Cardiovascular Flashcards
(152 cards)
1
Q
tapping apex beat
loud S1
rumbling mid-diastolic murmur at apex, loudest in left lateral position on expiration
A
mitral stenosis
2
Q
wide pulse pressure
displace, volume-overloaded apex beat
early diastolic murmur at lower left sternal edge (loudest on expiration, leaning forward)
A
aortic regurgitation
3
Q
displaced, volume overloaded apex beat
soft S1
pansystolic murmur at apex radiation to axilla
A
mitral regurgitation
4
Q
large systolic ‘v’ waves
pansystolic murmur lower left sternal edge (best heard on inspiration)
A
tricuspid regurgitation
5
Q
narrow pulse pressure
heaving undisplaced apex beat
soft S2
EJS murmur in aortic area radiating to carotids + apex
A
aortic stenosis
6
Q
harsh pansystolic murmur lower left sternal edge
left parasternal heave
A
ventricular septal defect
7
Q
tall tented T waves, wide QRS
A
hyperkalaemia
8
Q
hyperkalaemia
Ecg features
A
tall tented T waves, wide QR
Bradycardia
9
Q
hypokalaemia
A
flattened T waves, prominent U waves
10
Q
flattened T waves, prominent U waves
A
hypokalaemia
11
Q
long QT interval, tetany, perioral paraesthesia, carpopedal spasm
A
hypocalcaemia
12
Q
what is a normal PR interval?
A
120-200ms
3-5 small squares
13
Q
what is a normal QRS?
A
< 3 small squares (0.12s)
14
Q
What is Beck’s triad and what might it indicate?
A
pulsus paradoxus, JVP rise on inspiration, HS muffled
cardiac tamponade or constrictive pericarditis
15
Q
What might these findings suggest?
pulsus paradoxus, JVP rise on inspiration, HS muffled
A
cardiac tamponade or constrictive pericarditis
16
Q
What does a large ‘a’ wave and slow ‘y’ descent in JVP indicate?
A
JVP stenosis
17
Q
what might cannon ‘a’ waves on JVP indicate?
A
complete heart block
VT
single chamber pacemaker
18
Q
What does p mitrale suggest?
A
LV atrial hypertrophy
mitral stenosis
19
Q
What counts as significant ST elevation?
A
more than 1 small square in consecutive limb leads
or more than 2 small squares in consecutive chest leads
20
Q
What formula might you use to calculate heart rate from an ECG?
A
Number of R waves x 6 (10 second trace)
300 divided by the number of large squares between 2 R waves
21
Q
what is normal PR interval?
A
0.12-0.2 seconds
22
Q
What is prolonged PR interval in ECG squares?
A
larger than 5 small squares
23
Q
What might cause a short PR interval?
A
pre-excitation syndromes such as WPW
or that the depolarisation is occurring to the AV node
24
Q
What is a narrow and wide QRS?
A
a narrow QRS is one that is less than 0.12s (< 3 small squares)
a wide QRS is one > 0.12s (> 3 small squares)
25
what is significant myocardial ischaemia on an ECG?
ST depression more than 0.5mm in more than 2 continuous leads
26
what are the QTc intervals that are considered normal?
\> 440ms in men
\> 460 ms in women
\> 500 ms is considered risky for torsades des pointes
27
What is the supply to the SA node?
right coronary artery
28
What might be a consequence of an MI or pathology affecting the right coronary artery?
arrhythmia as the right coronary supplies the SA node
29
How do you treat ACS?
oxygen
morphine (10mg) + metoclopromide (10mg)
aspirin (300mg) + clopidogrel (300mg)
GTN
if STEMI -\> PCI if available in 2 hours, thrombolysis within 12hrs
if NSTEMI give fondaparinux and high risk go for PCI
30
What is the treatment for PE?
MONASH
morphine
oxygen
nitrates (GTN)
aspirin
heparin (LMWH)
warfarin
31
Why does warfarin have an initial pro-thrombotic effect?
initially it inhibits protein C & S which are usually anti-thrombotic. by inhibiting them overall it the patient enters a prothrombotic state
32
what are the effects of amyloidosis on the cardiovascular system?
restrictive cardiomyopathy
heart failure
arrhythmia
angina
33
what are the important causes of AF?
ischaemic heart disease
thyrotoxicosis
pneumonia
PE
alcohol
rheumatic heart disease
34
what are the reversible causes of cardiac arrest?
4 H's = hypothermia, hypoxia, hypo or hyperkalaemia
4 Ts = toxins + metabolic, thromboembolic, tamponade, tension pneumothorax
35
what rhythms are shockable?
pulseless VT or VF
36
what are not shockable rhythms?
pulseless electrical activity
asystole
37
causes of a dilated cardiomyopathy?
idiopathic
post-viral myocarditis
alcoholism
pregnancy + post-partum
chronic HTN
38
causes of a hypertrophic cardiomyopathy?
mostly genetic mutations or storage disorders
39
causes of a restrictive cardiomyopathy?
sarcoidosis
amyloidosis
radiation induced fibrosis
haemochromatosis
40
common organisms causing infective endocarditis?
CASSSH
candida
aspergillus
strep viridans (most common)
staph aureus
staph epidermis
histoplasma
40% = streptococci, 35% = staphylococci, 20% = enterococci, rest HACEK organisms (rare)
41
what heart structures are most commonly affected by infective endocarditis?
usually aortic or mitral valve
EXCEPT in IVDU were right sided disease is more common
42
what are some signs of IE and what is their cause?
septic signs -\> fever, tachycardia
new or changed heart murmur -\> vegetations + damage to heart
vasculitis, microscopic haematuria, renal failure, glomerulonephritis, roth spots, splinter haemorrhages, osler's node -\> immune complex diposition
janeway lesions -\> embolic
43
what are the cardiac causes of clubbing?
infective endocarditis
congenital cyanotic heart disease
atrial myxoma
44
are osler's nodes or janeway lesions tender?
osler's nodes are painful
Oh that hurts
45
what is the empirical therapy for IE on clinical suspicion?
benzylpenicillin and gentamicin
46
what is decubitus angina?
chest pain on lying down flat
47
what is prinzmetal angina?
due to coronary vasospasm.
48
what is coronary syndrome X?
angina symptoms with normal exercise ECG and angiogram
49
what are the ECG features of an MI?
hyperacute T waves
ST elevation
new-onset LBBB
late changes - T wave inversion, pathological Q waves
50
whats the most common cause of myocarditis in EU and USA?
viral
coxsackie B virus
51
what is the most common cause of myocarditis in S. America?
Chaga's disease (protozoa infection)
52
what is the triad of pericarditis?
chest pain + pericardial friction rub + serial ECG changes
53
what are the ECG changes seen in pericarditis?
1 - widespread SADDLE SHAPED ST elevation, PR depression (acute)
2 - resolution of ST changes, T wave flattening (1-3 wks)
3 - flattened T waves become inverted (3+ wks)
4 - return to normal (several weeks later)
54
what is heard of auscultation in pericarditis?
pericardial friction rub
note these can be difficult to hear and may come and go
55
what is considered to be the threshold for pulmonary hypertension?
pulmonary artery pressure greater than 25mmHg when resting
56
what organism causes rheumatic fever?
it is a inflammatory disorder which occurs after an infection with group A beta-haemolytic streptococci
57
what are the major criteria for rheumatic fever diagnosis?
CASES
Carditis - endocarditis, pericarditis, new murmur
Arthritis - migrating, fleeting polyarthritis or large joints
Syndenham's chorea
Erythema marginatum - crescent/ring-shaped red patches on trunk + proximal limbs
Subcutaneous nodules - extensor, joints, tendons
58
what blood test should be done if suspected rheumatic fever?
anti-streptolysin O titre (raised)
59
what CVD is pulsatile liver associated with?
tricuspid regurgitation
60
what wave is elevated in the JVP with tricuspid regurgitation?
V wave
caused by atrial filling at the same time as ventricular contraction. seen after S1
61
what does absent A waves indicate in the JVP?
atrial fibrillation
62
what murmur does tricuspid regurgitation give?
pansystolic murmur heard at the lower left sternal edge on inspiration
63
what are the triggers for vasovagal syncope?
emotional upset
fear
pain
orthostatic stress - heat, standing for a long time
64
What are the risk factors for ischaemic heart disease?
smoking
diabetes mellitus
hypertension
hyperlipidaemia
previous episode of IHD
FHx of IHD
65
Differentials for chest pain
cardiac: IHD/ACS, aortic dissection, pericarditis
resp: PE, pneumonia, pneumothorax
GI: oesophageal spasm, oesophagitis, gastritis
Musculoskeletal: costochondritis
66
ECG pattern for left ventricular hypertrophy
deep S in V1/V2
tall R wave in V5/V6
largest S and largest R in chest leads \> 45mm when added together
67
ECG features of ischaemia
ST change (elevation or depression)
T wave inversion (MI)
pathological Q waves (old MI)
68
Which leads on an ECG represent a lateral view of the heart?
I, aVL, V5, V6
69
what coronary artery supplies the lateral territory of the heart?
circumflex artery
70
what ECG leads present the anterior aspect of the heart?
V3, V4 and V2 to some extent
71
what coronary artery supplies areas of the heart matching to V3, V4 and V2 (to an extent)?
right coronary artery
72
what coronary artery supplies areas of the heart matching to I, aVL, V5 and V6?
circumflex artery
73
what ECG leads represent the septal region of the heart?
V1 and V2
74
What coronary artery supplies the septal region of the heart?
left anterior descending
75
what coronary artery supplies the region corresponding to V1 and V2 on ECG?
left anterior descending
76
what ECG leads correspond to the inferior aspect of the heart?
II, III and aVF
77
what coronary artery supplies the inferior region of the heart?
right coronary artery
78
what coronary artery supplies the area of the heart corresponding to II, III and AvF?
right coronary artery
79
what does a long QT on ECG mean?
abnormal ventricular repolarisation which predisposes patients to ventricular tachycardias
80
differentials for a raised JVP
right heart failure - secondary to LHF or pulmonary HTN
tricuspid regurgitation
constrictive pericarditis (infection, CTD, malignancy)
81
what causes a systolic murmur?
aortic stenosis
mitral regurgitation
tricuspid regurgitation
ventricular septal defect
82
Causes of sinus tachycardia
sepsis
hypovolaemia
thyrotoxicosis
phaeochromocytoma
anxiety
PE
83
causes of atrial fibrillation
thyrotoxicosis
ischaemic damage to heart muscle
chest infection
alcohol
pathology affecting the heart or lungs
84
causes of ventricular tachycardia
```
ischaemia
electrolyte abnormality (K+, Mg+)
long QT
```
85
Robert attends A&E with palpitations. His ECG shows an supra-ventricular tachycardia. His BP is 125/85 mmHg.
How would you manage this patient?
he is HAEMODYNAMICALLY STABLE
1. Vagal manoeuvres (e.g. carotid sinus massage)
2. Adenosine (IV) x 3
3. if unable to return to sinus may DC cardiovert
adenosine is CI in asthmatics
86
what are the 2 common types of supra-ventricular tachycardia?
AV nodal reentrant tachycardia [AVNRT]
atrioventricular reciprocating tachycardia [AVRT} - accessory pathway present
87
Alex attends A&E with palpitations. His ECG shows an supra-ventricular tachycardia. His BP is 80/60mmHg.
How would you manage this patient?
he is haemodynamically unstable
the arrhythmia is compromising his CO.
DC cardioverstion
88
Jo attends GP for a health check. The GP feels her pulse and finds it to be irregularly irregular. An ECG confirms AF.
How would you manage Jo?
as don't know onset....
Rhythm control:
anti-coagulate for 3-4 weeks if suitable candidate for cardioversion. use NOAC or warfarin
Rate control: beta blocker, digoxin
prophylaxis: CHADs VASC vs HASBLED. anti-coagulate with NOAC or warfarin e.g. riveroxaban
investigate possible underlying causes and treat
89
Lucy attends A&E with palpitations. Her ECG shows a ventricular tachycardia. She has a palpable radial pulse. her BP is 120/80mmHg
as she is haemodynamically stable do not shock immediately
1. IV amiodarone
if pulseless VT -\> start ALS and cardioversion as soon as possible
90
what is S3 associated with?
rapid ventricular filling
91
what is S4 associated with?
ventricular hypertrophy and the atria trying to contract against the stiff ventricle
92
Max is a 65yr old man who attends A&E with an acute deterioration of his heart failure.
How do you manage him in A&E?
1. sit him up
2. oxygen if saturations are low
3. GTN infusion (venodilates reducing preload)
4. diaMorphine (venodilates)
5. Furosemide IV - diuretic and venodilates
treat any underlying cause e.g. infection
93
What are ECG features of pericarditis?
saddle-shaped ST elevation across all leads or most of them (not belonging to a specific heart territory)
94
Long term management of heart failure
1. ACEi -\> prevent cardiac remodelling
2. beta-blocker - reduce work
3. spironolactone - prevents chronic RAAS activity
4. diuretic (furosemide)
5. digoxin
ABDDS
95
What is CHADSVASC score ?
Assessment of stroke risk in AF, \> 1 in men and \> 2 in female warrants consideration for anti coagulation
C - congestive heart failure 1
H - HTN 1
A2 - age \> 75 2
D - DM 1
S2 - previous stroke of TIA 2
V - known vascular disease 1
A - age 65-74 1
Sc - female 1
96
What are the anticoagulant options for AF?
- DOAC e.g. Apixiban, dabigatran, riveroxaban
- warfarin
- LMWH e.g SC enoxaparin, rare only if not tolerating oral
97
Describe the HASBLED score
Risk of significant bleed.
H - HTN 1
A - abnormal liver or renal function 1
S - previous stroke 1
B - previous major bleed 1
L - labile INR 1
E - elderly 65 + 1
D - drugs and ETOH 1 if single, 2 if both
98
What criteria is in the ORBIT score ?
Assessment of bleeding risk
Sex
Hb - \< 13 in M, \< 12 in F, 2 points
Age - 74+, 1
Bleeding history, 2
Renal function eGFR \< 60, 1
Concomitant anti platelet, 1
99
general MI complications
FAM
* Failure - heart failure
* Arrhythmias
* Murmurs
100
what features indicated aortic sclerosis?
ejection systolic murmur
## Footnote
Aortic sclerosis - no radiation, normal pulse, normally elderly
101
raised JVP causes
* Right sided heart failure
* Fluid overload
* Pericardial effusion or cardiac tamponade
* Tricuspid regurgitation
* Superior vena cava obstruction
* Non-pulsatile
* Complete heart block
102
complications of prosthetic valves
* Complications - FIBAT
* Failure
* Infection - infective endocarditis
* Bleeding - from warfarin or from operation
* Anaemia - haemolysis (macroangiopathic) or bleeding
* Thromboembolic → PE, stroke
103
complications of mitral stenosis
AF
pulmonary HTN (loud P2, L parasternal heave, Graham steel murmur)
104
causes of an irregular pulse (on palpation)
AF
ventricular ectopics
SVT with variable block
105
weak pulse on 1 side differentials
* coarctation
* Takayasu's
* iatrogenic - stenosis after angiogram or repeated COPD ABGs
106
collapsing pulse differentials
* AR (severe)
* hyperdynamic circulation
* AV fistula/PDA
* Pregnancy
* Anaemia
* Fever
* Thyrotoxicosis
* Paget's disease of the bone
* AV malformations can form
* Inferior collapsing pulse
107
Causes of raised JVP
* Fluid overload
* Tricuspid regurgitation
* Pulmonary HTN
* Pericardial effusion
* Pericarditis
108
Causes of fixed raised JVP
superior vena cava obstruction
109
cannon A waves
AF
110
large V waves
severe tricuspid regurgitation
111
cardiac conditions associated with the following syndromes
* marfans
* turner
* noonan
* williams
* marfans - mitral valve prolapse, bicuspid aortic valve, aortic dilation
* turner - coarctation of aorta, bicuspid aortic valve
* noonan - pulmonary stenosis
* williams - supravalvular aortic stenosis
112
what are the severity signs for aortic stenosis?
* outflow obstruction - slow rising pulse, low volume pulse, narrow PP
* HS abnormal - **soft S2**, longer murmur, S4, **reversed split S2**
* LVH
* heart failure signs
113
what are the Sx of AS and relation to severity?
in order of increasing severity
* angina
* syncope
* dyspnoea
SOB - highest death rate in 5 years
114
echo features of severe AS
* aortic valve size \< 1 cm^2
* gradient \> 50mmHg
NICE - for asymptomatic
* Vmax (peak aortic jet velocity) \> 5m/s on echocardiography
* Aortic valve area \< 0.6cm2 on echo
* BMP/NT-proBNP \> 2x upper limit of normal
* Symptoms unmasked during exercise test
115
what conduction abnormality can be associated with AS?
LBBB due to LVH
116
causes of AS
age related degeneration (degenerative calcification)
bicuspid valve (present \< 50 y.o)
rheumatic heart disease
117
Heyde's syndrome
AS associated
angiodyplasia in GI tract due to acquired vWF deficiency → high sheer stress vWF cleaved + removed by ADAMTS13 as passing through stenosed AS
friable capillaries develop in GI tract → IDA
Tx - AS replacement
118
causes of a wide split S2
* late closure of pulmonary valve
* RBBB
* pulmonary HTN
* pulmonary stenosis
* early aortic valve closure
* mitral regurgitation
119
causes of reversed split (S2 widens on expiration rather than narrows)
* severe AS
* LBBB
* HOCM
120
what are key echo features that are concerning?
LA, LV, septum, EF
* LA diameter \> 45mm - ↑ risk of AF/clot formation
* LV diameter \> 55m (diastole) = dilated
* Ventricular septum \> 13 mm = LVH
* More sensitive and specific than ECG
* Normal ejection fraction if **\> 55%**
* \>65% is usually considered hyperdynamic
121
what are the complications of valve replacement
FIBAT
* Failure
* Infection
* Bleeding
* Anaemia (haemolytic)
* Thromboembolism
122
core principle of AS
valve has smaller lumen → LV works harder → LVH to compensate → eventually maximal compensation has occurred + onset of heart failure
123
key features of AR
* Big pulse
* Collapsing character of pulse (severe)
* Wide pulse pressure
* Hypertension SBP, low DBP, very wide PP
* Obvious, thrusting/hyperdynamic apex
* Early diastolic murmur
* S1 + S2 + murmur (slurring of S2)
124
core principles of AR
* regurgitation of blood back → extra volume in LV during diastole → LV dilatates
* the extra blood → volume loaded LV → higher SV → high volume pulse
* dilation is the initial compensation to maintain SV/CO but eventually fails → HF
125
severity signs for aortic regurgitation
* wide PP
* displaced apex
* heart failure
* shorter murmur
* angina (coronary branches have reduced filling due to regurgitation)
126
causes of AR
* Non-functioning leaflets
* Endocarditis
* Bicuspid
* Functioning valves, but do not meet in the centre → aortic root dilation
* Aortitis (inflammation)
* Syphilis - Argyll-Robinson pupil
* Ank. Spondylitis (4%)
* CTD - Marfan's
127
mitral stenosis signs
* Rumbling mid-diastolic murmur
* Mitral facies - peripheral vasodilatation due to ↑ pulmonary venous pressure
* **Atrial fibrillation**
* ↑ JVP
* Pulmonary HTN
* May be mildly hypoxic if severe
* Tapping apex beat (palpable first heart sound)
* Pathognomonic for MS
* Loud S1 + P2
* Opening snap
128
severity signs of Mitral stenosis
* Pulmonary HTN
* LA enlargement and AF
* Echo - Valve area \< 1cm2
* Symptoms of CCF
129
core principles of Mitral stenosis
stenosised valves mean more blood stays in LA → dilates → contributes to LA and increases pulmonary vein pressure → high pressure transmitted through pul. vasculature → raised pulmonary artery pressure → R heart strain + RVH
130
what is ortner's syndrome?
LA dilation so severe it compresses recurrent laryngeal nerve → hoarse voice
e.g. mitral stenosis
131
causes of mitral stenosis
* **rheumatic fever**
* mitral annular calcification
* carcinoid syndrome
* SLE (Libman-Sacks endocarditis)
132
features of pulmonary HTN
* Loud and palpable P2
* Raised venous pressure - systolic V waves in JVP up
* Parasternal heave
* Pulmonary regurgitation murmur
* Graham Steele - shorter than AR murmur and louder in inspiration
* TR - murmur louder in inspiration (Carvallo's sign)
133
differentials for a mid-diastolic murmur
* MS
* Austin-Flint murmur (AR)
* Tricuspid stenosis
* Atrial septal defect
* Myxoma
* LA mass, fever, clubbing
134
treatable causes of AF
* Valvular heart disease e.g. MS
* Thyroid disease
* Electrolyte disturbance
* Alcohol
* Infection
* Hypovolaemia
* ASD
* Sleep apnoea
* Obesity
* COPD
135
syndrome associated with R sided heart valve stenosis
**carcinoid syndrome**
* GI tract tumours which produce serotonin → venous system → first valves encountered are tricuspid and pulmonary
* Once in lungs serotonin is metabolised and won't really reach the L heart
* Serotonin causes ↑ regulation of TGF-beta-1 and ECM components including collagen
treat with octreotide
if L stenosis then mets in lungs
136
pathogens for IE and their considerations
* Streptococcus viridans = most common
* Staphylococcus aureus (rising incidence)
* Associated with seeding from joint prosthesis or metal valves
* HACEK group _(culture negative_)
* Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella
* Streptococcus bovis is associated with **colorectal cancer**
* need _colonoscopy_
137
investigations in IE
* 2 x blood cultures 24 hours apart, no Abx unless septic or embolic features
* TOE (gold standard)
* TTE can be done first 50-60% sensitive
* monitor renal function (GN)
* if aortic valve affected → ECG every 2 days as abscess formation causes PR prolongation by affecting conductive septum
138
features of tricuspid regurgitation
* Big neck pulsations (CV waves)
* Peripheral oedema
* Pulsatile hepatomegaly
* Pansystolic murmur
* Pulmonary HTN (late complication)
139
causes of tricuspid regurgitation
* pulmonary hypertension
* endocarditis (IVDU, dialysis patients)
* Ebstein's anomaly - apical displacement of TV (congenital)
* Carcinoid syndrome
140
what are the core principles of R sided valve pathology
* diuretics - manage Sx, no other prognostic meds
* surgery - final resort
141
mitral regurgitation features
* AF (large LA)
* Dilated LV - therefore infero-lateral apical displacement
* S3 due to rapid ventricular filling
* Pan systolic murmur
142
causes of mitral regurgitation
* ACUTE
* papillary muscle rupture in MI
* non-ischaemic papillary muscle rupture (IE, RHD, trauma, spontaneous)
* CHRONIC
* age related degeneration
* RHD
* IE
* SLE
* CTD
* HOCM
143
what are the newer prognostic drugs in heart failure?
* ivabradine
* HCN channel blocker, sodium-potassium inward current that controls spontaneous diastolic SA node depolarisation so controls heart rate
* entresto
* neprolysin inhibitor + ARB together,
* neprilysin is responsible for ANP and BNP degradation
144
how to differentiate ICD vs pacemaker on x-ray
ICD has thick coil (1 or 2)
145
what graft is associated with the best prognosis in CABG for LAD?
LIMA (left internal mammary artery)
146
when timing JVP to pulse what is normal and not?
JVP should be in diastole
JVP during systole (with pulse) is abnormal, feature of TR
147
stages of normal JVP wave
JVP
- a - atrial contraction
- C - closure of tricuspid
- X descent - atrial dilation
- V - filling of atrium
- Y descent - ventricular relaxation
148
cannon A wave
extra large A wave due to atrium contracting against closed tricuspid (A + V)
* complete heart block
* atrial flutter
* single chamber pacing
* nodal rhythm
* ventricular ectopic
* ventricular tachycardia
149
Large A wave causes
* tricuspid stenosis - atria contracts against stiff tricuspid and so pressure in atria rises higher than normal
* pulmonary hypertension - there are generally higher pressures on the right side of the heart
* pulmonary stenosis
150
raised JVP with normal waveform causes
* right heart failure
* fluid overload
* bradycardia
151
what should JVP nromally do with respiration?
Normally the JVP should rise on expiration and fall on inspiration.
When the JVP rises on inspiration it indicates (paradoxical)
* Pericardial effusion
* constrictive pericarditis
* pericardial tamponade
152
differential for ST elevation
* myocardial infarction
* pericarditis/myocarditis
* normal variant - 'high take-off'
* Takotsubo cardiomyopathy
* Left ventricular aneurysm
* Prinzmetal angina
* Subarachnoid haemorrhage
