Cardiology_Medicine Flashcards
(95 cards)
1
Q
IHD - Types? Definition? Dx? Mx?
A
Stable angina - chest pain on exertion relieved by rest
- Path - mismatch in O2 supply and demand to the myocardium
- Ix: CT-angiogram
- Mx:
- B-blockers - reduces HR req for activity –> reduced likelihood of mismatch in O2 supply & demand
- GTN spray - reduce myocardial preload + reduces strain
- RF modification –> reduced risk of progression
Acute coronary syndrome - Sx caused by sudden reduced BF to the myocardium
- Dx:
- ST-elevation = STEMI
- Troponin raised = NSTEMI (+ dynamic T-wave inversion, ST depression)
- Unstable angina pectoris (pain at rest) = ischemia NOT infarct
- Generic ACS Mx - MONA BASH
- ALL immediate:
- 5-10mg Morphine IV + Nitrates (GTN spray)
- Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor)
- ALL long-term:
- Continue DAPT
- 1 year: 75mg OD Aspirin + 75mg OD Clopidogrel (or 90mg BD Ticagrelor)
- >1yr - 75mg OD Aspirin
- B-blocker (1.25-10mg Bisoprolol OD)
- ACEi (1.25-10mg Ramipril OD)
- Statin (80mg Atorvastatin OD)
- Continue DAPT
- ALL immediate:
- STEMI Mx: establish coronary reperfusion ASAP
- Sx <12hrs: PCI BUT if no PCI within 2hrs Dx –> thrombolysis (e.g. tPA - tissue plasminogen activator)
- Sx >12hrs: invasive coronary angiography ± PCI if needed
- PCI:
- If having PCI give Prasugrel (instead of Clopi/Ticagrelor)
- PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND IV unfractionated heparin during the procedure –> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) –> takes longer for endothelialization of stent so DAPT needed for 1yr
- If PCI with stents inserted –> DAPT 12 months
- NSTEMI Mx:
- 2.5mg SC Fondaparinux (direct factor 10a inhibitor)
- Risk stratify - GRACE criteria (& others)
- High risk = invasive coronary angiography (within 48-72hrs)
2
Q
Angiography & PCI
A
- Access usually gained through radial artery (or femoral) –> guide wire passed up through axillary artery –> subclavian artery –> relevant coronary artery
- Guidewire passed via X-ray guidance into the affected coronary artery
- IV unfractionated heparin during the procedure
- PCI - stent inserted impregnated with an anti-proliferative agent** (e.g. Tacrolimus - to prevent adverse tissue reaction) –> takes longer for endothelialization of stent so **DAPT needed for 1yr
3
Q
Heart failure def? Pathophysiology? Categories & Causes? Ix? Mx?
A
Def: pumping of blood by heart insufficient to meet the demands of the body
Pathophysiology:
- RHF - right side of the heart pumps deoxygenated blood from the body to the lungs to be reperfused - if the RH is not pumping effectively you get the fluid collection in the peripheries = PERIPHERAL OEDEMA
- LHF - left side of the heart pumps oxygenated blood from the lungs to the body - if the LH is not pumping effectively you pooling of blood in the lungs = PULMONARY OEDEMA
- Reduced CO –> shock, tachycardia, AKI
- CO = SV*HR
- Ejection fraction = SV/End-diastolic Volume
Categories:
- HF w/ preserved ejection fraction (left ventricular >50%) = inadequate filling of ventricles during diastole (from ventricular stiffness)
- Causes of ventricular stiffness:
- Volume overload (valve regurg)
- Pressure overload (HTN)
- Decreased distensibility (constrictive pericarditis)
- Causes of ventricular stiffness:
- HF w/ reduced ejection fraction (left ventricular <40%) = inadequate emptying of ventricles during systoles (from outflow obstruction/impaired contractility)
- Causes of outflow obstruction/impaired contractility:
- MI, Cardiomyopathy, Arrythmia
- Causes of outflow obstruction/impaired contractility:
Ix:
- Bedside: ECG - detects if anything precipitating HF (arrhythmia/ischaemic event)
- Bloods: ABG (if resp compromise from pul oedema), troponin (ACS), BNP (HF screening)
- Imaging: CXR (visualise pul oedema, cardiomegaly), ECHO (valvular abn/regional wall mov abn)
Mx: MON BA (out of MONA BASH)
- Immediate:
- Sit the patient up (reduce venous return to heart –> less strain)
- O2 15L/min NRM
- Medical:
- IV furosemide (loop diuretic) - remove excess fluid + venous dilation (reduce preload)
- Nitrates (GTN/Isosobide Mononitrate) AND Morphine - reduce preload on the heart
- Long-term:
- Reduced ejection fraction - prognostic benefit:
- B-blocker (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them
-
ACEi - reduce strain on heart
- After the above if LVEF <35% & Sx –> mineralocorticoid antagonist e.g. spironolactone
- 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT
- SGLT2 inhibitors (dapagliflozin)
- RF modification - poor glycaemic control/high cholesterol
- Sx (diuretics)
- Reduced ejection fraction - prognostic benefit:
4
Q
How does heart failure look on CXR?
A
Pulmonary oedema (fluffy alveolar shadowing = bilateral perihilar consolidation = batwings distribution) ±:
- Kurly B-lines (peripheral septal lines)
- Cardiomegaly (thoracic ratio >0.5)
- Upper lobe venous diversions (tubes going up towards apex instead of lines)
- Pleural effusion (costo-phrenic blunting)
5
Q
Atrial fibrillation (AF)
- Def? Causes? Ix? Mx?
A
Def: rapid, chaotic, and ineffective atrial electrical conduction
- ECG def: irregularly irregular narrow complex tachycardia with no p waves
Causes: idiopathic, cardio (IHD, valvular disease, cardiomyopathy), resp (PE, pneumonia), hyperthyroidism, alcohol
Ix: ECG (absence of p-waves, irregularly irreg rhythm)
Mx:
- Haemodynamically unstable (≤90 BP, chest pain, acute HF) –> DC Cardioversion
OR
- Rate control –> B-blocker (bisoprolol) OR rate-limiting CCB (verapamil - asthma)
OR
- Rhythm control - ONLY if clear reversible cause
- Sx onset <48hrs –> DC/chemical cardioversion (amiodarone/flecanide)
- NOTE: IV heparin started prior to cardioversion
- Sx onset >48hrs –> anticoagulate for 3wks –> elective cardioversion (also anticoag for 4wks after)
- Sx onset <48hrs –> DC/chemical cardioversion (amiodarone/flecanide)
AND
- Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score –> DOAC (Apixaban)
- If metallic heart valve –> warfarin INR 3-3.5
- Otherwise DOAC
- NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 –> anticoagulation not recommended
-
CHF, HTN, Age ≥75rs (2), DM, Stroke (2), Vascular disease, Age 65-74, Sex - female
- Score 1 - consider; ≥2 - DOAC/Warfarin needed
- Lifetime risk = annual risk x estimated years of life left (up to 80 yrs e.g. if 60 then x annual risk by 20)
6
Q
Types of anticoagulant
A
Heparins
- LMWH (SC) - VTE prophylaxis BUT bad for renal function
- UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring
DOACs - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD)
Vit K antagonist = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions
7
Q
Virchow’s triad to determine anticoag vs antiplatelets
A
1) Stasis - coag factor activation–> venous clot (AF, DVT/PE)
* Anticoags (DOAC/Hep/Warfarin) are most effective as coag factors cause clot
2) Vessel wall injury - plaque rupture - thrombogenic material release –> platelets activated –> arterial thrombosis (MI, stroke)
* Antiplatelets (Aspirin/Clopidogrel) most effective as platelets cause clots
3) Hypercoagulability - does not change acutely
8
Q
SVT - Def? Types? Presentation - case example? Mx?
A
Def: regular narrow-complex tachycardia with no p-waves + supraventricular origin
Junctional types:
- AVNRT - local re-entry circuit within AV node
- AVRT - re-entry circuit between atria and ventricles –> after SVT termination = delta wave = WPW syndrome:
- Assoc w/ HOCM
- Avoid digoxin, verapamil, amiodarone (reduce conduction down SAN –> worsen retrograde conduction –> risk of VT)
- Can use B-blocker/flecainide instead
Case example: 23yrs, 1-hr palpitations + SoB, 2 similar episodes prev following alcohol, this time severe chest pain
Mx:
- Unstable tachycardia (<90 BP/chest pain/acute heart failure) –> synchronised DC Cardioversion
-
Vagal manoeuvres (increase parasympathetic stim via vagus nerve to slow conduction via AV node)
- Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe
-
Adenosine 6mg –> 12 mg –> 12mg
- NOTE: if adenosine CI (e.g. asthma) –> VERAPAMIL (rate-limiting CCB)
- Other:
- IV B-blocker/amiodarone/digoxin
- Synchronised DC Cardioversion
9
Q
Key heart murmurs?
Accentuation manoeuvres?
Causes?
Left vs right heart valve abn epidemiology?
Mx?
A
Key murmurs:
-
AS = ejection systolic + radiates to carotids, slow rising pulse, narrow pulse pressure, heaving apex beat
- Sound: Wooooshhh
- Severe AS - absent/soft 2nd heart sound, reversed splitting of 2nd HS, heaving apex beat
- A longer murmur is worse (small space for blood to pass through = takes longer)
-
MS = mid-diastolic + LLP, malar flush, AF, loud/palpable S1 “tapping” apex, pul HTN (loud P2 - pul thrill)
- Sound: Wooosh de (loud S1) de (early diastolic snap)
-
AR = early diastolic + sitting forward (LLSE), collapsing pulse, wide pulse pressure, displaced apex
- Sound: de woooshhhh
- Severe AR –> Austin-flint murmur = ‘Rumbling mid-diastolic murmur’
- Best heard at apex, caused by blood flowing back through aortic valve and over mitral valve
- Shorter murmur is worse (quicker to flow back through large hole)
-
MR = pan-_systolic_ + radiates to left axilla, AF, displaced thrusting apex, LVF/pul HTN
- Sound: Woooooshhh (holosystolic)
- NOTE: same pattern for pulmonary & tricuspid (pul stenosis & tricuspid regurgitation = systolic)
- TR - pulsatile liver
- PS - radiates to back, assoc w/ Noonan’s (AD, webbed neck, wide-spaced eyes etc.)
Accentuation manoeuvres:
- R-sided murmurs (tricuspid + pulmonary) –> louder on INspiration = blood goes IN to right-side of heart
- L-sided murmurs (aortic + mitral) –> louder on EXpiration = blood EXits left-side of heart
- AS radiates to the carotids + louder on leaning forward + listen on right sternal edge
- MS louder on turning to the left, MR radiates to axilla
Causes:
- AS (stenosis/sclerosis): senile calcification (aortic valve)
- MR: IHD (papillary-muscle dysfunction post-MI), Infective endocarditis, cardiomyopathy, RHD
- AR: acute (infective endocarditis, aortic dissection), chronic (CTD, RHD, HTN, congenital)
- MS: rheumatic heart disease (RHD)
Left vs Right valve abn:
- Left = more common as higher pressure system, more likely in damaged valves, commonly Strep Viridans
- Right = more common in IV drug users –> tricuspid valve is first valve reached, commonly S. aureus
Management:
- AS:
- C: 6-monthly ECHO, exercise-stress test if asymptomatic
- M: RF optimisation (statins, HTN, DM), HF Sx (diuretics, ACEi)
- S: Based on severity/comorbid - STS-PROM (surgical risk calc)
- If severe AS:
- Medically fit (req midline sternotomy & cardiopul bypass) = Surgical aortic valve replacement (SAVR)
- Not fit = Transcatheter aortic valve replacement (TAVR)
- Acutely Sx/cardiogenic shock = Balloon valvuloplasty
- If severe AS:
- MR:
- M:
- ACEi ± B-blockers (as HTN worsens MR)
- Tx AF & anti-coagulate
- Diuretic (if refractory to surgery)
- S: for acute MR (post-MI, chordae tendinae rupture), asymptomatic LVEF <60%, symptomatic LVEF >30%
- Valve _R_epair > _R_eplacement
- M:
- AR:
- M: asym + Reassurance (good prog)
- Unfit for surgery/waiting - ACEi & vasodilators (e.g. hydralazine)
- S: acute/Sx/severe = surgery
- Valve _R_eplacement > _R_epair
- M: asym + Reassurance (good prog)
-
MS:
- C: asymptomatic - Monitor
- M:
- AF Tx, anti-coagulate & diuretics (if Sx/severe)
- S: Sx/severe - can do balloon valvuloplasty/replacement
- Valvuloplasty = lateral thoracotomy scar
- Do not do percutaneously if persistent left atrial thrombus/rigid calcified valve –> need open heart surgery (CABG, concurrent severe MS)
10
Q
MI location based on ECG
A
- Inferior – right coronary artery (2,3, aVF foot)
- Anterior – left anterior descending artery (V1-2)
- Lateral – circumflex artery (1 ,aVL, V5/6)
- Posterior - ST depression in V2-4, abnormal R wave in V2
11
Q
Infective endocarditis - RFs? Ix? Dx criteria? Mx?
Acute vs subacute bacterial endocarditis - what hearts affected? who are commonly affected? What bacteria most likely?
A
Def: infection of heart valves (typically mitral/aortic or tricuspid in IVDU)
RFs: bacteraemia (long-term lines, IVDU, dental work), abn valves (prosthetic, RHD), prev endocarditis, VSD, piercings
Presentation: low-grade fevers, night sweats
- Exam:
- Splenomegaly
- Splinter haemorrhages, osler’s nodes, Janeway lesions, petechiae, Roth spots (eyes)
- Chronic = clubbing (rare, mostly acute now)
Ix:
- Urine dip - haematuria
- Serial BCs (x3 but start empirical abx), ESR
- Transoesophageal Echo (TOE - vegetations)
Dx: DUKE’S CRITERIA (2 major OR 1 major + 3 minor OR 5 minor):
- Major: +ve BC (typical organism), new regurg murmur/veg on echo
- Minor: RF, fever (>38), embolic (vascular) phenomena, immune phenomena, +ve BC (another organism)
- Mx: IV abx for 6wks – fluclox/vanc/gent
Acute in structurally normal heart – In IV drug user the first valve met is tricuspid valve, commonly S. aureus (also most common cause in prosthetic valve endocarditis)
Subacute in structurally abn heart – mitral & aortic valves more commonly affected as high pressure system, more likely damaged valves, commonly Strep Viridans (overall most common cause of endocarditis)
13
Q
ECG Important Considerations
A
- Make sure to compare to a previous ECG = dynamic changes (acute)
- Coronary infarcts commonly present as T-wave inversion/RBBB/LBBB, not always with ST-elevation/depression
14
Q
NSTEMI Mx? Scoring? Ix?
A
Immediate:
- Aspirin PO stat AND Ticagrelor OR Clopidogrel PO stat
- Fondaparinux SC
On discharge (give all despite BP/HR):
- Aspirin for life
- Ticagrelor OR Clopidogrel for 1 year (2 needed for 1 year as stent impregnated with Tacrolimus
- Ramipril (ACEi) - titrate up to 10mg
- Atorvastatin
- Bisoprolol (B-blocker) - titrate up to 10mg
Scoring Risk: GRACE score
Ix if high risk: cathlab for angiogram (will be started on IV unfractionated heparin instead of fondaparinux as procedure is very thrombogenic) –> PCI (stent)
15
Q
Heart failure key consequences x2
A
1) Reduced CO (SV*HR) –> shock, tachycardia, AKI
2) Congestion –> pulmonary oedema + peripheral oedema
16
Q
Acute HF vs ACS
A
17
Q
Irregularly irregular heart rhythm - Dx? Ix? Mx?
A
AF - narrow complex tachycardia with no p-waves
Ix:
- ECG, Echo (valve check)
- Bloods - U&E, Mg (QT interval), Troponin (ischaemic), TFTs
Mx:
- Haemodynamically unstable –> DC cardioversion
- Rate control - Bisoprolol 2.5mg OD (max 10mg, can use rate-lim CCB)
- Rhythm control - if clear reversible cause: <48hrs = DC/chemical cardioversion (flecanide/amiodarone); >48hrs = anticoag 3-4wks (clot may have formed)
- Stroke risk Mx - CHADS-Vasc Vs HAS-BLED/ORBIT - Apixabab 5mg BD (DOAC, can use Warfarin)
18
Q
How do you calculate ejection fraction? What are the different types of HF based on ejection fraction?
A
Ejection fraction = SV/End Diastolic Volume
HF w/ preserved EF: >50% - inadequate filling of stiff ventricles
- Causes: volume overload (valve regurg), pressure overload (HTN), decreased distensibility (constrictive pericarditis)
- No drugs w/ prognostic benefit, Mx Sx w/ diuretics
HF w/ reduced EF: <40% - inadequate emptying of ventricles from outflow obstruction or impaired contractility
- Causes: MI, cardiomyopathy, arrhythmia
19
Q
Types of anticoagulant
A
- Heparins
- LMWH (SC) - VTE prophylaxis BUT bad for renal function
- UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring
- DOACs - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD)
- Vit K antagonist = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions
22
Q
Virchow’s triad + anticoagulants vs antiplatelets
A
1) Stasis - coag factor activation–> venous clot (AF, DVT)
* Anticoags are most effective as coag factors cause clot
2) Vessel wall injury - plaque rupture - thrombogenic material release –> platelets activated –> arterial thrombosis (MI, stroke)
* Antiplatelets most effective as platelets cause clots
3) Hypercoagulability - does not change acutely
23
Q
Bibasal crackles indicates what? Ix? Mx?
A
Fluid overloaded with pulmonary oedema = acute heart failure
HF = pumping of blood by heart isn’t meeting body demands
Ix:
- Bedside - ECG
- Bloods - ABG, troponin, BNP
- Imaging - CXR, Echo (further down the line)
Acute HF Initial Mx:
- Immediate: sit patient up, O2 15L/min NRM
- Medical: IV furosemide (higher dose if on LT Tx), GTN, Morphine IV
- If no improvement: repeat furosemide (after 15mins) –> consider CPAP
Long-term HF Mx:
- Reduced ejection fraction - prognostic benefit:
- B-blocker (bisoprolol) - reduce strain on heart
- ACEi - reduce strain on heart
- SGLT2 inhibitors (dapagliflozin)
- RF modification - poor glycaemic control/high cholesterol
- Sx (diuretics)
24
Q
ECG changes in IHD
A
ST-elevation
Ischaemic changes
- Dynamic T-wave inversion
- ST depression
25
Q
What heart condition is malar flush associated with?
A
Mitral stenosis
26
Q
Key features of mitral stenosis
A
- Malar flush
- Middle-aged female
- AF
- Tapping apex beat (palpable/loud first heart sound)
- Quiet blowing mid-diastolic murmur –> accentuate leaning to left and listening over mitral area while holding breath exhaled –> if can’t be heard then would get the patient to do exercise
27
Q
Complications of MI
A
FAP (failure, arrhythmias, pericarditis)
Arrythmias (incl. VF)
Heart failure
Pericarditis
- Early - positional chest pain day after MI –> give NSAIDs
- Late - Dressler’s syndrome - immune response @6wks (fever, pleuritic chest pain, pericarditis/pericardial effusion)
28
3rd & 4th heart sounds - sounds & cause?
3rd = rapid ventricular filling = **HF** (reduced EF/systolic)
* KEN...TU.CKY (deee. de.de)
4th = atrial contraction against stiff ventricles = **longstanding AS** & other causes of left ventricular hypertrophy (HTN heart disease**,** HOCM, HF with preserved EF/diastolic)
* TE.NE..SSEE (de.de.deee)
29
In the context of HF what is cardiogenic shock? How do you treat? How do you treat rate-dependent cardiogenic shock (complete heart block)?
How will they describe cardiogenic shock in question?
1. HF so severe pressure insufficient to perfuse brain & heart alone --\> 100% death if untreated
2. Treat with inotrope - dobutamine/dopamine --\> increase perfusion of coronary arteries (saves 1/10)
3. Temporary external pacing --\> permanent pacemaker
Q: cold peripheries & low UO
30
Apex beat displacement vs left ventricular hypertrophy?
* Apex beat displaced by dilation = exam finding – caused by fluid overload
* LVH = ECG Dx (peaked R-waves, ST depression and T-wave inversion in lateral leads) – caused by pressure overload e.g. HTN
31
What is widespread ST elevation?
Acute pericarditis
32
RFs for IHD?
HTN, DM, Smoking, FHx IHD, Hypercholesterolaemia
33
What drug should be held for 48hrs before and after an angiogram?
Metformin
34
What drug caused this ECG in AF patient
Flecainide can convert AF to 1-1 atrial flutter (normally given with bisoprolol to compensate) \>200bpm
35
Complications of prosthetic heart valves
**FIBAT**
* Failure
* Infection
* Bleeding - MAHA
* Anaemia
* Thromboembolic phenomena
36
AS vs aortic sclerosis signs?
AS:
* Radiates to carotids
* Slow-rising pulse
* Narrow pulse pressure
* Heaving apex beat
* Severe = absent 2nd heart sound
Aortic sclerosis (calcification) = just murmur
37
AS - causes? Sx? Signs? Indications for surgery?
Causes:
* Calcific degeneration
* Bicuspid valve e.g. Turner's syndrome (XO female) - develop 10yrs earlier
Sx: **ASH** (in this order)
* A - angina
* S - syncope
* H - HF
Signs:
* Key:
* Radiates to carotids
* Slow-rising pulse
* Narrow pulse pressure
* Severe = **absent/soft 2nd heart sound,** _reversed splitting of 2nd HS_, heaving apex beat, longer murmur is worse
Indications for surgery: symptomatic (syncope) OR CCF
Mx: **_TAVI_** (transcatheter aortic valve implantation) or surgical replacement
* + inf endocarditis abx prophylaxis
* + long-term Warfarin (not DOAC)
* Medical Mx: anti-HTN + anti-lipids + statin
38
What arrhythmia is common in AS and metallic aortic valve?
AF
39
What should I look for if they have a midline sternotomy scar (cardio)?
Long saphenous vein harvesting in the leg = CABG
40
Indications for CABG? Vessels used for graft? Meds post-CABG?
Indications:
* Left main-stem disease
* 2+ vessel disease
* Failure of medical Mx
* Concomitant (aortic) valvular replacement
Grafts:
* Great saphenous vein
* Internal thoracic (mammary) artery - NOW the most commonly used
Meds post-CABG:
* DAPT - aspirin + ticagrelor (for 12 months then just aspirin) ± specialist opinion
* Cardio-selective beta-blocker (bisoprolol)
* ACEi (or ARB)
* *
41
Mitral regurgitation - causes? presentation?
Causes:
* Chr:
* Myxomatous degeneration
* Functional (w/ LV dilatation)
* Acute:
* IE
* Papillary muscle rupture (supplied by posterior intraventricular artery, after inferior/posterior MI)
Presentation:
* Pan-systolic murmur
* Radiates to axilla
* Severe: displaced/thrusting apex beat, LVF, 3rd HS
42
Causes of HF?
43
Distinguishing between observations during cardio PACES station
* Murmur - AS, aortic sclerosis, MR
* Sternotomy w/ Warfarin - Metalic valve, CABG + AF
* Sternotomy no Warfarin - Tissue valve, CABG
* Oedema (& none of above) - CCF
44
What does bradycardia with AV nodal block indicate?
Inferior MI
45
2 days of chest pain following 4 days of generalised muscle aches
* Worse on inspiration & lying flat
* Low-grade fever
* Exam: pericardial rub
Causes? Dx? Ix? Mx?
Pericarditis
Causes:
* Viral (most common)
* MI (can be Dressler's syndrome)
* TB (constrictive)
* Uraemia (CKD where urea high --\> pericarditis) = indication for haemodialysis (HUMP)
* Hydralazine (AI pericarditis)
* NOTE: also causes _drug-induced lupus_
* SLE, RF, radiation
Presentation:
* Pleuritic chest pain, worse lying flat
* Exam: pericardial rub - "creaking/scratching"
* Tip - put on all-fours, put stethoscope on sternal edge, hold inspiration
Ix:
* ECG: ST elevation widespread
* Only slightly raised/normal troponin
Mx: **_colchicine (3 months)_** + NSAIDs (ibuprofen, max 2wks)
46
I am treating AF, what is C/I in structural heart disease?
Flecainide, CCB
47
In context of AF patient, patient is on Dabigatran, what do I do?
Only DOAC with reversible agent --\> _Idarucizumab_
48
Facial swelling after starting ACEi/Entresto (Sacubitril/Valsartan)?
From angioedema (not anaphylaxis)
49
What is a loop diuretic with better oral bioavailability than furosemide?
Bumetanide
50
HTN Mx?
51
What is Dressler's syndrome?
AI pericarditis (pleuritic chest pain + fever, global ST-elevation + PR depression) weeks-months after acute MI
52
When to Ix cause of HTN?
Causes of secondary HTN?
When:
* \<40 - without clear FHx/RFs
* Severe/resistant HTN
* Malignant HTN w/ evidence of end-organ damage
* HTN with electrolyte disorders
Causes:
* Renal artery stenosis - renal artery duplex scan, note: _sign rise in creatinine after starting ACEi_
* Primary kidney disease
* Sleep apnoea syndrome
* Endo:
* Primary aldosteronism (Conn's) - renin: creatinine ratio
* Cushing's syndrome
* Hypothyroidism
* Phaeochromocytoma
53
What is headache, sweating, palpitations, severe HTN
Phaeochromocytoma
54
What is AV nipping on fundoscopy?
Hypertensive retinopathy
55
Pedal oedema resistant to diuretics is S/E of what drugs?
CCB
56
What BP is Dx of HTN? Vs Severe?
\>140 = HTN
\> 180 = Severe HTN
57
Prolonged QT, twisting of QRS complexes - Dx? Causes of long QT?
How to Tx?
Torsades de pointes (form of VT)
Causes:
* _Low_ Ca/Mg/K --\> **_Pro_**longs QT
* Drugs - **Clari**, Ciprofloxacin, Haloperidol
* Inherited - Romano- Ward (AD no deafness), Jervell-Lange-Nielsen (AR sensorineural deafness)
Tx: IV Mg SO4 (also used for refractory VF, all other VTs treated with Amiodarone)
58
In cardiac exam - what should I not forget?
Hands/arms:
* CRT, clubbing, arm bruising
* Radio-radial delay
* Collapsing pulse (_lightly_ palpate radial and brachial pulses --\> feel stronger for a few pulses) = AR
* BP standing/sitting
Head/neck:
* Check for carotid bruits before taking carotid pulse (character, volume) - slow rising = AS, bounding = AR
* JVP + hepatojugular pressure (RUQ), rockstar hand
* **PQRST:** **P**ul HTN/PE/Pericarditis/Pericardial effusion, **Q**uantity of fluid, **R**HF, **S**VC obstruction, **T**amponade/TR
Auscultation:
* Feel carotid pulse while listening to all below heart valves
* Mitral valve - diaphragm mitral + axilla (MR) --\> roll onto left side and listen mitral with bell + hold on expiration (MS - low tones)
* Tricuspid valve
* Pulmonary valve - listen for loud P2 (loud vs A2 = pul HTN)
* Aortic valve - aortic area then lean forward & listen at left sternal edge + expiration (AR)
* Listen @carotids (radiation = AS + bruits)
* NOTE: on woman listen at submammary fold not on top of breast
* NOTE: right valves heard best on inspiration; left heard best on expiration
Other: lung bases (pul HTN), peripheral oedema (RHF)
59
Causes of raised JVP (\>4cm)?
JVP + hepatojugular pressure (RUQ), rockstar hand
**PQRST:**
* **P**ul HTN/PE/Pericarditis/Pericardial effusion/PS
* **Q**uantity of fluid (fluid overloaded)
* **R**HF
* **S**VC obstruction
* **T**amponade/TR
60
"The heart stops for a second followed by a pounding sensation? - Dx?
Ectopics - _supraventricular_ (younger) or _ventricular_ premature beats
61
SVC obstruction - presentation? Tx?
Presentation: swollen face and neck and distended veins on her chest in background of cancer
Mx: dexamethasone to reduce tumour swelling
* Insert EV stent if stridor (after intubation and steroids)
62
Bradycardia arrhythmia with a palpable pulse (peri-arrest) - Mx?
Innitial: A-E
* If unstable - 500mcg IV atropine (/5mins up to 3mg)
* Also considered unstable if:
* Recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block
* Caution in acute MI, C/I if heart transplant
* If persistent --\> transcutaneous pacing + analgesia/sedation (very painful)
* If can't be achieved properly --\> IV isoprenaline/adrenaline (specialist help)
* Arrange transvenous pacing (temporary if recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block)
63
Heart block causes? types? Ix? Mx? Complications?
Causes:
* MI/IHD (MOST COMMON)
* Inf (RHD, IE)
* Drugs (digoxin)
* Metabolic (hyperkalaemia)
* Infiltration of conducting system (e.g. sarcoidosis)
* Degeneration of conducting system
Types:
* First Degree AV block - fixed prolonged PR interval (\> 0.2 s) - _ASYMPTOMATIC_
* Second degree AV block:
* Mobitz TI (Wenckebach) - progressively prolonged PR interval --\> P-wave NOT followed by a QRS complex = 'going, going, gone'
* _Normally asymptomatic_
* Mobitz Type II - intermittently P wave NOT followed by a QRS
* May be regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1)
* Can cause:
* Stokes-Adams Attacks (syncope caused by ventricular asystole)
* Dizziness, palps, chest pain, HF
* Complete AV heart block - no relationship between P waves and QRS complexes
* Presentation as in Mobitz T2
Ix: ECG
* Bloods: TFTs, Digoxin, cardiac enzymes (troponin, CK, BNP)
* CXR (cardiac enlargement, pulmonary oedema)
* Echo (wall motion abn, aortic valve disease, vegitations)
Mx:
* Acute block - if clinical deterioration:
* IV atropine
* Consider temporary transcutaneous pacing
* Chronic block:
* 1st degree monitored
* Permanent pacemaker in:
* Symptomatic Mobitz T1
* Advanced Mobitz T2
* Complete heart block
Complications: asystole, cardiac arrest, HF, surgical complications of pacemaker insertion
64
Types of pacemaker? When to use each type? Complications?
Types:
* Implantable Cardioverter Defibrillator (ICD, has a thicker end)
* Single-chamber pacemaker (right ventricle)
* Used in permanent AF (no organised atrial contraction so atrial lead not required to sense contraction)
* Rarely can have atrial lead only - if SA disease in young with good AV conduction
* Dual-chamber pacemaker (right atrium & ventricle)
* Can have ICD dual-chamber pacemaker
* Used in paroxysmal AF/all other scenarios (there is sometimes organised atrial contraction - this is sensed by the atrial lead)
* Cardiac Resynchronisation Therapy/Biventricular pacemaker (right ventricle, left ventricle ± right atrial lead)
* Can have ICD biventricular pacemaker
When to use each type:
* Atrial lead only → Sino-atrial disease in young people with good AV node conduction
* RV lead only → Pacing whilst in _permanent atrial fibrillation_
* Dual-lead → All other scenarios (paroxysmal AF, bradycardia)
* CRT → LV dysfunction + broad QRS --\> _end-stage HF_
* Indications for ICD:
* Primary prevention = **@risk of serious ventricular arrhythmia**
* Familial cardiac conditions (hypertrophic cardiomyopathy, long QT)
* Previous surgical repair of congenital HD
* Previous MI + LVEF \<35% + HF Sx
* Secondary prevention = **had previous serious ventricular arrhythmia _wo/ treatable cause_**
* Cardiac arrest from VT/VT
* Spontaneous sustained VT AND:
* Syncope/haemodynamic compromise OR
* LVEF \<35% + sign HF Sx (NYHA 3+)
* NOTE: VT/VF from STEMI has treatable cause (open occluded vessel)
Complications:
* Surgical complications - infection, bleeding, damage to underlying structures
* Displacement (of lead)
* Pacemaker syndrome (if ventricular lead with no atrial) --\> AV node conducts in retrograde direction = mitral/tricuspid regurge + HF Sx
65
What are prominent V waves in the JVP indicative of?
What are cannon A waves in the JVP indicative of?
What is a prominent x descent in the JVP indicative of?
Tricuspid regurgitation
Complete heart block
Acute cardiac tamponade/Constrictive pericarditis
66
What is radio-femoral delay a sign of? Which congenital condition is strongly associated?
Aortic coarctation
Turner's (1 X chromosome in female)
67
Immediate Mx of rheumatic fever?
Aspirin prn
Benzylpenicillin IM stat --\> 10 day course of benzylpenicillin PO
68
How long can someone not drive post-MI?
- Patients who are completeley revascularised with okay LVEF = 1 week
- Patients with severely reduced LVEF = 4 weeks
69
Which drug should be held 48 hours before and after angiogram?
Metformin
70
Atrial flutter Mx?
1. Treat underlying cause
2. Anticoagulate as you would for atrial fibrillation
If haemodynamically unstable: rate control or cardioversion
71
Recall 2 causes of an irregularly irregular pulse that aren't AF?
Ventricular etopics
Atrial flutter
72
If in a suspected DVT the D-dimer is positive but the the USS is negative, what should you do?
Stop anticoagulation and repeat scan in one week
73
What might CXR reveal in AS?
Left ventricular hypertrophy
Pulmonary oedema
Valve calcification
74
Management of heart valve disease?
AR-specific Mx? MR-specific Mx? MS-specific Mx?
QRISK3 score to stratify risk
Manage risk with a statin (eg atorvastatin) and an antiplatelet (aspirin/ clopidogrel)
Manage coexistent HTN/ angina etc
Valve replacement if Sx/acute
AR/MR - reduce afterload:
* ACE inhibitors
* Beta-blockers
* Diuretics (furosemide)
MS:
* RhF prophylaxis with benzylpenicillin
* AF (rate control + DOAC)
* Diuretics for symptomatic relief (furosemide)
* 1st line surgical - Balloon valvuloplasty
75
Pros/cons of TAVI?
Pros: no bypass required, no large scars
Cons: higher risk of stroke compared to open replacement
76
What is an Austin Flint murmur? When in the heart cycle is an Austin flint murmur heard, and what causes it?
What:
* 'Rumbling mid-diastolic murmur'
* Associated with severe aortic regurgitation
* Best auscultated in 5th ICS in MCL
* Caused by blood flowing back through the aortic valve and over the mitral valve
When:
* Mid-diastole
* Caused by regurgitant jet that runs over the mitral valve leaflets
77
Clinical signs of pul HTN?
Malar flush
Raised JVP
Right ventricular (parasternal) heave, pulmonary thrill
Loud S2
78
Describe briefly the NYHA classifications
For HF
1 - no limitation on activity
2 - comfortable at rest but dyspnoea on ordinary activity
3 - marked limitation on ordinary activity
4 - dyspnoea at rest
79
What would pericardial effusion produce on ECG?
Low-voltage complexes
80
Different pulse forms? Causes?
**Pulsus paradoxus** - greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
* severe asthma, cardiac tamponade
**Slow-rising/plateau**
* AS
**Collapsing**
* AR, PDA
* hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
**Pulsus alternans** - regular alternation of the force of the arterial pulse
* severe LVF
**Bisferiens pulse** - 'double pulse' - two systolic peaks
* Mixed aortic valve disease
* HOCM (also causes 'Jerky' pulse)
81
acute heart failure 5 days after MI + A new pan-systolic murmur is noted on examination - Dx?
VSD
82
What should I look for on ECG if they have fast AF before prescribing drugs?
Delta wave - WPW
* Can't give digoxin, verapamil, amiodarone
* Can give B-blockers, flecainide
83
Ventricular tachycardia - Dx? Presentation? Ix - appearance on ECG? Mx?
**VT** or SVT w/ aberrancy
* SVT \>200bpm, also often irregular
* VT more likely if LAD
* Acutely treat any broad complex tachy as VT until proven otherwise
Presentation: _palpitations, light-headed, chest pain_, syncope, seizure
* Tachycardia, LVF
* ACS most common cause
* **_NEVER IGNORE palpitations & light-headedness_**
Ix: ECG - regular broad complex tachycardia
* U&E (Mg, Ca, K), TFTs, Troponins
Mx:
* Unstable tachycardia (BP \<90, chest pain, acute cardiac failure) = _DC cardioversion_
* Stable:
* Prepare for DC cardioversion
* IV amiodarone, b-blocker
84
Cardiac tamponade - key finding on exam? Triad? Mx?
Pulsus paradoxus - BP variation between inspiration & expiration (≥10)
Beck's triad (50%):
* Raised JVP
* Muffled heart sounds
* Hypotension
Mx:
* IV fluids (RV filling depends on venous pressure & effusion is constricting)
* Echo --\> refer to cardiology for pericardiocentesis
* Coagulation profile (to prep for pericardiocentesis)
85
Pulsatile liver is seen where?
Tricuspid regurgitation
86
Case: male - SoB on exertion, webbing of neck, pectus excavatum, ejection systolic murmur (louder on inspiration)
Dx? What is the associated murmur?
Dx: **Noonan's syndrome** (AD) - short stature, scoliosis, webbed neck, wide-spaced eyes, nystagmus
* Associated with _PS_, ASD, HOCM
* NOTE: if it was a woman & no murmur could be Turner's syndrome
Murmur was louder on inspiration = **PS** - ejection systolic, radiates to back
87
What is the causative organism of prosthetic valve endocarditis?
S. aureus
88
What is the causative organism in endocarditis assoc w/ _colorectal cancer?_
What Ix do they need?
**Strep. bovis**
If they have S. bovis endocarditis --\> _colonoscopy_ (as may have colon cancer)
89
Harsh murmur @sternal edge, had all their life - what type? What is this a RF for?
VSD
Endocarditis
90
What is the non-infective cause of endocarditis? What is this condition associated with?
**Libman-Sacks** = non-bacterial thrombotic endocarditis (marantic endocarditis) - occurs in _SLE_
* Assoc w/ malignancy/AI conditions/hypercoagulable states
91
* 19yrs, SoB on exertion, one episode of AF
* Exam - fixed splitting of 2nd HS, mid-diastolic murmur in pulmonary area
* ECG - slight RAD, incomplete RBBB
Dx? Assoc conditions? Ix?
ASD - commonest is _ostium secundum_
* Mid-diastolic murmur + fixed split S2
* High risk of AF & paradoxical emboli (prev stroke?)
* NOTE: commonest inherited cardiac condition to present in adulthood (as can be asymptomatic in childhood)
* NOTE: this is not Eisenmenger's syndrome as patient not cyanotic
Assoc w/ down's syndrome (& AVSD), Turner's & Noonan's syndrome
Ix:
* ECG - _incomplete RBBB_ (90%, can be normal variant), RVH (T-wave inversion V1-3), P pulmonale (tented P-waves), AF
* Ix: _bubble study_ (+ RV dilatation)
* Also done for patent foramen ovale (PFO)
92
Constrictive pericarditis - def? Cause? Ix? Complication?
Def: chr inflamed pericardium (this is why colchicine is given for 3 months in normal pericarditis)
Cause: classically previous TB in the pericardium
Ix:
* (Exam - pericardial knock on auscultation (bit old school))
* Kussmaul's sign - JVP rises on breathing in
* _Small heart on CXR_ ± calcifications
* Low voltage ECG w/ T-wave inversion/flattening (could also be pericardial effusion)
Complication: _cardiac liver cirrhosis_
* Right ventricle struggles --\> tricuspid regurg (pulsatile liver) --\> liver failure (oedema +++)
93
What conditions can Hydralazine cause?
AI pericarditis
Drug-induced lupus - _anti-histone ab_
94
Case:
* 26yrs, BP 180/100, femoral pulses weaker than radial pulse
* Mid-systolic murmur in infra-scapular area
* Trying to get pregnant unsuccessfully for 2yrs
What is the Dx? Assoc? What is there a risk of & what advice is given?
Young + very high BP --\> must be _secondary HTN_ (causes: endo - Conn's, Phaeo; coarctation of Aorta (CoA), renal artery stenosis, chronic renal failure)
**CoA** - tissue restricting flow across aortic arch
* Murmur across the coarctation = _left infrascapular area_ (due to turbulent BF)
* Lower body underdeveloped vs upper (97% men going to gym)
* Assoc: **_Turner's_** (+ Marfan's, Ehlers-Danlos)
* Short stature, webbed neck, wide-spaced eyes, lack of other secondary sexual characteristics, shield-like chest, short 4th metacarpals/tarsals
* Advice: avoid extreme isometric exercises e.g. weight-lifting --\> risk of _aortic dissection_
* How do you Dx dissection? CT aortogram w/ contrast
95
How do you know this is the JVP and not the carotid pulse?
* Not palpable
* Double pulsation
* Obliterated when pressure applied at base of neck
* Rises with hepatojugular reflux
* Height changes with respiration
96
Types of cardiac scar?
* Midline sternotomy + leg scar = CABG
* Midline sternotomy (no leg scar) = Valve replacement most likely (rarely can be CABG without vein graft)
* Left subclavicular -\> pacemaker, debfibrillator, resynchronisation device
* L shaped scars under either breast -\> L/R Thoracotomy
97
Absent radial pulse - causes?
* Coaractation
* Congenital Cervical Rib (\> subclavian steal syndrome)
* Coronary Angiography previously
* Arterial embolism e.g. due to AF
98
Radioradial delay causes?
* Coarctation of aorta
* Subclavian stenosis
* Takasayu’s arteritis
