Cardiovascular 🫀 Flashcards
(149 cards)
1
Q
What are the symptoms of Left Sided HF?
A
- pulmonary conjestion
- SOB/ Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Nocturnal cough
- Pink frothy sputum
- fatigue
- Tachypnoea
- Bibasal fine crackles on ascultation
- Cyanosis
- prolonged capillary refill
- Hypotension
- Pulsus alternans
2
Q
What are the symptoms of Right sided HF?
A
- ankle swelling
- weight gain
- ascites
- hepatomegaly
- raised JVP
- trasudative pleural effusion
3
Q
What are the common signs of CHF:
A
- tachycardia
- tachypnoea
- laterally displaced apex beat
- gallop rhythm
- hepatosplenomegaly
- basal crepitations
4
Q
What is the initial Ix you would do if a patient presented with sx of HF?
A
- Bloods
- Troponin
- BNP/ NT-BNP
- ECG
- CXR
5
Q
What is the GOLD standard Ix for HF?
A
Echocardiography
6
Q
What is the management of HF with preserved EF?
A
- manage comorbidities
- exercise
- cardiac rehab
7
Q
What is the management of HF with reduced EF?
A
1st line - ACEi/ ARB and BB
* if cannot tolerate ACEi/ ARB, give Hydralazine + Nitrate
2nd line- specialist advice
* if EF <35% = replace ACEi with sacubitril valsartan
* if HR >75 and EF <35% and sinus rhythm = add ivabradine
* if patient is black = add hydralazine + nitrate
* if HF with sinus rhythm = Digoxin
8
Q
How will you treat fluid overload?
A
Loop diuretic- furosemide
9
Q
Define Cardiac Tamponade?
A
Accumulation of pericardial fluid/ blood/ pus/ air in the pericardial space which leads to increased pericardial pressure on the heart to then reduce cardiac filling leading to reduced cardiac output.
10
Q
What are the symptoms of Cardiac Tamponade?
A
- Chest pain
- tachycardia
- SOB
- confusion
11
Q
What are the clinical signs of Cardiac Tamponade?
A
BECKS TRIAD: hypotesion, raised JVP, distant/ muffled heart sounds
12
Q
What Ix should be done if a patient is suspected to have Cardiac Tamponade?
A
- ECG- low volatage QRS complex and electrical alternans
- CXR- large globular heart
- echocardiogram
13
Q
What is the management of Cardiac Tamponade?
A
1st line when patient is haemodynamically unstable: PERICARDIOCENTISIS
14
Q
Define Angina:
A
Pain caused by reduced blood flow to the myocardium.
15
Q
Define Stable Angina:
A
Pain during stress/ exercise that is relieved in <15 minutes of rest + GTN spray.
16
Q
Define Unstable Angina:
A
Pain during rest lasting >15 minutes and not relieved by rest.
17
Q
What are the risk factors of Angina:
A
- smoking
- obesity
- CVD
- high cholesterol
- Diet/ exercise
- diabetes
- lung cancer
18
Q
What are the symptoms of Angina:
A
- Sharp crushing chest pain
- SOB
- n+v
- clammy/ sweaty
19
Q
What Ix would be done for Angina?
A
- ECG
- UNSTABLE ANGINA- troponin
- 1st Line CT coronary angiogram
- 2nd Line stress echocardiogram/ myocardial perfusion SPECT/ cardiac MRI
- 3rd Line Invasive coronary angiography
20
Q
How is Angina managed?
A
- 1st- GTN spray + statins + Aspirin (300 ONCE then 75mg OD + PPI)
- 2nd BB + CCB
- 3rd Invasive surgery to revascularize the vessel (PCI/ CABG)
21
Q
MI
A
ADD MI CARDS
22
Q
Define Aortic Coarctation:
A
Congenital narrowing of aorta at/ distal to the left subclavian artery.
23
Q
What are the risk factors of Aortic Coarctation?
A
- men
- turners
- ductus arteriosus
- ventricular septal defect
- mitral murmurs
- circle of willis aneurysms
24
Q
What are the symptoms of Aortic Coarctation?
A
- generally asymptomatic
- HTN- headaches/ nosebleeds
- claudication of legs
- cold legs
25
What are the signs of Aortic Coarctation?
* HTN in upper limbs
* weak/ delayed pulse in legs
* radio-femoral delay
* incidental finding of systolic murmur
26
What Ix should be done for Aortic Coarctation?
* Echocardiogram
* ECG
* CXR
* Aortography
* Cardiac CT/ MRI
* Cardiac catheterisation- to detect pressure gradients
27
What is the treatment of Aortic Coarctation?
* Mild- monitor via echo + control HTN
* Severe- surgery
* most cases- balloon angioplasty and stent insertion
28
Define Aortic Dissection:
Dissection occurs when a tear in the tunica intima of the aorta creates a false lumen whereby blood can flow between the inner and outer layers of the walls of the aorta.
29
What are the risk factors of Aortic Dissection?
* Male > 50
* HTN
* Connective tissue disease (marfans)
* Valvular heart disease
* Cocaine/ amphetamine usage
30
What are the types of Aortic Dissection?
* Type A- Ascending/ arch of aorta
* Type B- Descending aorta
31
What are the Symptoms of Aortic Dissection?
* Tearing chest pain radiating to back
* Bowel/ limb ischaemia
* renal failure
* syncope
32
What are the signs of Aortic Dissection?
* radial - radial delay
* radial - femoral delay
* different BPs in arms
33
What Ix is done for Aortic Dissection?
* CT angiogram
* ECG
* Echocardiogram
* CXR
* Bloods: raised troponin, + D-dimer
34
What is the definitive treatment for Aortic Dissection Type A and Type B?
Type A- surgical graft
Type B- Conservative measures
35
What is the Initial Treatment if Aortic Dissection is suspected?
* resus
* cardiac monitoring
* Strict BP control- IV metoprolol infusion
36
What are the Risk Factors of HTN:
- age
- sex
- ethnicity
- genetics
- smoker
- obesity
- salt
- stress
37
What are the symptoms of HTN:
* usually asymptomatic
* headaches
* dizzy
* visual changes
38
What are the complications of Uncontrolled HTN:
* kidney damage
* eye damage
39
What Ix are appropriate for HTN?
* ABPM
* ECG
* U&E
* fundoscopy
* QRISK3
40
The management of HTN:
See nice guidelines
41
Define Pericarditis:
Inflammation of the pericardium which is the sac surrounding the heart.
42
What are the causes of pericarditis?
* idiopathic
* Infective
* Malignant: lung/ breast/ Hodgkin's
* cardiac: Heart failure, dressler's syndrome
* radiation
* Drugs/ toxins: Methyldopa, phenytoin, peneciliin, isoniazid, hydralazine
* Rheumatology: SLE, RA, sarcoidosis
* renal failure
* hypothyroid
* IBD
* ovarian hyperstimulateion
43
What are the symptoms of Pericarditis:
* pleuritic chest pain: central/ worse on inspiration
* postural chest pain: worse on lying flat and relieved on leading forward
* fever
44
What are the signs of Pericarditis:
* Pericardial friction rub- left sternal border on expiration
* pericardial effusion
* Cardiac Tamponade
45
What Ix can be considered for Pericarditis?
* 1st line- ECG: wide saddle ST elevation; PR depression
* blood test: troponins, CRP, ESR, WCC, viral serology
* echo
* Angiogram
* Cardiac MRI
46
What is the management of pericarditis?
Unknown cause/ viral:
* no exercise
* 1st NSAIDs with PPI cover
* 2nd colchicine
* 3rd Corticosteroids
Bacterial
* 1st abx IV +/- pericardiocentesis
* 2nd Pericardiectomy
47
Define Infective Endocarditis:
Infection of the inner surface of the heart/ valves.
48
What are the risk factors of Infective Endocarditis?
* > 60 years
* men
* IV drug users
* poor dentition
* valve disease
* congenital heart disease
* prosthetic valves
* hx of endocarditis
* HIV
* haemodialysis
49
How can Infective endocarditis be classifies?
* Acute- sx < 6 weeks
* Subacute- sx 6 weeks up to 3 months
* chronic- sx persist longer than 3 months
50
What are the common organisms causing Infective endocarditis?
* Staph. Aureus = most common
* Strep. Viridans
* Enterococci
* Strep. Bovis- links to colorectal caner (colonoscopy and biopsy)
* coagulase neg. Staphylococci- common in prostetic valve IE
* HACEK organisms- neg culture
51
What might cause NON-INFECTIVE endocarditis?
* Pancreatic cancer
* Libman-Sacks Endocarditis
52
What are the symptoms seen in Infective endocarditis?
* fevers
* night sweats
* anorexia
* weight loss
* myalgia
* headache
* arthralgia
* cough
* chest pain
53
What are the signs of Infective endocarditis?
Systemic signs:
* febrile
* cachectic
* clubbing
* Splenomegaly
Cardiac signs:
* murmur - fever + new murmur is IE until proven otherwise
* bradycardia leading to heart block
Vascular Signs:
* septic emboli
* janeway lesions
* splinter haemorrhages
Immunology signs:
* Roth spots
* Osler's nodes
* Glomerulonephritis
54
What investigations should be done if query Infective Endocarditis:
* ECG
* urine dip
* blood cultures
* bloods
* 1st line- transthoracic echocardiogram
* 2nd line- transoesophageal echocardiogram
* CT CAP?
* PET CT - for septic emboli
55
What are the complications of infective endocarditis if left untreated?
* HF then death
* Brain complications: stroke, abscess, haemorrhage
* Embolic complications- causing infarction of kidneys, spleen, lung
* infections- Osteomyelitis, septic arthritis
56
What is the abx treatment of Infective Endocarditis:
6/52 course IV abx
Unknown organism:
* Native valve: amox +/- gent
* Pen-allergy/ MRSA: Vanc +/- gent
* Prosthetic valve: Vanc + Rifamp +Gent
Native Valve S. Aureus:
* 1st- fluclox
* 2nd- Vanc + Rifamp
Prosthetic valve S. Aureus:
* 1st- Fluclox + rifamp + gent
Strep Viridans:
* 1st- benzylpenecillin
* 2nd- Vanc + gent
HACEK:
* 1st- Ceftriaxone
57
When is surgery indicated as a treatment for Infective Endocarditis:
* Heamodynamic instability
* severe HF
* Severe sepsis despite abx
* Valvular obstruction
* Infected prosthetic valve
* Persistent bacteraemia
* Repeated emboli
* Aortic root abscess which can lead to PR PROLONGATION in patient with IE
58
What is the DUKES Criteria?
Used to diagnosis IE: 'BE FIVE PM'
Major Criteria
* Blood cultures
* Endocardial involvement: ECHO
Minor Criteria
* Fever
* Immunological signs
* Vascular signs
* Echocardiogram
* Predisposing features- risk factors
* Microbiological evidence
For definitive diagnosis of IE two major criteria or one major and three minor criteria OR all 5 minor criteria must be present.
59
Define Atrial Fibrillation:
Atrial fibrillation is characterised by irregular, uncoordinated atrial contraction (300-600 bpm). Delay at the AVN means that only some of the atrial impulses are conducted to the ventricles, resulting in an irregular ventricular response.
60
How can AF be classified?
* Acute: lasting <48 hours
* Paroxysmal: lasts <7 days and is intermittent
* Persistent: lasts >7 days and is amenable to cardioversion
* Permanent: lasts >7 days and not amenable to cardioversion
* Fast AF: >100 bpm
* Slow AF: <60 bpm
61
What are the causes of Atrial Fibrillation?
Cardiac
* IHD
* HTN
* rheumatic HD
* pericarditis/ myocarditis
Non-cardiac:
* dehydration
* endocrine causes- hyperthyroid
* infective causes- sepsis
* lung causes- pneumonia/ PE
* alcohol abuse
* electrolyte imbalance: hypokalaemia, hypomagnesaemia
62
What are the symptoms of Atrial Fibrillation?
* palpitations
* chest pain
* SOB
* lightheaded
* syncope
63
What are the signs of Atrial Fibrillation?
* irregularly irregular pulse with variable volume
* A single waveform on the JVP (due to loss of the a wave - this normally represents atrial contraction).
* An apical to radial pulse deficit (as not all atrial impulses are mechanically conducted to the ventricles).
* On auscultation there may be a variable intensity first heart sound.
* Features suggestive of underlying cause e.g. hyperthyroidism, alcohol excess, sepsis
* Features suggestive of complications from the AF e.g. heart failure, stroke
64
What investigations should be done for Atrial Fibrillation?
* DEFINATIVE- 12 lead ECG- absent P waves
* Bloods to rule out other causes
* Imaging- echocardiogram
65
What are the complications of Atrial Fibrillation:
* HF
* stroke
* mesenteric ischaemia
* GI/ brain bleeds
66
If a patient had Atrial Fibrillation, when is emergency admission/ cardiology referral indicated?
* New-onset AF within the past 48 hours and is haemodynamically unstable
* Severe symptoms of AF due to rapid (bpm > 150 ) or very slow (bpm < 40) ventricular rate
* Concomitant acute decompensated heart failure
* Complications of AF, such as TIA/stroke
* An acute, potentially reversible trigger such as pneumonia/sepsis or thyrotoxicosis
67
What is the management of Acute/ New-onset Atrial Fibrillation?
If adverse signs of shock, syncope, MI, HF: 1st line- synchronised DC cardioversion +/- amiodarone
If not adverse signs and patient has AF for < 48 hours: rate control (BB)/ rhythm control (DC cardioversion- if too late then give heparin)
If patient is stable and onset of AF >48 hours/ unclear time of onset: rate control only with BB/ diltiazem/ digoxin; AND anticoagulated minimum 3 weeks before attempting cardioversion.
68
What is the management of Chronic Atrial Fibrillation?
Rate control:
* 1st line: BB/ diltiazem
* 2nd line: dual therapy- specialist
* can consider digoxin monotherapy in non-paroxysmal AF
Rhythm control:
* electrical cardioversion
* amiodarone, fleicanide, sotalol
* Catheter ablation
69
When should we offer rhythm control in patients with AF?
* AF secondary to a reversible cause
* HF caused by AF
* New-onset AF
* Clinical judgement
70
What else should we do with patients who have AF?
They're at high risk of stroke:
* CHADS2VASc Score
* Orbit Score/ HASBLED Score
71
What is CHADS2VASc Score?
C: 1- congestive cardiac failure.
H: 1- hypertension.
A2: 2 - >/=75
D: 1 - DM
S2: 2 - hx stroke/ TIA
V: 1 - vascular disease
A: 1 - age 65-74.
Sc: 1 - female.
72
Interpretation of CHADS2VASc Score?
* Score is 0 (associated with 0% annual stroke risk)
* Score is 9 (15% annual stroke risk).
* Males who score 1 or more or females who score 2 or more should be anticoagulated (as long as the risk of stroke outweighs the risk of bleeding).
73
What is the HASBLED score:
Risk of anticoagulation
H: Hypertension = 1
A: Abnormal renal function or LFT = 2 points if both present
S: Hx Stroke = 1
B: Hx major bleed =1
L: Labile INR = 1
E: Elderly (>65) = 1
D: Drugs/alcohol = 1 (2 if both present)
74
What is the ORBIT Score:
2021 AF guidelines NICE suggested the use of the ORBIT score which takes into account:
* Sex
* Haemoglobin (<13mg/Dl in males, <12mg
- 74) 1 point
* Bleeding history 2 points
* Renal function (eGFR <60) 1 point
* Concomitant use of anti-platelets 1 point
75
The Anticoagulant options of AF?
1st line: DOACs:
* Edoxaban, apixaban, rivaroxaban & dabigatran
* Generally associated with fewer bleeding risks compared to warfarin.
* Most have approximately 12 hour half-lives therefore if a patient misses a dose they are not covered.
Warfarin:
* Requires cover with LMWH for 5 days when initiating treatment (because warfarin is initially prothrombotic).
* Regular INR monitoring.
* 40 hour half-life therefore anticoagulant effect lasts days.
LMWH:
* Enoxaparin
* Those who cannot tolerate oral meds
* Daily injections.
76
Define Atrial Flutter:
Is a common supraventricular tachycardia (SVT) characterised by an abnormal cardiac rhythm with atrial rate 300bmp and ventricular rate which can vary.
77
Risk factors of Atrial Flutter:
* men
* elderly
78
What are the causes of Atrial flutter?
Pulmonary disease:
* COPD
* OSA
* PE
* Pulm HTN
Other:
* IHD
* sepsis
* Alcohol
* cardiomyopathy
* Thyrotoxicosis
79
What are the signs and symptoms of Atrial Flutter?
* Asymptomatic
* palpitations
* SYNCOPE
* lightheadedness
* Chest pain
* irregular irregular pulse (variable block)
80
What Ix is done for patients with Atrial Flutter?
ECG
81
What would be seen in an ECG in a patient who has Atrial Flutter?
* Regular rhythm
* Saw-tooth baseline with repetition at 300bpm (atrial flutter waves)
* Narrow QRS complexes
* Ventricular rate depending on level of AV block:
- 150bpm if 2:1
- 100bpm if 3:1
- 75bpm if 4:1
- 60bpm if 5:1
NOTE: If a patient has flutter with variable block the rhythmn may be irregularly irregular and this may be hard to distinguish from AF.
82
What is the management of an hemodynamically unstable patient with Atrial Flutter?
* 1st line = DC synchronised cardioversion +/- amiodarone.
83
What are the signs of haemodynamic instability?
* Shock: suggests end-organ hypoperfusion.
* Syncope: cerebral hypoperfusion.
* Chest pain: myocardial ischaemia.
* Pulmonary oedema: evidence of heart failure.
84
What is the management of an hemodynamically stable patient with Atrial Flutter?
Treat reversible causes: fluid rehydration (in septic/dehydrated patients) can revert atrial flutter into sinus rhythm.
85
Rate and Rhythm control in patients with Atrial Flutter:
Rate and rhythm control:
* 1st line = BB (bisoprolol) OR CBB (diltiazem, verapamil)
* 2nd line = if rate control fails to control flutter than consider cardioversion.
* 3rd line = recurrent or refractory flutter managed with ablation of arrhythmogenic foci at cavotricuspid isthmus.
86
What are the complications of Atrial Flutter?
* Ischaemic Stroke
* Tachycardia induced cardiomyopathy leading to HF
87
What are Broad Complex Tachycardia:
Dysrhythmias that have a heart rate greater than 100bpm and a QRS complex that is greater than 120ms.
* Ventricular tachycardia
* Ventricular fibrillation.
88
What are the ECG findings in a patient who has a Broad Complex Tachycardia?
* > 100bpm
* Absent P waves
* Monomorphic regular broa dQRS complexes (>120ms)
89
What is the management of Broad Complex Tachycardia when the patient has no pulse?
Pulseless VT
* The patient should be managed according to the Advanced Life Support algorithm.
* Pulseless VT is a shockable rhythm so a 200J bi-phasic unsynchronised shock should be administered.
* IV adrenaline (1mg of 10ml 1:10,000 solution)
* IV amiodarone (300mg) should be administered after delivery of the 3rd shock.
* Adrenaline should be administered every 3-5 minutes thereafter.
90
What is the management of Broad Complex Tachycardia when the patient has a pulse and adverse sx?
Pulsed VT with Adverse Features
* Adverse features (shock, syncope, myocardial ischaemia, or heart failure) manage according to Resuscitation Council Tachyarrhythmia algorithm.
* Administer synchronised DC shocks (up to 3 attempts); patient conscious they require sedation or anaesthesia.
* Expert help to guide amiodarone administration (300mg IV over 10-20 minutes followed by 900mg infusion over 24 hours).
91
What is the management of Broad Complex Tachycardia when the patient has a pulse and no adverse sx?
Pulsed VT with No Adverse Features
If the patient has a pulse and is not demonstrating adverse features then the Resuscitation Council Tachyarrhythmia algorithm should be followed.
* Amiodarone 300mg IV over 10-60 minutes.
* If this is ineffective then administer synchronised DC shocks (up to 3 attempts). If the patient is conscious this will require sedation or anaesthesia.
NOTE: if there has been a previous certain diagnosis of SVT with aberrancy treat as for regular narrow complex tachycardias
92
What are the ECG findings in a patient who has a Ventricular Fibrillation?
- > 100 bpm
- QRS complex are polymorphic and irregular (>120ms)
93
How to manage Ventricular Fibrillation?
The patient should be managed according to the Advanced Life Support algorithm.
* VF is a shockable rhythm so a 200J bi-phasice unsynchronised shock should be administered.
* IV adrenaline (1mg of 10ml 1:10,000 solution) and IV amiodarone (300mg) should be administered after delivery of the 3rd shock.
* Adrenaline should be administered every 3-5 minutes thereaf
94
Define Narrow Complex Tachycardia:
Is a dysrhythmia that has a heart rate greater than 100bpm and a QRS complex that is less than 120ms.
95
What is the difference between SVT and Sinus Tachyardia?
Sinus tachycardias frequently change rate and gradually speed up or slow down over seconds to minutes.
SVT starts suddenly then stays at the same rate until it ends.
96
How to classify Narrow Complex Tachycardia?
Regular/ irregular Rhythm
Regular:
* Sinus tachycardia
* Focal atrial tachycardia
* Atrial flutter
* Atrioventricular re-entry tachycardia (AVRT)- Associated with Wolff-Parkinson White.
* Atrioventricular nodal re-entry tachycardia (AVNRT)
* Junctional tachycardia
Irregular:
* AF
* Atrial Flutter
* Multifocal Atrial Tachycardia- found in those with severe COPD
97
Symptoms of Narrow Complex Tachycardia?
* Palpitations
* Lightheadedness
* Dyspnoea
* Chest pain
* Syncope
98
Signs of Narrow Complex Tachycardia?
* Tachycardia
* Haemodynamic Instability: Shock, chest pain, HF, syncope
99
Ix for Narrow Complex Tachycardia:
* ECG
* 24 Hour tape- due to Narrow Complex Tachycardia being paroxysmal
* FBC, TFTs, U&Es
* echo
* loop recorder
* cardiac catheterisation
100
What is the initial management for Narrow Complex Tachycardia?
Initial management:
* For emergencies- A-E structure. Identify reversible causes
* If there are adverse signs (e.g. shock, syncope, heart failure, myocardial ischaemia):
- 1st line = synchronised DC cardioversion +/-
amiodarone.
* If there are no adverse signs: consider whether the rhythmn is regular or irregular.
101
What is the management for Regular Narrow Complex Tachycardia?
Regular:
* 1st line = vagal manouevres including Valsalva manouevre and carotid sinus massage. Increasing vagal input can help terminate the SVT.
* 2nd line = IV adenosine. Initially give a 6mg bolus. If this is unsuccessful give 12mg. If this is still unsuccessful give 18mg.
* 3rd line = verapamil or beta-blocker
* 4th line = synchronised DC cardioversion
102
What is the initial management for Narrow Complex Tachycardia?
Irregular:
* Probable atrial fibrillation and to treat with beta-blockers.
* If there are signs of heart failure digoxin may be trialled.
* If onset >48h the patient will need to be anticoagulated.
103
Define Myocarditis:
Myocarditis, also known as an inflammatory cardiomyopathy, refers to inflammation of the myocardium (heart muscle). It often occurs alongside inflammation of the pericardium (sac that surrounds the heart) and it is then described as myopericarditis.
104
Risk Factors of Myocarditis:
- age 19-35
105
Causes of myocarditis:
The most common cause in Europe and the UK are viruses, with Cocksackie B being the most common culprit.
Worldwide, Chagas disease is the most common cause following infection from Trypanosoma cruzi.
Viral Infections:
* Cocksackie B virus
* COVID-19
* Adenovirus
* Epstein Barr Virus
Bacterial Infections:
* Diphtheria
* Clostridia
* Neiseria gonorrhoea
Protozoan:
* Trypanosoma cruzi
Auto-Immune:
* Kawasaki disease
* Scleroderma, SLE, sarcoid and systemic vasculitides
Drug Reactions:
* Antipsychotics incl. clozapine
* Immune-checkpoint inhibitors
* Mesalazine
106
What are the symptoms of Myocarditis?
* Chest pain: often described as sharp, stabbing.
* Shortness of breath
* Palpitations
* Lightheadedness
* Syncope
* Fever and viral prodrome
* Severe cases can present with sudden unexplained cardiac death.
107
What are the signs of Myocarditis?
* Dull heart sounds
* If myopericarditis a pericardial rub may be heard.
* heart failure
108
What are the Investigations to be done in a patient with Myocarditis?
* ECG: non-specific ST segment and T wave changes (may suggest location of myocardial involvement); arrhythmias; tachycardia; and ectopic beats.
* Raised Troponin and CK-MB
* Inflammatory markers raised
* viral serology
* Echocardiogram: reveal ventricular dysfunction or regional wall motion abnormalities.
* Cardiac MRI: help CONFIRM diagnosis of myocarditis and indicate extent of inflammation.
* Endomyocardial biopsy: GOLD-standard
109
What is the GOLD Standard Ix for Myocarditis adn what will is show?
Endomyocardial biopsy: GOLD-standard
Histopathology shows infiltration of inflammatory cells into the myocardium and myocardial necrosis.
110
What is the management of Myocarditis?
Hallmark of treatment is supportive and addressing the underlying cause- can take 4 weeks to recover.
* Patients with severe myocarditis may require ITU support and vasopressors.
* Patients with viral acute myocarditis may benefit from a course of corticosteroids.
* After recovery, patients should be advised to limit activity for a few months.
111
The complications of Myocarditis:
* heart failure
* arrhythmias
* dilated cardiomyopathy.
112
Define Aortic stenosis:
Aortic stenosis refers to the narrowing and tightening of the aortic valve leading to reduced blood flow from the left ventricle into the aorta and ultimately to the rest of the body.
113
Causes of Aortic Stenosis:
* Senile calcification: most common cause in those >65y/o.
* Congenital bicuspid valve: most common cause in those <65y/o.
* Rheumatic heart disease
* William's syndrome: supravalvular stenosis
114
What type of murmur is Aortic Stenosis?
Ejection systolic murmur
115
Where is Aortic stenosis heard best?
Heard best at the second intercostal space on the right- radiating to the carotids
116
What are the Symptoms of Aortic Stenosis?
Mild-to-moderate aortic stenosis may be asymptomatic and may be picked up incidentally on cardiac auscultation or on echocardiogram.
Severe AS can be remembered by the mnemonic 'SAD'.
* Syncope
* Angina
* Dyspnoea
Other symptoms include: pre-syncope, palpitations, left ventricular heart failure symptoms (exertional dyspnoea, orthopnoea, PND) or can present in cardiac arrest/sudden cardiac death.
117
What are the signs of Aortic Stenosis?
* Slow-rising carotid pulse
* Narrow pulse pressure
* Heaving, non-displaced apex beat (can be displaced if there is left ventricular hypertrophy)
* Can be described as "harsh"
* Soft S2 heart sound: absent S2 corresponds with severity
* Ejection click may be heard in some cases (early systolic)
118
What are the complications of Aortic Stenosis if left untreated?
Aortic stenosis if left untreated can lead to LV failure. It is also implicated in sudden cardiac death.
119
What Investigations should be done if someone has Aortic stenosis?
* ECG: LVH, left axis deviation, and poor R wave progression.
* CXR: cardiomegaly and evidence of pulmonary oedema. Occasionally, a calcified aortic valve is visible.
* Echocardiogram: definitive diagnosis.
* Cardiac MRI: details of valve morphology, dimensions of the aortic root and the extent of valve calcification.
120
Management of Aortic Stenosis:
Conservative
* Asymptomatic and stable may not require treatment
* Patients who do not meet the criteria for intervention should have regular echocardiography follow-up
- Severe Aortic Stenosis being monitored every 6
months
- Mild-to-moderate AS monitored yearly
- Younger patients can be monitored every two to
three years.
Medical
* Symptom management of LV failure with diuretics and optimising heart failure medications BB, ACEi
Surgical and Interventional- only indicated if:
* All patients with symptomatic aortic stenosis
* Asymptomatic patients with a left ventricular ejection fraction (LVEF) < 55%
* Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing
* Asymptomatic patients with an LVEF > 50% who have the following risk factors
Aortic valve peak velocity > 5m/s x2
* Severe calcification and peak velocity progression >= 0.3m/s x2
* Markedly elevated BNP levels (more than twice upper limit) without other explanation
* Severe pulmonary hypertension (pulmonary artery systolic pressure > 60mmHg)
* Aortic valve area less than 0.6 cm2
* Choices of intervention are transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).
TAVI is favoured with patients with severe comorbidities, previous heart surgery, frailty, restricted mobility, and those older than 80 years of age.
SAVR is favoured for patients who are low risk and younger.
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Define Aortic Regurgitation:
Aortic regurgitation (AR), or aortic insufficiency (AI), occurs when the aortic valve fails to prevent blood from leaking back across the valve during diastole.
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What type of murmur is Aortic Regurgitation?
Early Diastolic Murmur
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Where is Aortic Regurgitation heard best?
* Heard best at the aortic region, leaning forward and on expiration.
* Soft S1 and occasional ejection flow murmur.
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Risk factors of Aortic Regurgitation:
Risk Factors:
* Older populations
* Male>Female
* Congenital aortic valve/root defects (bicuspid aortic valve, Marfan's syndrome)
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What are the causes of Acute and Chronic Aortic Regurgitation:
Acute Aortic Regurgitaion causes:
* Infective endocarditis- most common
* Aortic dissection
* Traumatic rupture of valve leaflets
* Iatrogenic causes: balloon valvotomy or TAVI.
* Non-native aortic valve regurgitation
Chronic Aortic Regurgitation
* Rheumatic heart disease
* Age-related calcification
* Congenital bicuspid aortic valve
* Connective tissue disorders: Marfan's syndrome, Ehler's Danlos
* Infective endocarditits
* Rheumatological conditions: rheumatoid arthritis, ankylosing spondylitis, APLS, giant cell arteritis,
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What is the symptoms of Acute and Chronic Aortic Regurgitation:
Acute AR
* Sudden cardiovascular collapse
* Acute pulmonary oedema - shortness of breath, sweating, pallor, peripherally vasoconstricted
Chronic AR
* More insidious, slower onset
* Exertional dyspnoea, orthopnoea, PND
* Stable angina even in absence of coronary artery disease (due to reduction in diastolic coronary perfusion)
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What are the signs of Aortic Regurgitation?
Peripheral findings:
* De Quincke's sign - nail bed pulsation
* Waterhammer pulse
* De Musset's sign - head hobbing
* Corrigan's sign - dancing carotids
* Muller's sign - pulsation of the uvula
* Traube's sign - pistol shot (bruit heard on auscultation of femoral pulse)
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What are the Ix for Aortic Regurgitaion?
* Observations: widened pulse pressure.
* Throat swab for group A strep.
* ECG: LVH and p mitrale in chronic AR.
* Inflammatory markers and blood cultures - infective endocarditis.
* Auto-antibody screen - rheumatological causes.
Imaging:
* Transthoracic echocardiogram - DEFINITE diagnosis.
* Cardiac MRI
* Invasive cardiac catheterisation - detailed information on AR severity, LV function and size, pressures and valve gradient, and dimensions of aortic root.
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What is the management of Aortic Regurgitation?
Conservative management
* Depends on the severity of the AR: mild-to-moderate AR commonly monitored and no specific treatment is required.
Medical management
* Used to slow the rate of aortic root dilatation in high risk patients (e.g. Marfan's or bicuspid aortic valve).
* Beta blockers +/- losartan are used to lower systolic blood pressure.
* Patients with severe asymptomatic AR should be seen and monitored annually. If LV diameters or systolic function change significantly, follow-up should be 3-6 monthly.
Surgical intervention is indicated in:
* Symptomatic AR.
* Asymptomatic AR with: poor LVEF (<=50%), LV and diastolic diameter >70mm or LV end-systolic diameter >50mm.
* Infective endocarditits refractory to medical therapy.
* Significant enlargement of ascending aorta.
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What are the complications of Aortic Regurgitation?
Acute AR can lead to cardiovascular collapse and de novo acute heart failure.
Chronic AR that is not treated will lead to chronic heart failure with predominantly left ventricular symptoms (pulmonary oedema).
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Define Pulmonary Stenosis:
Pulmonary stenosis obstructs the blood flow from the right ventricle into the pulmonary bed, resulting in a pressure gradient greater than 10 mmHg across the pulmonary valve during systole.
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Causes of Pulmonary Stenosis:
Pulmonary stenosis is usually congenital is associated with the following syndromes:
* Tetralogy of Fallot (valvular)
* Noonan syndrome (valvular)
* Williams syndrome (supravalvular)
* Congenital rubella infection.
* Carcinoid syndrome.
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What kind of murmur is Pulmonary Stenosis and where is it best heard?
* Ejection systolic murmur that radiates to the left shoulder and is best heard on expiration.
* Widely split S2 with a delayed P2.
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What are the symptoms of Pulmonary Stenosis?
Pulmonary stenosis typically causes right heart failure and may present with the following symptoms:
* Dyspnoea
* Fatigue
* Peripheral oedema
* Ascites
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Signs of Pulmonary Stenosis:
* Dysmorphic facies if it occurs with a congenital syndrome such as Noonan syndrome or Williams syndrome.
* Raised JVP
* Right ventricular heave
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What are the Ix of Pulmonary Stenosis:
* ECG: p pulmonale, right axis deviation, and right ventricular hypertrophy.
* CXR: prominent pulmonary arteries and post-stenotic dilatation.
* Echocardiogram: degree of stenosis and ventricular function.
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What is the Management of Pulmonary Stenosis?
Mild asymptomatic valve disease rarely requires intervention.
Surgical options for severe pulmonary stenosis include valvotomy (for valvular lesions) and balloon angioplasty (for supravalvular lesions).
Treatment is considered in those with transvalvular pressure gradients >50mmHg.
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What is the complication of Pulmonary Stenosis?
The main complication of pulmonary stenosis is right heart failure. These patients are also at increased risk of infective endocarditis.
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Define Mitral Stenosis:
Mitral stenosis refers to the narrowing of the mitral valve which reduces blood flow to the left ventricle.
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What type of murmur is Mitral Stenosis?
Mid-late Diastolic mumur
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Where is Mitral Stenosis best heard:
* Low pitched rumble, most prominent at apex
* Loudest in expiration
* Heard best with patient lying on left side
* Heard best using stethoscope bell (low frequency)
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What are the causes of Mitral Stenosis?
* Rheumatic Heard Disease
* Mitral annular calcification (age-related)
* Congenital mitral stenosis (rare)
* Mucopolysaccharidosis (metabolic disorder affecting connective tissue)
* Carcinoid syndrome, causing valve disease
* Systemic disease, including systemic lupus erythematosus (SLE) and rheumatoid arthritis.
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What are the symptoms of Mitral Stenosis:
Mitral stenosis typically remains asymptomatic until the degree of stenosis is advanced. Symptoms tend to begin when the valve area falls <1.5cm^2. Common symptoms include:
* Gradual exertional dyspnoea
* Haemoptysis: pink/blood stained sputum
* Palpitations: atrial fibrillation
* Chest pain
* Thromboembolism (cerebral or systemic)
* Hoarseness: enlarged L atrium can compress the recurrent laryngeal nerve (Ortner's syndrome).
* Peripheral oedema / abdominal discomfort (hepatomegaly) - due to right heart failure.
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What are the Signs of Mitral Stenosis:
Peripheral signs:
* Mitral facies (malar flush)
* Low volume pulse
* Irregularly irregular pulse: AF.
* Elevated JVP (prominent 'a' wave due to raised right atrial pressure, or absent 'a' wave in AF).
* Tapping, non-displaced apex beat (palpable S1).
* Right ventricular heave (suggestive of pulmonary hypertension).
* Inspiratory crepitations (pulmonary oedema) and other signs of right heart failure.
Findings on auscultation:
* Loud S1 (becomes softer with increasing calcification)
* Loud P2 with pulmonary hypertension (later stages S2 splits)
* Opening snap heard at apex (only with pliable valves)
* Graham-Steell murmur (early diastolic murmur - only if pulmonary regurgitation present secondary to pulmonary hypertension)
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What are the Ix for Mitral Stenosis?
ECG may show:
* P-mitrale (a broad notched P wave due to left atrial enlargement)
* Right ventricular hypertrophy
* Right axis deviation
* Atrial fibrillation: caused by left atrial enlargement
CXR may show evidence of pulmonary oedema and left atrial enlargement
Echocardiogram: will show degree of stenosis and impairment of ventricular filling.
Cardiac MRI may show valvular vegatations.
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What are the complications of Mitral Stenosis?
In the absence of intervention, mitral stenosis may progress and cause worsening symptoms over time.
Initial symptoms are related to the following complications:
* Atrial fibrillation (AF) and Thromboembolism
* Pulmonary hypertension - dyspnoea and haemoptysis.
* Dilated left atrium - can impinge on local structures, leading to hoarseness, dysphagia and bronchial obstruction.
* Decompensated heart failure
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How to manage Mitral Stenosis?
Conservative
8 If a patient has asymptomatic MS they should undergo regular follow-up echocardiography to assess degree of stenosis and its progression.
Medical
* Treatment of complications including atrial fibrillation with rate control and anticoagulation.
* Diuretics can provide symptomatic relief for pulmonary congestion and peripheral oedema.
Interventional and Surgical if symptomatic:
* Balloon valvuloplasty: only appropriate if valve is pliable and non-calcified.
* Percutaneous mitral valvotomy: for patients with moderate disease.
* Open valve repair/replacement: for patients with severe disease who are not too high risk for surgery but are not candidates for percutaneous intervention. * Valves are more likely to be metal than bioprosthetic.
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Define Mitral Regurgitation:
Mitral regurgitation (MR) is the backflow of blood into the left atrium during systole due to the incompetence of the mitral valve.
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Causes of acute and chronic Mitral Regurgitation?
