Cardiology (Structural disease) Flashcards

Question

management of asymptomatic patients with HOCM

Answer 1

**High risk of sudden death:** * 1st line: implantable cardioverter-defibrillator (ICD) + avoid high-intensity exercise **Not at high risk of sudden death:** * 1st line: observation

Answer 2

**1st line:** beta-blockers or verapamil **Consider ICD if:** * Higher risk level * New symptomatic or concerning asymptomatic ventricular arrhythmias develop **Consider amiodarone to prevent recurrences of atrial fibrillation** **Consider if medical therapy is inadequate:** * Myectomy or * Dual-chamber pacing if cannot have surgery/not desired If patients develop heart failure, they are treated using standard heart failure therapy.

Answer 3

* Avoid high-intensity athletics * Undergo regular testing with echocardiography, Holter monitors, ECGs etc. to assess their risk of sudden cardiac death and consideration of an ICD to prevent it * Be considered for anticoagulation if they develop atrial fibrillation * Be followed-up lifelong * Seek medical help if they have exertional chest pain, dyspnoea, palpitations, presyncope/syncope

Answer 4

stress cardiomyopathy or 'broken heart syndrome'

Answer 5

* a type of non-ischaemic cardiomyopathy characterised by a sudden transient weakening and ballooning of the myocardium. **Pathophysiology** * Its pathophysiology is not fully understood, but it is thought that significant elevations in catecholamines may cause microvascular spasms and injury to the myocardium. * Stress cardiomyopathy is more common in post-menopausal women * Oestrogen promotes vasodilation in the cardiovascular system, therefore, in times of vasoconstriction, it is exaggerated in post-menopausal women

Answer 6

Patients present with chest pain with or without features of heart failure following physical or psychological stress (e.g. finding out bad news, such as a relative passing away). Features include: * Chest pain * Dyspnoea * Syncope * Features of heart failure

Answer 7

**ECG:** * May show ST-elevation **Troponins**: * May be mildly elevated **Transthoracic echocardiogram:** * Shows apical ballooning of the left ventricle

Answer 8

observation and monitoring, along with supportive treatment. Most patients improve with supportive treatment.

Answer 9

infection of the endocardium of the heart - non specific symptom - causes vegetation of the valves of the heart - mitral valve most commonly affected - IVDU- tricuspid valve more commonly affected

Answer 10

* **Staphylococcus aureus** is the most common cause in developed countries and IVDUs * **Streptococcus viridans** (Streptococcus mitis and Streptococcus sanguinis) are the most common in developing countries and in patients with poor dental hygiene following a dental procedure * **Staphylococcus epidermidis** and other coagulase-negative Staphylococci are a common cause in indwelling lines or prosthetic valves in the first 2 months * After 2 months, S**taphylococcus aureus** predominates * **HACEK species** – Haemophilus, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, and Kingella species

Answer 11

* Previous infective endocarditis * Valvular heart disease * Valve replacements * Structural congenital heart disease, even if it has been corrected * Hypertrophic cardiomyopathy * Intravenous drug use * Invasive vascular procedures e.g. haemodialysis

Answer 12

* Fever and signs and symptoms of embolism * Fever and heart failure with risk factors for IE * Fever and a new/worsening murmur – this is rare Other symptoms * Fever/chills * Heart murmurs * Night sweats * Malaise * Fatigue * Anorexia * Weight loss * Myalgias * Joint pain * Headaches * Shortness of breath * Weakness e.g. asymmetric weakness consistent with a stroke

Answer 13

* Fever * Heart murmurs * Petechiae in the conjunctiva, on the chest or abdominal wall, dorsum of the hands and feet, or in the oral mucosa and soft palate * Splinter haemorrhages * Osler’s nodes * Clubbing – usually if long-standing * Roth’s spots – retinal haemorrhages with pale centres * Janeway’s lesions – usually with Staphylococcus aureus IE * Meningism ## Footnote =

Answer 14

**Blood cultures:** * If the patient is septic, do not delay giving empirical antibiotics * If possible, take 3 blood cultures at different venepuncture sites at 30-minute intervals before giving empirical antibiotics **Transoesphageal Echocardiography:** * May show valvular, mobile vegetations **Full blood count (FBC):** * May show normocytic anaemia * May show leukocytosis **C-reactive protein (CRP):** * A non-specific marker of inflammation, may be elevated * Useful for monitoring treatment **Urea and electrolytes (U&Es):** * As a baseline * Urea may be elevated **Urinalysis**: * To look for the distal spread of IE * May show haematuria, RBC casts, white cell casts, proteinuria, pyuria **ECG**: * Progression of IE may lead to conduction abnormalities * May cause PR prolongation or AV node blocks **Echocardiography** – a key investigation: May show vegetations

Answer 15

**Modified Duke criteria** IE is diagnosed if any of the following are met: * A pathological criterion is positive * 2 major criteria * 1 major and 3 minor criteria * 5 minor criteria

Answer 16

* Microorganisms demonstrated by culture or on histological examination of valve tissue, vegetation, a vegetation that has embolised, or an intracardiac abscess sample

Answer 17

* Positive blood cultures for IE * Evidence of endocardial involvement

Answer 18

* Predisposing heart condition of IVDU * Fever over 38°C * Vascular phenomena: Major arterial emboli, septic pulmonary emboli, intracranial haemorrhage, conjunctival haemorrhage, Janeway lesions **Immune phenomena:** Glomerulonephritis, Osler nodes, Roth spots, and Rheumatoid factor present **Microbiology:** * Positive blood cultures that do not meet major criteria * Identification of previous recent embolic events or infectious aneurysms by imaging

Answer 19

* Native valve endocarditis: amoxicillin (or ampicillin) + consider low-dose gentamicin * If penicillin allergic/suspected MRSA/severe sepsis: vancomycin + low-dose gentamycin * Prosthetic valve endocarditis: vancomycin + rifampicin + low-dose gentamicin

Answer 20

* Flucloxacillin * If penicillin allergic/MRSA: vancomycin + rifampicin

Answer 21

* Flucloxacillin + rifampicin + low-dose gentamicin * If penicillin allergic/MRSA: vancomycin + rifampicin + low-dose gentamicin

Answer 22

* Benzylpenicillin * If penicillin allergic: vancomycin (or teicoplanin) + low-dose gentamicin

Answer 23

* Benzylpenicillin + low-dose gentamicin * If penicillin-allergic or highly penicillin-resistant: vancomycin (or teicoplanin) + low-dose gentamicin

Answer 24

* Amoxicillin (or ampicillin) + low-dose gentamicin or * Benzylpenicillin + low-dose gentamicin * If penicillin-allergic or penicillin-resistant: vancomycin (or teicoplanin) + low-dose gentamicin * If gentamicin resistant: amoxicillin (or ampicillin) + streptomycin

Answer 25

* Amoxicillin (or ampicillin) + low-dose gentamicin * If amoxicillin-resistant: ceftriaxone (or cefotaxime) + low-dose gentamicin

Answer 26

Surgery is indicated if: * Heart failure develops * There is severe valvular dysfunction * There is an uncontrolled infection which may be characterised by: * Abscess formation * Enlarging vegetation * Prosthetic valve endocarditis due to Staphylococcus or non-HACEK gram-negative bacteria * Fungal or multidrug-resistant organism endocarditis * Recurrent embolic events e.g. stroke

Answer 27

Narrowing of the aortic valve - obstructs blood flow - can be caused by valve fibrosis and calcification

Answer 28

* Degenerative calcification and fibrosis – most common * Congenital bicuspid valves (Turner’s syndrome) * Rheumatic heart disease

Answer 29

* Exertional dyspnoea is the most common symptom * Exertional syncope * Fatigue * Chest pain

Answer 30

- Ejection systolic murmu - Louded over right upper sternal border - radiates to carotids - louder on inspiration

Answer 31

- Transthoracic echocardiogram - ECG - CXR

Answer 32

Asymptomatic - watch and wait Asymptomatic but LVEF <50% - Aortic valve replacement Symptomatic - Aortic valve replacement Unfit for surgery - Balloon vlvuloplasty

Answer 33

Acute heart failure Cardiac arrest Infective endocarditis Prosthetic valve infection Mechanical valve thrombosis

Answer 34

inadequate closure of the aortic valve leading to the backflow of blood during diastole. It can be due to problems with the aortic valve or the aortic root.

Answer 35

- Rheumatic fever - Degenerative calcification - Connective tissue disorders e.g. Marfans, Ehlers danlos - IE - Bicuspid aortic valve

Answer 36

Early diastolic murmur - louder on sitting forward - louder on expiration - Collapsing pulse Other signs - Quinckes sign- nailbed pulsation - De Mussets sign- head bobbing

Answer 37

ECG - Left axis deviation CXR - cardiomegaly Echocardiogram

Answer 38

1. Medical management of any associated heart failure 2. Surgery: aortic valve indications include * symptomatic patients with severe AR * asymptomatic patients with severe AR who have LV systolic dysfunction

Answer 39

describes the narrowing of the tricuspid valve leading to obstructed blood flow through the pulmonary valve, which separates the right ventricle and pulmonary artery. This obstruction can lead to increased workload on the right ventricle and **right ventricular hypertrophy.**

Answer 40

Tetralogy of Fallot Noonan syndrome Maternal rubella syndrome Infective endocarditis Carcinoid syndrome Marfan syndromeCauses

Answer 41

* Shortness of breath * Chest pain * Exertional syncope * Sudden cardiac death * Critical PS – causes cyanosis in neonates

Answer 42

ejection systolic murmur - louder on inspiration

Answer 43

- ECG -CXR - Echo

Answer 44

treating the underlying cause, managing heart failure, and surgery.

Answer 45

describes the inadequate closure of the pulmonary valve leading to the backflow of blood during diastole. The pulmonary valve normally separates the right ventricle and pulmonary artery. It occurs rarely as a congenital abnormality.

Answer 46

* Congenital * Rheumatic fever * Infective endocarditis * Pulmonary hypertension and its causes * Marfan syndrome

Answer 47

PR is generally asymptomatic. Right sided heart failure - results in systmeic congestion: * Peripheral oedema, classically ankle or sacral oedema * Raised jugular venous pressure * Hepatomegaly which may be pulsatile * Weight gain due to fluid retention * Anorexia

Answer 48

early diastolic murmur in the left upper sternal edge that is louder on inspiration

Answer 49

describes the narrowing of the mitral valve leading to obstructed blood flow through the mitral valve, which separates the left atrium and left ventricle of the heart. This obstructed flow results in increased pressures in the left atrium, pulmonary vasculature, and the right side of the heart. Over time, continued increased left atrial pressure can lead to left atrial hypertrophy and atrial fibrillation.

Answer 50

* Rheumatic fever is the most common cause * Degenerative calcification * Carcinoid syndrome * Autoimmune diseases (e.g. rheumatoid arthritis, systemic lupus erythematosus)

Answer 51

* Progressive shortness of breath on exertion * Haemoptysis: due to increased left atrial pressure leading to the rupture of bronchial veins * Atrial fibrillation: due to left atrial enlargement

Answer 52

Mid-late diastolic murmur that is louder in the left lateral position in expiration

Answer 53

- malar flush - elecated JVP

Answer 54

ECG: * May show atrial fibrillation * May show bifid P waves Chest x-ray: * May show left atrial enlargement * May show features of pulmonary oedema (e.g. Kerley B lines) Transthoracic echocardiogram: * Confirms mitral stenosis

Answer 55

**If atrial fibrillation** is present: lifelong warfarin **If asymptomatic:** * Monitor with regular echocardiography **If symptomatic**– treat, options include: * Percutaneous mitral balloon valvotomy * Mitral valve surgery (e.g. valve replacement or commissurotomy)

Answer 56

second most common valve disease after aortic stenosis is the result of the mitral valve failing to close properly, leading to leakage of blood from the left ventricle through the mitral valve and back into the left atrium when the left ventricle contracts. People with mild-moderate MR may be asymptomatic for a long time, but as the disease progresses, the myocardium hypertrophies leading to left ventricular dysfunction and heart failure.

Answer 57

* Degenerative changes * Infective endocarditis * Myocardial ischaemia – papillary muscle dysfunction or rupture can happen after a myocardial infarction * Acute rheumatic fever * Connective tissue disease e.g. systemic lupus erythematosus, Ehlers-Danlos syndrome, Marfan’s syndrome * Congenital heart disease

Answer 58

**Chronic mitral regurgitation may have:** * No symptoms * Shortness of breath on exertion * Decreased exercise tolerance * Peripheral oedema – typically the lower limb * Palpitations * Features of left ventricular dysfunction e.g. orthopnoea/paroxysmal nocturnal dyspnoea **Acute mitral regurgitation** leads to rapid pulmonary oedema and is a medical emergency, as it can be life-threatening. This requires emergency valve repair surgery.

Answer 59

pansystolic (holosystolic), blowing murmur at the apex that radiates to the axilla

Answer 60

emergency surgery: * They may need preoperative diuretics: furosemide is used * Surgical options are: annuloplasty, bioprosthesis/mechanical valve replacement

Answer 61

Depends on left ventricular ejection fraction (LVEF): * If LVEF >60%: 1st line: ACE inhibitors and beta-blockers * If LVEF ≤60%: surgery

Answer 62

**LVEF ≥30%:** * Surgery and ACE inhibitors + beta-blockers + diuretics (furosemide or indapamide) * Surgical options are: annuloplasty, bioprosthesis/mechanical valve replacement **LVEF <30%:** * ACE inhibitors + beta-blockers + diuretics (furosemide or indapamide) * Surgery is not indicated due to significant operative risk

Answer 63

is an **autoimmune** disease that may happen following a throat infection with **group A Streptococcus i.e. Streptococcus pyogenes.** Pathophysiology - It is thought to be the result of molecular mimicry. - This is where the antigens presented on the bacterium are mistaken to be the same as antigens on the human host tissue. The disease can affect joints, skin, the heart, and the nervous system. It can lead to mitral stenosis and congestive heart failure.

Answer 64

Risk Factors * Younger age * Poverty * Overcrowding in living conditions * Family history

Answer 65

Jones Criteria Diagnosis is based on the Jones criteria (mentioned in presentation). Diagnosis can be made if there is: * Evidence of recent streptococcal infection and two major criteria or * Evidence of recent streptococcal infection and one major and two minor criteria

Answer 66

**Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP):** * Usually raised **Full blood count (FBC):** * May have elevated white cells **Blood cultures:** * To rule out sepsis or infective endocarditis **ECG**: * May show PR prolongation which is an acute criterion **Chest x-ray:** * May show cardiomegaly and congestive cardiac failure **Echocardiogram**: * May show valvular dysfunction e.g. mitral regurgitation **Throat swab and culture:** * May show group A Streptococci e.g. Streptococcus pyogenes * Provides evidence of a streptococcal infection **Throat swab and rapid antigen test for group A Streptococci** * Provides evidence of a streptococcal infection Anti-streptococcal serology – anti-streptolysin: - May be positive - Provides evidence of a streptococcal infection **Throat swab and polymerase chain reaction (PCR):** - May be positive - Provides evidence of a streptococcal infection

Answer 67

**1st line:** * IM benzathine benzylpenicillin or oral phenoxymethylpenicillin (penicillin V) * If allergic then give erythromycin **If arthritis present:** * NSAIDs: ibuprofen or naproxen **If heart failure develops:** * Treat with standard heart failure treatment

Cardiology (Structural disease) Flashcards

(92 cards)