulse, dancing carotids (corrigans pulse) (characterised by rapid systolic rise and rapid diastolic collapse)
Soft A2
Quincke’s sign (pulsation of capillary bed in nail)
De Musset’s sign (rythmic nodding of head in syncrhony with heartbeat)
Traube’s sign is pistol shot sounds heard over femoral artery
Duroziez’s sign (systolic and dialostic bruit heard over femoral artery)

Question 3

What are the common causes of AR?

Answer 3

Marfan’s
Ankylosing spondylitis
Syphillis
Aortic dissection

Question 4

What are the common causes of AS?

Answer 4

Age-related progressive calcifications (>50%) (65-70y/o)
Calcification of congenital bicuspid valve (30-40%) (40-50y/o)
Acute rheumatic fever (<10%)

Question 5

What are the features of AS

Answer 5

Ejection systolic, crescendo-decrescendo
Radiates to carotids
Syncope, Angina, Dyspnoea (SAD)

Question 6

What are the common causes of MR?

Answer 6

Marfan’s, RA, cardiomyopathy, rheumatic fever, MVP, IHD

Question 7

What are the common causes of MS?

Answer 7

Rheumatic fever

Uncommonly: calcifications and congenital heart disease

Question 8

Features of MR

Answer 8

Pan systolic murmur, loudest at apex, radiates to axillae

LVS3

Question 9

Differential diagnoses for pansystolic murmur

Answer 9

MR, TR, VSD, HOCM (midsytolic murmur), aorto-pulmonary shunt

Question 10

Differential diagnoses for midsystolic murmurs

Answer 10

AS (loudest in midsystolic), PS, HOCM

Question 11

Differential diagnoses for late systolic murmurs

Answer 11

MVP, papillary muscle dysfunction, HOCM

Question 12

What dynamic manouvres do you know and what murmurs do they accentuate?

Answer 12

Inspiration - right heart murmurs (increased venous return, and preload)
Expiration - left heart murmurs
Valsava - decreased preload during strained phase, everything softer (except HOCM and MVP)
Stand-to-squat - increased venous return and systemic arterial resistance, increased stroke volume and arterial pressure, most murmurs louder (LV size increased, reducing obstruction to outflow)
Isometric exercise - e.g. hand grip, increased afterload, AS may become softer (often unchanged) most murmurs become louder

Question 13

How do you differentiate JVP from carotid pulse?

Answer 13

JVP, occlude it and it will fill from the top
JVP has double-flicker with each cardiac cycle
JVP bounded by two heads of sternocleidomastoid
JVP decreases on inspiration
JVP visible but not palpable
JVP more prominent inward movement

Question 14

How do you measure the JVP?

Answer 14

Position at 45 degree angle
Turn head slightly to the left
Measure vertical height of column of blood in jugular vein from the sternal angle in line with base of the neck by:
Identifying the highest point of pulsation
Extending a long rectangular card/ruler horizontally from this point and a centimeter ruler vertically from the sternal angle (make an exact right angle)
Measure the vertical distance (in centimeters) above the sternal angle where the horizontal card crosses the ruler
Add to this distance 4 cm (the distance from the sternal angle to the centre of the right atrium)
Normal from sternal angle <3cm
Normal from RA <8cm

Question 15

Signs of LHF

Answer 15

Fluid overload (SOB, orthopnoea, PND) (lung crackles, LVS3, functional MR), poor cardiac output (cyanosis, hypotension, tachycardia), signs of RHF

Question 16

Signs of RHF

Answer 16

Fluid overload (sacral, ankle, abdominal edema), anorexia, nausea
Raised JVP, RVS3, functional TR, pulstile liver, hepatojugular reflux (when pressure is applied to liver, JVP remains elevated for >10-20s suggesting RHF)
Pulmonary HTN (palpable P2, parasternal impulse)

Question 17

Causes of LHF

Answer 17

IHD, volume overload (AR, MR, PDA), pressure overload (AS, systolic HTN)

Question 18

Causes of RHF

Answer 18

LHF, IHD, volume overload (TR, ASD), pressure overload (PS, pulmonary HTN)

Question 19

SYSTOLIC HTN –> LHF –> PULMONARY HTN –> RHF

Answer 19

SYSTOLIC HTN –> LHF –> PULMONARY HTN –> RHF

Question 20

What is cor pulmonale?

Answer 20

RVH caused by pulmonary pathology leading to scarring and sustained pulmonary hypertension. Eventually lead to RHF.

Question 21

How would you take blood pressure?

Answer 21

Position patient, arm at heart level
Do not use arms with pathology e.g. post-mastectomy lymphoedema
Using appropriately sized, fully deflated cuff,
1) Wrap cuff over patients upper arm with the cuff marker overlying the brachial artery (palpate to locate)
2) Palpate radial pulse, inflate cuff until radial pulse can no longer be felt to estimate systolic BP
3) Open valve, and deflate BP cuff
4) Place diaphragm of stethoscope over brachial artery
5) Inflate cuff to 20-30mmHg above estimated SBP
6) Deflate cuff at slow rate of 2-3mmHg/s
7) Listen for pulsatile noise, pressure at which first korotkoff sound is heard is the SBP
8) Continue to deflate until pulsatile noise completely disappears, the 5th and last korotkoff sound is DBP

Sounds

1) Thud
2) Blowing/ swishing sound
3) Thud softer than 1
4) Soft blowing
5) Disappearing

Question 22

Important history in infective endocarditis

Answer 22

• Preenting symptoms e.g. malaise, fever, symptoms of anaemia
• CHF e.g. PND, orthopnoea, SOB
• Embolic phenomena in large vessels: e.g. brain, viscera (focal neurological deficits) or small vessels e.g. kidney (AKI, haematuria, loin pain)
• Risk factors/ recent precipitating event: dental work, endoscopic procedures, IVDU (tricuspid and pulmonary valve regurgitation), history of rheumatic fever,
• Antibiotic use (prophylaxis for procedures/ treatment): how long, which antibiotics, allergies
• History of any valve surgery (when, surgeon performed, type of valve, any complications)
• PMHx especially those associated with immunosuppression e.g. renal transplantation/ steroid use

Question 23

Duke’s criteria

Answer 23

Pathological Criteria (either is evidence)

1. Microorganisms in a vegetation (demonstrated by culture or histologic examination)
2. Pathologic lesion (vegetation of intra-cardiac abscess confirmed by histology)

Major Criteria (if both positive, diagnosis definite)

1. Blood cultures positive for IE with typical microorganisms consistent from 2 separate blood cultures
2. Evidence of endocardial involvement (echocardiogram positive for IE)

Minor Criteria (if all positive, diagnosis definite)

1. Predisposing heart condition or injecting drug use
2. Fever
3. Vascular phenomenon )major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, Janeway’s lesions)
4. Immunologic phenomena (Glomerulonephritis, Osler’s nodes, Roth’s spots, Rheumatoid factor)
5. Microbiological evidence (positive blood culture not meeting major criteria)

Question 24

Investigations for IE

Answer 24

Bedside: ECG (might see AF), U/A (haematuria, proteinuria)

My diagnostic investigations of choice would be 3-6 sets of blood cultures taken from 3 different peripheral sites (over 24 hours, 3 in 1st hour), and a trans-oesophageal echocardiogram (2D + doppler) looking for any vegetations (must be more than 2mm to be detected) (TOE more sensitive 86-92% vs 17-36% and better at picking up complications such as abscesses), evidence of heart failure

Other investigations include FBC (anaemia, neutrophilia), ESR/CRP, EUCs, LFT, Coagulation studies (INR), G+H, CXR (look for any LV/RV hypertrophy, increased pulmonary artery markings, Kerley B lines, valve calcification in lateral film to rule out any ddx, complications)

Question 25

Signs of IE

Answer 25

New murmur/ prosthetic valve murmur Peripheral stigmata of IE o Hands: clubbing, splinter haemorrhages, Osler’s nodes (rare immunologic embolic phenomenon, painful and on finger pulp), Janeway lesions (rare non-tender erythematous maculopapular vascular lesions containing bacteria on palms or pulps) o Eyes: Roth’s spots in fundus, conjunctival petechiae o Abdomen: splenomegaly (late sign) o Neurological signs of embolic disease: cranial nerve, UL + LL

Question 26

Management of IE

Answer 26

Management will require MDT approach with early involvement of cardiac surgeon, ID, cardiology Empiric antibiotics after blood cultures in haemodynamically unstable patients Prosthetic valves: Flucloxacillin + vanc + gent Native valve Fluclox + benpen + gent Tailored therapy for 6-8 weeks (prosthetic), 4-6 (native) after sensitivity testing Consider surgery if haemodymic instability, cardiac failure due to valvular dysfunctiom, persistently positive BC despite treatment, paravalvular abscesses/infection causing conduction disturbances

Question 27

Valvular AF

Answer 27

"Valvular AF" according to the European Society of Cardiology Guidelines only refers to patients with moderate to severe mitral stenosis or prosthetic heart valves (and valve repair in North American guidelines), and should be treated with Vitamin K Antagonists. Valvular

Question 28

What is the HASBLED score?

Answer 28

The HASBLED score is used to assess risk of bleeding in patients on anticoagulation to assess risk benefit in AF care. Could be used as tool to potentially guide starting anticoagulation. Use in conjunction with CHADSVASC to determine in benefit of anticoagulation outweighs risk. ``` Hypertension (uncontrolled) Abnormal liver function Abnormal renal function Stroke Bleeding risk (personal medical history, previous bleeds) Labile INRs Elderly (age>65) Drugs (anticoagulants, NSAIDs, stuff that increase bleeding risk, excessive alcohol) ``` >3 high risk of bleeding, use with caution with regular review

Question 29

What is the CHADSVASC score and how is it used?

Answer 29

CHA2DS2VASC is used to estimate risk of stroke in patients with non-valvular AF ``` CCF Hypertension >140/90 or treated w meds Age >75 (2 points) Diabetes mellitus Stroke or TIA (2 points) Vascular disease (PAD, MI, aortic plaques) Age >65 (1 point) Sc (Sex Category) (Female +1) ``` 0 in males or 1 in females no anticoagulant ≥2 consider anticoagulation

Question 30

Duration of AF

Answer 30

First diagnosed Paroxysmal (self terminating, <48 hours, usually but up to 7 days if cardioverted) Persistent >7 days and cardioverted Long standing persistent >1 year and decided to use rhythm control Permanent AF when rhythm is NOT used bc patient accepts being in Afib . If rythmn control later used, reclassified to persistent.

Question 31

Management of AF

Answer 31

The treatment of atrial fibrillation consists of: 1. reduction of thromboembolism and stroke risk (anticoagulant therapy) 2. symptom relief (rate and/or rhythm control) 3. treatment of associated comorbidities, such as heart failure 4. treat underlying aetiologies If haemodynamicaly unstable --> accept risk of stroke if timing unknown, immediate direct current cardioversion (up to 3x), and then anticoagulate for 4 weeks Stable (rate control preferred, control cardioverting after rate control achieved) <48 hours: low risk of acute thromboembolism, initial rate or rhythm strategy might be considered and then if rhythm --> anticoagulate at time of cardioversion, continue anticoagulation for 4 weeks >48 hours: do not cardiovert unless ruled out left atrial thrombus via TOE or patient has had therapeutic anticoagulation for past 3 weeks, continue anticoagulation for 4 weeks. When thrombus ruled out, start IV UFH and then cardiovert within 24 hours. Pharmacological Cardioversion: flecainide 1.5mg/kg up to 150mg (10 min)or amiodarone 300mg by IV (1-2 hours) followed by 900mg over 24 hours

Question 32

Rate vs Rhythm control in AF

Answer 32

Meta-analysis showed no significant difference between rate and rhythm control for all-cause mortality, cardiovascular mortality or ischaemic stroke in patients with atrial fibrillation Rate control --> asymptomatic, normal left ventricular function Rhythm control --> highly symptomatic, or have left ventricular dysfunction that might be secondary to atrial fibrillation electrical over pharmacological cardioversion

Question 33

Causes of AF

Answer 33

``` Heart failure Elevated blood pressure (see blood pressure reduction) Valvular heart disease Diabetes mellitus Excess body weight Obstructive sleep apnoea Hazardous alcohol use Hyperthyroidism ```

Question 34

Drug choice for rate control in AF

Answer 34

usually beta blocker --> metoprolol if not, CCB (non dihydropyridine) if LV dysfx: consider digoxin/ amiodarone

Question 35

Management of ACS

Answer 35

1. Stabilise. + MONA (morphine, O2, nitrates, aspirin chewable) 2. STEMI (reperfusion by PCI within 90 minutes or fibrinolysis within 30 minutes if PCI not possible)/N-STEMI (plaque stabilisation and prevention of occlusion and then consider revascularisation based on risk stratification, no fibrinolysis) If PCI --> give anticoagulaiton and antiplatelet before, and if fibronylisis load antiplatelets and then anticoagulate after 3. Long term management with: SAAB-C (statin, aspirin, anticoagulant, beta-blocker, clopidogrel)

Question 36

Criteria for STEMI

Answer 36

Refer to PACSA or LHD guidelines: Ongoing chest pain AND ST elevation of 1mm or more in 2 or more adjacent leads (except v2 and v3 which require ≥2.5mm in men < 40 or ≥2mm in men >40 and ≥1.5 or more in any woman) OR LBBB + haemadynamically unstable OR LBBB , HD stable with positive modified sgarbossa criteria. OR Posterior infarct (ST depression in V1-V3) OR dewinter T waves

Question 37

Management of ACS

Answer 37

1. Stabilise. + MONA (morphine, O2, nitrates, aspirin chewable), dobutamine in cardiogenic shock. do NOT administer nitrates in right ventricular infarct (present with inferior ecg changes, hypotension, elevated JVP, hepatomegaly, clear lungs) as will cause cardiovascular collapse 2. STEMI (reperfusion by PCI within 90 minutes or fibrinolysis within 30 minutes if PCI not possible)/N-STEMI (plaque stabilisation and prevention of occlusion and then consider revascularisation based on risk stratification, no fibrinolysis) If PCI --> give anticoagulaiton and antiplatelet before, and if fibronylisis load antiplatelets and then anticoagulate after 3. Long term management with: SAAB-C (statin, aspirin, ACE-I, beta-blocker, clopidogrel)

Question 38

ECG changes in STEMI

Answer 38

Perform: 0 and 2 hours When repeating trops Every 30 minutes if ongoing symptoms Minutes - Hyperacute/ peaked T waves, large T waves, loss of ST segment Minutes to hours: ST segment changes (ST elevation or depression), inverted T waves (onset of myocardial necrosis) Days: pathological Q waves (represents total loss of electrical activity due to scar tissue in an area that had transmural infarction)

Question 39

Investigations for ACS

Answer 39

Serial ECGs, Serial troponins Preferably use high sensitivity (I and T) troponins, looking for rise and/or fall Other: FBC (infection, anaemia), EUC, LFT, Coags, Group + Hold, VBG, BSL CKMB for recurrent infarction down the track (quicker return to baseline than troponins) CXR for APO, and to rule out respiratory causes of chest pain

Question 40

What is the third heart sound?

Answer 40

Occurs 120-160ms after 2nd heart sound, low-pitched, best heard with bell of stethostcope Not dependent on atrial contraction, not influenced by presence of AF Associated with RAPID ventricular filling Normal before 30 years, not normal above 40 years (always implies ventricular disease) Commonly heard in LVF, as after MI, severe MR, constrictive pericarditis (where 3rd heart sound represents cessation of ventricular filling)

Question 41

What is syncope?

Answer 41

Symptom that presents with an abrupt, transient, or complete loss of consciousness, associated with inability to maintain postural tone, with rapid and spontaneous recovery. Presumed mechanism of cerebral hypoperfusion. Should not have other clinical features e.g. seizure, antecedant head trauma, or apparent loss of consciousness

Question 42

What is pre-syncope?

Answer 42

Symptoms before syncope such as extreme light-headedness; visual sensations (tunnel vision/ graying out); variable degrees of altered consciousness without complete loss of consciousness. Could or could not progress to syncope.

Question 43

What are the common types/ causes of syncope?

Answer 43

1. Orthostatic - syndrome consisting of constellation of symptoms that include frequent, recurrent, or persistent light-headedness, palpitations, tremulousness, generalised weakness, blurred vision, exercise intolerance, and fatigue upon standing. Can occur without orthostatic tachycardia, orthostatic hypotension, or syncope. Classic orthostatic hypotension is a sustained reduction in blood pressure of systolic BP of more than 20mmHg or diastolic BP of more than 10mmHg. Neurogenic OH - due to dysfunction of the autonomic system not solely due to environment e.g. dehydration or drugs. Neurogenic OH is due to lesions involving the central or peripheral nerves. 2. Cardiogenic: syncope caused by bradycardia, tachycardia, or hypotension due to low cardiac index, blood flow obstruction, vasodilatation, or acute vascular dissection. Cardiac factors: HR, contractility Coupling factors: Preload, afterload Things that affect CO. 3. Reflex (neurally mediated)_ syncope: syncope due to a reflex that causes vasodilation, bradycardia, or both. - -> Vasovagal - may occur with any posture with exposure t emotional stress, pain, or medical settings, typically characterised by diaphoresis, wartmh, nausea, and pallor, is associated with vasodepressor hypotension, often followed by fatigue. - -> Carotid sinus syncope (more common in older patients) - -> Situational syncope -- syncope associated with specific actions such as coughing, laughing... closesly associated with specific physical features.

Question 44

What other differentials for syncope (actual LOC)?

Answer 44

``` Seizures Sleep disturbances (narcolepsy, cataplexy) Falls leading to TBI Intoxication and metabolic disturbances Psychiatric (pseudoseizures) ```

Question 45

Differentials for dizziness

Answer 45

Vertigo, pre-syncope, disequilibrium (imbalance when walking e.g. diabetic neuropathy, MSK, cerebellar), nonspecific (psychiatirc e.g. major depression, anxiety, hyperventilation)

Question 46

What is vertigo?

Answer 46

Arises from acute asymmetry of vestibular system - there are both peripheral and central causes Peripheral - BPPV, meniere's, labyrynitis, ototoxicity Central - migraine headache, MS, cerebellar haemorrhage/infarct, vertebrobasilar insufficiency Distinguishing it from other types of dizziness: Time course: Will not be longer than a few weeks, because CNS can adapt to defect. Constant dizziness lasting months --> psychogenic not vestibular. Vestibular - acute prolonged severe vertigo (vestibular neuronitis and stroke) vs recurrent spontaneous attacks (meniere's and vestibular migraine) vs recurrent positional (BPPV) and chronic persistent (psychogenic, cerebellar ataxia) Provoking factors: Spontaneous vs precipitated by manouvres that change head position. Positional vertigo vs pre-syncope: both assoc w dizziness on standing, differentiate: w/o lowering bp/cerebral blood flow e.g. lying down, rolling over in bed, bending neck to look back up --> suggest positional vertigo. Aggravating: ALL VERTIGO MADE WORSE BY MOVING HEAD Associated: generally accompanied by nystagmus and postural instability. Ear involvement (e.g. hearing loss, tinnitus) suggestive of peripheral cause although absence does not exclude diagnosis. Illusion of motion - 'spinning sensation' (not reliable)

Question 47

Medications that predispose to syncope

Answer 47

1. Hypovolaemia and electrolyte distyrbance: diuretics 2. Hypotension: anti-hypertensives 3. Long QT: anti-arrhythmics, anti-infectives (azole antifungals, fluoroquinolones, macrolides), antipsychotic, antidepressant

Question 48

Management of orthostatic hypotension

Answer 48

If autonomic features present e.g. parkinsonionism, CNS features, peripheral neuropathies, underlying diseases --> refer for further evaluation (neurologist) If orthostatic hypotension: 1. Address reversible factors e.g. volume depletion or medications 2. Non-pharm - Review/remove suspected meds as above - Modify behaviour: raise head of bed by 10-20deg, arise slowly from supine, isometric handgrip, dorsiflexing feet, liberalise salt and water intake (supplement sodium 1g PO with each meal), fitted compression stockings and abdominal binderds (not well tolerated) 3. Pharm - Fludrocortisone (increases reabsoption of sodium, and plasma volume) - Midodrine (alpha1agonist, improves symptoms of OH in patients with neurogenic OH) - Droxidopa (metabolised to noradrenaline --> improves symptoms of neurogenic OH due to Parkinsons, pure autonomic failure, and multiple system atrophy), might reduce galls All pharm meds are limited by supine hypertension