Cardiology - Valvular Disease Flashcards
(327 cards)
1
Q
Where are most valve disease found
A
L side
2
Q
What can go wrong with valves
A
Stenosis - doesn’t fully open
Regurgitation - doesn’t close properly
3
Q
What is valve disease caused by
A
Disease of valve leaflets OR
Stretching of the structure that the valve is attached to
4
Q
Congenital causes of valve disease
A
Bicuspid aortic valve
5
Q
Acquired causes of common valve disease
A
Degenerative
Rheumatic
Endocarditis
6
Q
Secondary/ functional regurgitation
A
Stretching of structure the valve is attached to causing leakage
7
Q
How do valves work in a normal ventricle
A
Valve cusps meet –> valve closes
8
Q
How do valves work in a dilated ventricle
A
In a stretched valve ring, cusps don’t meet –> valve doesn’t close (leaking valve)
9
Q
Causes of 2’ regurgitation
A
Dilated LV
Dilated aortic root
10
Q
Causes of dilated L ventricle
A
IHD
Dilated cardiomyopathy
HTN
11
Q
What type of regurgitation can be caused by dilated LV
A
MR
12
Q
What can cause dilated aortic root
A
Cystic medial necrosis
Bicuspid AV
Aortic dissection
13
Q
Cystic medial necrosis
A
Medial layer undergoes necrosis of connective tissue –> weakening
14
Q
When does cystic medial necrosis happen
A
Aging
CTD e.g Marfan’s, EDS
Accelerated by hTN
15
Q
What type of regurgitation can be caused by dilated aortic root
A
AR
16
Q
What can high LA pressure cause
A
Pulmonary oedema
17
Q
What can high RA pressure cause
A
Increased JVP
Ascites
Peripheral oedema
18
Q
What is rheumatic fever
A
An infl condn involving heart, skin and connective tissue usually affecting children (occasionally young adults)
19
Q
When does rheumatic fever develop
A
3 weeks after sore throat from group A strep
20
Q
What % of rheumatic fever pts have cardiac involvement
A
50%
Usually occurs after recurrent episodes (fibrosis)
21
Q
How can rheumatic fever cause valve damage
A
Abnormal immune response to Group A Strep
22
Q
How can rheumatic fever be prevented
A
Penicillin after sore throat
Also treated w/ penicillin
23
Q
Rheumatic heart disease
A
Long-term consequence of rhematic fever
24
Q
Primordial prevention of RHD
A
Improved living condn
Access to medical care
25
Primary prevention of RHD
Penicillin for confirmed strep pharyngitis
26
Secondary prevention of RHD
Extended abx (yrs - lifelong)
27
Epidemiology of rheumatic disease causing valve disease
Commonest cause in developing world but rare in developed world
28
How does valve disease present
Incidental finding - hearing murmur or in ECG
| Heart failure symptoms - fatigue, breathlessness on exertion, swollen legs
29
What is mitral valve disease often associated with
AF
30
What can aortic valve disease be associated with
Angina
Dizziness
Sudden death
31
Normal valve function in systole
Mitral valve closed
| Aortic valve open
32
Normal valve function in diastole
Mitral valve open
| Aortic valve closed
33
What can cause MS
Thickening of leaflets that fuse at commisures
| Repeated infl also causes valve damage
34
Where do valve leaflets meet
Commisures
35
What can cause MR
```
Damage to any part of MV structures
LV dilatation (2' MR)
```
36
Pathophysiology of MR
Blood leaks back from LV into low pressure LA during systole
37
What can be heard during MR
Pan-systolic murmur radiating to axilla
| Displaced apex beat
38
Which pts with MR will have surgery
Severe symptomatic MR
Asymptomatic with LV impairment
Most pts are asymptomatic
39
Mitral valve prolapse
Displacement of some part of one/both mitral valve leaflets into LA during systole
40
Commonest cause of c/c MR
Mitral valve prolapse
41
Auscultation of mitral valve prolapse
Mid-systolic click with a late systolic murmur
42
Mitral valve repair
Removal of extra tissue
Leaflet edges closed with sutures
Annuloplasty ring tightens valve
43
Normal mitral valve area
4 - 6 cm2
44
Area of mitral valve when stenosed
<2 cm2
45
Mitral valve stenosis pathophysiology
Problem of diastole - blood unable to be pushed from LA to LV
Reduced filling of LV --> reduced SV and CO
High pressure of LA transmitted back to pulmonary circulation --> pulmonary oedema
Increases risk of AF
46
Mitral faces
Rosy cheeks - malar rash
| Rest of face has bluish tinge due to cyanosis
47
Listening for MS
Left lateral position
Place bell lightly over apex
Low frequency rumbling sound beginning in mid-diastole
48
Auscultation of MS
Loud S1
Opening snap - sudden tensing of chords
Mid-diastolic murmur (+presystolic accentuation)
49
Treatment of mitral stenosis
Balloon valvotomy
Catheter passed into femoral vein into RA then into MV
Balloon rapidly inflated to crack open commissures
50
Aortic stenosis
Thickening of aortic leaflets causes obstruction to outflow
| Issue of systole
51
How many aortic leaflets are there
3
52
Common causes of aortic stenosis
```
Calcific disease (older pt)
Bicuspid valve (younger pt)
Rheumatic heart disease
```
53
Effects of aortic stenosis on heart structure
LV is pressure loaded because of obstruction to flow and hypertrophies
54
Symptoms of aortic stenosis
Exertional dyspnoea
Angina-like chest pain
Light-headedness and syncope
Sudden death caused by arrhythmias
55
What causes exertional dyspnoea
Raised LVEDP
56
Why is there reduced myocardial oxygen supply in aortic stenosis
Coronary Perfusion Pressure = aortic diastolic pressure - LVEDP
In severe AS, the stiff, hypertrophied LV has a high LVEDP --> reduced CPP
57
Survival in aortic stenosis
Short lifespan after onset of severe symptoms
| Mortality majorly increased by valve replacement surgery
58
Commonest congenital heart defect
Bicuspid aortic valves - screen 1st degree relatives
59
Main risks with bicuspid aortic valves
Aortic stenosis and/or regurgitation
Associated aortopathy
IE
60
Aortopathy
Dilatation of any part or all of the proximal aorta forth aortic root to aortic arch
61
What condns are bicuspid aortic valves associated with
```
Coarctation of action (BAV in 50%)
Turner Syndrome (BAV in 30%)
```
62
Mx of bicuspid aortic valve
All pts must have lifelong surveillance and will require surgery on valve and/or aorta in their lifetime
63
Is aortic regurgitation a problem of diastole or systole
Diastole - leaflets of aortic valve don't meet properly allowing blood to leak back into LV
64
What causes aortic regurgitation
Disease of leaflets
| Dilatation of aortic root
65
Clinical features of aortic regurgitation
Angina-like chest pain (decreased perfusion pressure and compensatory hypertrophy)
Dilated LV --> displaced apex
Collapsing pulse
Wide pulse pressure
66
Collapsing pulse
High systolic pressure
| Low diastolic pressure
67
Corrigan's sign
Prominent carotid pulsation
68
Why is there reduced myocardial oxygen supply in AR
CPP = Aortic Diastolic Pressure - LVEDP
| In severe, ar, the aortic diastolic pressure is low --> reduced CPP
69
Listening for aortic regurgitation
```
Ask pt to:
Sit up
Lean forward
Exhale completely
Hold breath in full expiration
```
Hold diaphragm firmly at LSE
Early diastolic murmur - decrescendo
70
Cause of significant tricuspid regurgitation
RV enlargement
| Usually functional
71
Signs of tricuspid regurgitation
Distended JVP w/ prominent v wave
Enlarged and pulsatile liver
Systolic murmur at LSE
72
Treatment of tricuspid regurgitation
Of the cause of RV enlargement (occasionally surgery is needed)
73
How common is tricuspid stenosis
Rare
74
Cause of tricuspid stenosis
Rheumatic heart disease
75
How common is pulmonary stenosis
Rare
76
Usual cause of pulmonary stenosis
Congenital
77
Pulmonary regurgitation as a functional issue
Due to dilated pulmonary artery caused by pulmonary HTN
78
Epidemiology of CVD
1 in 4 deaths in England
79
Modifiable risk factors for CHD
```
HTN
DM
High cholesterol
Smoking
Obesity
Diet
Alcohol
Stress
Sedentery lifestyle
```
80
Non modifiable risk factors for CHD
Fhx
Gender
Ethnicity
Age
81
Risk calculator for primary prevention of CVD
QRISK2/3
82
2' prevention of CHD
```
Antipltelts (Asp, clop, prasugrel, ticagrelor)
Beta-blockers/ ivabridine
Statin
ACEi
Lifestyle modification
Cardiac rehab
```
83
BP recommendations for pts at risk of CHD
Lower BP to <140/90mmHg
| Systolic 120-130 in pts 18 to 69 years old
84
By how much does medication affect BP
Reduces bp by 10/6 mmHg
| Doubling dose results in only further 20% drop
85
Lifestyle modification for HTN
```
Wt loss
Mediterranean diet
Reduced Salt intake (2.4Na/day)
Physical activity (30mins aerobic/ day)
Mod alcohol
```
86
When does cholesterol level become worrying
> 5.2mmol/l
| Contributes to 46% of CHD deaths
87
Where do HDLs carry cholesterol
Away from arteries and back to liver, then excreted from body
88
What do LDLs do
Build up in walls of the arteries to form thick, hard deposits that narrow the arteries and make them less flexible
89
Main storage form of LDL
Triglycerides
90
Treatment of hypercholesterolaemia
Statins first line therapy for all pts with CVD and T2DM
| Atorvastatin 80mg OD
91
Treatment for dysglyceamia
Diet, aerobic exercise and resistance training
| Improves lipid profile, alters glucose metabolism and tightens glycemic control
92
1st line therapy for DM
Metformin
93
Issues associated with obesity
```
Raised BP
Raised LDL & triglycerides
Low HDL
Impaired glucose tolerance
Increased insulin resistance
```
94
What % of pts have depression post-MI
15-20%
95
Cardiac rehab
Comprehensive, long-term program involving prescribed exercise, risk-factor modification, education and counselling
96
What does CVD incl
CHD
CVA
PAD
97
What types of fat should we be eating
MUFA/PUFAs
98
Mediterrenean-style diet
More bread, fruit, vegetable and fish
| Less meat and replace butter/cheese with products based on plant oils
99
How does HR affect myocardial demand
The higher the HR, the higher the demand
100
How does force of contraction affect myocardial O2 demand
The stronger the force of contraction, the higher the demand
101
Types of drugs for CAD
Reduce cardiac workload
| Coronary vasodilators
102
Drugs that reduce cardiac workload
Beta-blockers
Ca channel blockers
Other channel inhibitors - ivabradine, ranolazine
103
Coronary vasodilators
Nitrates
| K channel opener - Nicorandil
104
Block L-type Ca channels present in
Arterial smooth muscle
Cardiac muscle
Cardiac pacemaking tissue
105
What does blocking Ca channels in arterial smooth muscle do
Causes vasodilation
106
What does blocking Ca channels in cardiac muscle do
Reduces force of cardiac muscle contraction
107
What does blocking Ca channels in cardiac pacemaking tissue do
Reduce HR
| Blocks AVN
108
Types of Ca channel blockers
Non-dihydropyridine (-ve inotropic)
| Dihydropyridine (non-inotropic)
109
Examples of non-dihydropyridine Ca channel blockers
Verapamil - mainly cardiac effects
| Diltiazem - both cardiac and vascular
110
Uses of non-dihydropyridine Ca channel blockers
Angina
Arrhythmias
(Some effect on BP)
111
Examples of dihydropyridine Ca channel blockers
Amlodipine
| Nifedipine (decreases arterial resistance)
112
Uses of dihydropyridine Ca channel blockers
Acts mainly on vascular smooth muscle to reduce BP
Little to no cardiac effect
Widely used for HTN
113
Known adverse effects of Ca channel blockers - cardiac
Slow HR
| Reduced contraction - may worsen heart failure
114
Known adverse effects of Ca channel blockers - vascular
```
Headache (hypotension)
Peripheral oedema
Reflex tachycardia (may be harmful to those with CAD)
Rash
Constipation
```
115
How do you choose Ca channel blockers
Whether you want arterial or cardiac effects
116
Types of beta-adrenoceptors
Beta-1 in the heart
| Beta-2 in the airways
117
What do beta-adrenoceptors bind to
Circulating adrenaline and noradrenaline released by sympathetic system
118
Example of non-selective beta-blocker
Propanolol
119
Examples of cardio selective beta-blockers
Atenolol
Bisoprolol
Metoprolol
120
Examples of beta-blockers with vasodilator activity
Carvedilol
| Labetalol
121
Adverse effects of beta-blockers - cardiac
```
Bradycardia
Initially worsens heart failure
Bronchoconstriction
Fatigue
Cold extremities
Erectile dysfunction
```
122
Adverse effects of beta-blockers - sympathetic blockade
Bronchostriction (blockade of beta2-adrenoceptors)
| Tiredness, feel cold
123
Nitrates MOA
Increases conc of endothelium NO --> vascular smooth muscle relaxation
124
Effects of nitrates
Arterial dilation
| Venous dilation that reduces blood return to heart
125
Effects of arterial dilation - nitrates
Improve coronary supply
| Reduce afterload by lowering BP
126
Effects of venous dilation - nitrates
Decreased preload and stretching of heart
| Decreased pressure in the ventricles (esp diastolic wall pressure)
127
Commonly used nitrates
GTN/ NTG
| Isosorbide mononitrate
128
Administration of GTN/ NTG
s/l, spray, buccal
| For a/c use
129
Administration of isosorbide mononitrate
po OD
130
Nitrates and IHD
Symptomatic relief of ischaemic pain
| NOT shown to have major impact on mortality
131
Adverse effects of nitrates
Hypotension
Reflex tachycardia
Headache
Flushing
132
Who prescribes specialist drugs for angina
Experienced drs for 3rd to 4th line treatment
133
Examples of specialist drugs for angina
Nicorandil
Ranolazine
Ivabradine
134
Nicorandil
Has nitrate action
| Opens K channel
135
Ranolazine
Late Na current inhibitor
136
Ivabradine
Spp sinus node inhibitor
Blocks cardiac conduction
Similar to BB
137
How does cardiac output affect MAP
Slower and less vigorous pumps lowers MAP
138
How does vascular resistance affect MAP
Wider arteries, lower MAP
139
Types of drugs for HTN
Reducing intravascular volume
Reduce sympathetic tone
Relax peripheral arteries
Block neuroendocrine mediators of bp
140
What drugs reduce intravascular volume
Diuretics - thiazides
141
Which antihypertensives reduce sympathetic tone
Alpha and BB; central acting agents
142
Which antihypertensives relax peripheral arteries
Ca-channel blockers
143
Which antihypertensives block neuroendocrine mediators of bp
ACEi
ARBs
Renin inhibitors
144
Examples of ACEi
Captopril
Enalapril
Ramipril
145
What does aldosterone release cause
Salt and water retention
| Increasing intravascular volume
146
When to use ACEi
1st line HTN except for selected pt (<55 or African descent)
| 1st line in pervious heart failure or cardiac damage
147
Safety and suitability of ACEi
```
Drops BP (first dose)
Worsens renal function
Retains K
```
148
Mitigating ACEi dropping BP
Give small test dose
| Check pt not too volume depleted
149
ACEi and renal function
Check U&E's before and one week after
150
ACEi and K retention
Stops K supplement or K-sparing diuretic
151
Mechanism of ACEi
Inhibits angiotensin converting enzyme
| Reducing generation of angiotensin II and thus aldosterone --> Na and water aren't reabsorbed as much
152
ARBs
Angiotensin II receptor blockers
| Similar to ACEi
153
What happens when AT1 receptors bind to angiotensin II
Vasoconstriction
Increased sympathetic stimulation
Increased ADH secretion
154
Examples of ARBs
Losartan
| Irbesartan
155
Which pts take ARBs
Pts who can't tolerate ACEi
156
Types of diuretics
Loop
Thiazides
Thiazides-like
K sparing
157
What are Loop diuretics v efficient for
Heart failure
158
Examples of loop diuretics
Furosemide
| Bumetanide
159
Na excretion in loop diuretics
Up to 25% Na load excreted, can be used in renal impairment
160
How long do loop diuretics take to work
30 mins (IV) to 1 hr (rapid action)
161
Administration of loop diuretics
po OD in the morning
| Can be used orally for long-term control
162
Thiziade diuretiucs
Bendroflumethiazide for HTN
163
Thiazide-like diuretics and Na excretion
5-10% Na load excreted
| Ineffective if eGFR is <30 and should be avoided
164
Example of a thiazide-like diuretic
Indapamide
165
K sparing diuretics and Na excretion
<5% Na load excreted
| Used together with more effective diuretics
166
Example of K sparing diuretics
Spironolactone - blocks aldosterone for heart failure and HTN
167
Diuretics safety
Hypovalemia, dehydration and hypotension
| Electrolyte imbalance
168
Electrolyte imbalance on diuretics
Low K, Na
High urea - due to dehydration
Check electrolytes regularly if on high dose
169
Monitoring for diuretics
BP, urine output or body wt
170
4th line drugs for resistant HTN
```
BB
Alpha-blockers
Renin inhibitors
Central sympathetic outflow
K channel opener
```
171
Renin inhibitors - reistant HTN
Aliskiren
172
Central sympathetic outflow - resistant HTN
Clonidine
| Methyldopa
173
K channel opener - resistant HTN
Minoxidil
174
Antihypertensive algorithm
Aged <55 yrs - start w/ ACEi/ARB
Aged >55yrs or Afro/carribean - CCB
ACEi/ARB + CCB
ACEi/ARB + CCB + thiazide-like diuretic
4th line drugs
175
What is the early part of P wave due to
RA depolarisation
176
What is middle part of p wave due to
RA and LA depolarisation
177
What is late part of p wave due to
LA depolarisation
178
Normal height of p wave
<2.5mm (squares) tall
179
What can cause tall p waves
RA abnormality - RA is overloaded, usually associated with enlargement of RA
180
In which leads can you see RA abnormalities in best
Tall, peaked P waves, normal duration
| Inferior leads - II, III, aVF
181
In which condns do we see tall p waves
Pulmonary disease
| Congenital heart disease
182
Normal width of p wave
<3mm wide
183
What can cause broad p waves
LA abnormality
184
In which leads can you see LA abnormality best in
Limb leads
185
In what condns do we see broad p waves
Valvular heart disease - left side
Hypertensive heart disease
Cardiomyopathies
CAD
186
When might p waves be intermittently absent
Sinus arrest
| SA exit block
187
Sinus arrest
SAN fails to generate impulse
188
SA exit block
Impulse fails to leave SAN
189
What can cause a short PR interval
Low atrial pacemaker
| Accessory pathway
190
Why would a low atrial pacemaker cause a short PR interval
Lies closer to AVN so distance is shorter
191
Why would an accessory pathway cause a short PR interval
The extra connection may conduct more quickly than AVN e.g. Wolf-Parkinson-White
192
What can cause a long PR interval
AV block
| Can be 1st, 2nd or 3rd degree
193
1st degree AV block
Prolonged PR interval as impulses travel slower from atria
194
2nd degree AV block
Leads to intermittent failure off the atrial impulse to conduct to ventricles (some impulses make it through AVN)
195
3rd degree AV block
None of the atrial impulses travel to ventricles
196
Possible abnormalities of QRS complex
Too wide
Too big (hypertrophy)
Pathological Q waves (after MI)
197
Supraventricular origin of wide QRS complex
```
Aberrant conduction:
Bundle branch block
Brugada pattern
'Toxic' conduction delay
Preexcitation
```
198
Ventricular origin of wide QRS complex
Ventricular ectopic beat
| Ventricular paced beat
199
Wolf-Parkinson-White on an ECG
Short PR interval
Wide QRS complex
Delta wave
200
Normal ventricular depolarisation
Phase 1 - septum depolarises L --> R
| Phase 2 - both ventricles depolarise simultaneously (but LV is electrically predominant)
201
Why is LV electrically predominant
LV has more muscle mass so depolarisation move sin that direction (causes -ve deflection in V1 and +ve in V6)
As depolarisation continues, deflections get more pronounced until both ventricles are fully depolarised and everything goes back to baseline
202
Features of bundle branch block on ECG
Broad QRS complex
Unique QRS shape - 3mm or more
Repolarisation abnormalities in leads over affected area
203
Repolarisation abnormalities seen on ECG
ST depression
| T wave inversion
204
Causes of bundle branch block
```
CAD
HTN
Valve disease
Cardiomyopathy
Post cardiac surgery
```
205
Ventricular depolarisation in RBBB
Phase 1 - septum depolarises normally
| Phase 2 - ventricles depolarise sequentially, RV is delayed
206
RBBB appearance on ECG
MaRRoW
M in V1
W in V6
207
Why is RBBB more common than LBBB
R bundle is easier to become damaged
208
Ventricular depolarisation in LBBB
Phase 1 - septum depolarises abnormally (R --> L)
| Phase 2 - ventricles depolarise sequentially, LV is delayed
209
LBBB appearance on ECG
WiLLiaM
W in V1
M in V6
210
Brugada pattern
RBBB-like in appearance in R precordial leads (V1 - 3) w/ coved ST elevation (shark fin)
211
What is Brugada pattern caused by
Abnormal RV depolarisation
212
Epidemiology of Brugada pattern
Rare
Inherited
M > F
213
How might pts with Brugada syndrome present
With life threatening ventricular arrhythmias ---> syncope, seizures & cardiac arrest
214
ECG changes in hyperkaleamia
T waves become tall and peaks
PR interval prolongs and P wave becomes smaller (may disappear)
QRS complexes progressively widen --> sinusoidal appearance --> asystole
215
How does hypertrophy affect QRS complex
Produces bigger complexes - simply more +ve and more -ve charges
216
Depolarisation in RV hypertrophy
Opposite to normal depolarisation
217
Commonest cause of RV hypertrophy
Pulmonary HTN
Congenital heart disease e.g. pulmonary stenosis
Chronic lung diseases
218
What is RV hypertrophy associated with
R axis deviation and repolarisation abnormalities in leads V1 - V4
219
RV hypertrophy appearance on ECG
Large R waves in V1, V2
| Deep S waves in V5, V6
220
Depolarisation in LV hypertrophy
Exaggeration of normal depolarisation
221
LV hypertrophy appearance on ECG
Axis is usually normal but can be L
Abnormally deep S wave in V1
Abnormally tall R wave in V6
May also see depolarisation abnormalities
222
Normal Q wave appearance
Short (1mm max) and small (<25% of total QRS height)
223
Pathologic Q waves appearance
Wide and/or deep
224
What can cause ST elevation
```
STEMI - regional ST elevation (V1 - V4)
Pericarditis - widespread ST elevation
BBB
High take off
LV aneurysms
```
225
Causes of ST depression
Ischaemia
Posterior MI
Repolarisation abnormalities
226
In which leads would you see an inferior MI
II
III
aVF
227
In which leads would you see a lateral MI
I
aVL
V5
V6
228
In which leads would you see an anterior MI
V1 - V6
229
ECG dx of STEMI
ST elevation >1mm in >2 related leads
However, LBBB can hide ST changes in MI and certain areas aren't seen well by standard ECG
230
ECG appearance in unstable angina/ NSTEMI
A/c changes - T wave inversion, ST depression
231
Normal T wave size
<50% size of preceding QRS
232
In which leads are T wave normally inverted in
aVR
| V1
233
Causes of a tall T wave
ACS - hyperacute stage of MI
| Hyperkalaemia
234
Causes of inverted T wave
```
May be normal
Myocardial disease (ischaemia, infarction, cardiomyopathy)
Ventricular hypertrophy
BBB
CVA
```
235
Normal range for QT interval
0.33 to 0.44 seconds (up to 0.45 in women)
236
What are both long and short QT intervals associated with
Increased risk of ventricular arrhythmias ---> syncope and sudden death
237
How do people get long or short QT intervals
Inherited
| Acquired due to drugs (esp antiarrhythmic) or electrolyte disturbance e.g. K, mg, Ca
238
Adjusting QT interval for HR
QTc = QT/ square root of RR interval
239
Easy way to check for prolonged QT interval
Look at where T wave ends - if its beyond halfway point of RR interval then it is prolonged
240
Systematic ECG checklist
```
Basics - name, pt identifier, date, speed, calibration
Rate
Rhythm
Axis
Waves
Intervals
```
241
Determining sinus rhythm from rhythm strip
Ask:
Regular or irregular?
P wave before QRS?
242
Clinical evaluation for valve disease pt
```
Severity of stenosis
Degree of regurgitation
Ventricular size and function
Atrial size
Estimated pulmonary artery pressure
```
243
Key ix for valve disease
ECG
244
Symptoms of valve disease
SOB and HF
Fatigue
Palpitations/AF - spp mitral valve disease
245
Spp symptoms seen in aortic stenosis
Angina
| Syncope (particularly on exercise)
246
Principles of valve disease mx
Limited benefit from meds
| Surgery is usually indicated in severe disease
247
Medical therapy for AF
Prevent embolism - anticoagulants w/ vit K anatag or DOAC
| Rate control - BB and digoxin
248
Do DOACs work in pts with prosthetic valves
No
249
Surgical/ interventional options for valve disease
Valvotomy
Repair valve surgically
Valve replacement
250
How can a valvotomy be done
Surgical
| Percutaneous w/ a balloon
251
Different valves used in valve replacement
Mechanical valves
Tissue valve - heterograft, homograft
TAVI
252
TAVI
Transcatheter aortic valve implantation
253
Using mechanical valves as replacement
Durable but anticoags needed
254
Using tissue valves as replacement
Last less time (15 yrs approx) and less in the young
| No anticoags needed unless AF
255
Repairing valves
Best if it can be done - only mitral
| Long lasting, no anticoags, better function
256
Factors influencing risk of valve surgery
Age
General physical state and comorbidities
Damage already done to heart - particularly LV in c/c cases
Renal function
Cerebral and carotid arteries - risk of CVA
257
What are the best valves to repair
Those with leaflet prolapse and chordal rupture
| Surgeons can repair chord that support valve and repair valve cusps
258
Use of TAVI
Safe
Suitable for elderly pts w/ contraindications to surgery
Durability unknown
Avoid long-term anticoagulant
259
Infective endocarditis
Infection of inner lining of heart
| Usually affects valves
260
Why is IE difficult to dx
Masquerades as many other condns
| Rare but 100% fatal w/out abx
261
Examples of organisms causing IE
Staph A - very a/c onset
Strep Viridans - slow onset
Strep faecalalis (enterococcus)
262
Sites attacked in IE
Prosthetic valves
Previously abnormal valves e.g. MR, AR, AS
High virulence bacteria e.g. staph A attack normal valves
263
Vegetation
Collection of organisms and thrombus
| Embolisation risk
264
IE clinical px
Very variable and diff to dx
| Depends of organisms/ underlying cardiac defect
265
Signs and symptoms of IE
Fever, night sweats
Roth spots
Osler nodes
Murmur
Janeway lesions
Anaemia
Nail-bed (splinter) haemorrhage
Emboli
266
Symptoms seen in c/c IE
Enlarged spleen
Clubbing
Pigmentation
Glomerulonephritis
267
Major complications of IE
Systemic embolisation - vegetation breaking off
| Heart failure - damage to valve
268
Cerebrovascular complications of IE
Embolism
Infected aneurysm - mycotic aneurysm
(May rupture and cause major cerebral damage)
269
Diagnosing endocarditis
```
Clinical suspicion
Blood cultures - do before abx
High infl markers
Low grade anaemia and mildly raised WBC
Echo to image vegetations, valve damage, abcess
```
270
Types of echocardiogram
Transthoracic
| Transoesophageal - better views for IE, detects accesses, vegetations and valve damage
271
Mycotic aneurysm
Dilation of artery wall due to damage to vessel wall following infection
272
Why is endocarditis so deadly
Antibody antigen complexes damage small blood vessels
| Direct damage to heart/ valves due top vegetations or abcesses
273
Prosthetic endocarditis
V serious complication
May affect any intracardiac device
Makes valves come lose/ detach
Nearly always needs replacement
274
Mx of endocarditis
Abx - usually IV for 4-6 wks (50% need surgery as well)
| MDT approach - cardiology/ microbiology/ cardiac surgery
275
When should surgery be considered urgently in endocarditis pts
Haemodynamic deterioration due to damage caused by infection
Infection not responding to abx
Abcesses seen on echo
276
PND
Paroxysmal nocturnal dyspnoea
Waking up gasping for air after 1-2 hrs of sleep
277
Orthopnoea
Breathlessness lying down
| Seen in heart failure
278
Determining whether murmur is systolic or diastolic
Feel radial pulse while listening - pulse syncs with 1st heart sound
279
Examples of systolic murmurs
AS
MR
Pulmonary stenosis
280
Examples of diastolic murmurs
AR
MS
Tricuspid stenosis
Pulmonary regurgitation
281
Auscultatory areas of heart
Aortic - 2nd IC space (R)
Pulmonary - 2nd IC space (L)
Tricuspid - 4th IC space (L)
Mitral - 5th IC space (L)
282
Differentiating between AS and MR murmurs
AS radiates to neck and MR radiates to axilla
AS is pan systolic murmur
MR is crescendo-decrescendo
283
Divisions of left bundle
Anterior fascicle
| Posterior facsicle
284
In which leads can we see the L anterior fascicle
I
| aVL
285
In which leads can we see L posterior fascicle
II
III
aVF
286
Px of a/c symptomatic MR pts
Severe dyspnoea
Pulmonary oedema
Hypotension
287
Contraindications of nitrates
Aortic or mitral stenosis
Pericarditis
HCM
Hypotensive condns
288
Contraindications for BB
Asthmatics
Hypotension
Unstable cardiac failure
289
Contraindications for CCB
A/c anginal attacks
Cardiogenic shock
Significant aortic stenosis
UA within 1/12 of MI
Interacts w/ BB
290
Adverse effects of ACEi
```
Cough - increase in bradykinin
Hypotension
Angiodema
Diarrhoea
Muscle pains, skin reactions
```
291
Contraindications of ARBs
Pregnancy
Severe renal stenosis
Aortic stenosis
292
Adverse effects of ARBs
```
Cough - not as common
Hypotension
Hyperkalemia
Nausea, vomiting
Angiodema
```
293
Contraindications of loop diuretics
Severe renal impairment
| Treatment with cardiac glycoside
294
Contraindications of thiazides
Electrolytic disturbances
| Cardiac glycosides
295
Contraindications of K sparing diuretics
ACEi
296
How may pts with tricuspid stenosis present
Hepatomegaly and distended abdomen due to passive vein congestion
297
Initial ix for heart murmurs
Echo
CXR
ECG
298
Qualities of benign murmurs
```
Soft
Humming
Position-dependent
Usually systolic
Pt otherwise healthy
```
299
Janeway lesions
Painless spots on palms/soles of feet
300
Oslers nodes
Painful nodules in pulp of fingers/ toes
301
What is a low volume pulse usually caused by
Low output state (dehydration, heart failure)
| Aortic stenosis
302
When is upstroke delayed
Aortic stenosis
303
What physiological reasons cause a high volume pulse
Advanced age
| High output states (exercise, pregnancy)
304
What pathological reasons cause high volume pulse
HTN
Aortic regurgitation
High output states (fever, anaemia, thyrotoxicosis)
305
Chest lead placement for ECG
V1 - 4th intercostal space at LSE
V2 - 4th intercostal space at RSE
V3 - Midway between V2 & V4
V4 - 5th IC space in mid clavicular line
V5 - same level at V4 but more left (---> axillary)
V6 - Mid axillary line (same level as V4 & V5)
306
Limb lead placement
Red - ulnar styloid process of R arm
Yellow - ulnar styloid process of L arm
Green - malleolus of L leg
Black - malleolus of R leg
307
Which murmur is best heard in expiration with th eats rolled onto their left
Mitral stenosis
308
Which type of echo is best
Transoesphageal
309
Conventional echo
Transthroacic
310
Why might pts get pan systolic murmurs post-MI
Damage to papillary muscles causes MR
| May have ventricular septal defect
311
Myxoma
Benign tumour usually found in atria
312
Main ix for AS
Cardiac echo
| Coronary angio
313
What is usually seen in severe AS
LV hypertrophy
314
CXR in AS
May still appear normal in severe cases as LV is hypertrophied rather than dilated
315
Causes of increased JVP
Congestive or R heart failure
Tricuspid regurg
Iatrogenic volume overload
316
Waveforms of JVP
a wave - atrial contraction
| v wave - ventricular contraction
317
JVP vs carotid pulse
2 peaks vs 1 peak
JVP falls on inspiration
JVP rises with hepatojugular reflux
318
What could high CRT be a sign of
Low CO
319
When is the volume of the carotid pulse high
Regurgitation
320
When is the volume of the carotid pulse reduce
Those with low CO
321
Conditions changing the character of carotid pulse
AS - slow to rise
| AR - rapid upstroke and downstroke
322
Which murmurs are heard best with the pt lying on their left side
Mitral or triscupid murmurs
323
In which positions are aortic murmurs heard best
Sitting up
324
Which murmurs are louder in inspiration
Right sided - M or P
325
Which murmurs are louder on expiration
Left sided murmurs - A or T
326
Describing heart murmurs
Timing - sys or diastole
Location
Radiation
Manoeuvres
Pitch
Intensity
327
What is the main trigger for RAAS
Decreased blood flow to renal arteries
| Can be initiated in a/c haemorrhage
