Condition 2

Question 1

definition for valvular heart disease

Answer 1

any disease affecting one of the 4 heart valves

can include stenosis and regurgitation - can then lead to AF

Question 2

which of the heart valve is most commonly affected by valvular disease

Answer 2

mitral and aortic valves are more common than tricuspid or pulmonary due to the high pressure on the left side of the heart

Question 3

what are the most common pathogenesis for valvular disease

Answer 3

stenosed or incompetent (can either be acquired or congenital)

Question 4

what are some examples of valvular heart disease

Answer 4

Fallot’s tetralogy - congential disorder whcih includes pulmonary valve stenosis

ebstein’s anomaly - abnor of tricuspid valve

rheumatic heart disease - valvular disease due to rheumatic fever

endocarditis - inflammation of the heart valves due to bacterial infection, malignancy, autoimmune disease or hypereosinophilic snydrome (Loeffler’s endocarditis)

Question 5

what is one of the early presentation for infective endocarditis

Answer 5

fever + new murmur

Question 6

what are the common pathogens which causes infective endocarditis

Answer 6

staph aureus

strep viridans - common cause <35%

Question 7

what are some common causes for infective endocarditis

Answer 7

mouth

• dental disease or procedure
• alpa haemolytic streptococcus viridans

native or prosthetic valve endocarditis

• early (poor prognosis) - occuring within 60 days of valve surgery and acquired i ntheatre or soon after on ICU - most common eg staph aureus and staph epidemidis, MRSA
• late - occuring more than 60 days post surgery and presumed to have acquired in the community - strep ciridans (50-70%), staph aureus

prolonged inwelling vascular catheter and antibiotic use, IVDU (Staph aureus, candida)

gut and perineum
- underlying GI disease or procedure
prolonged hospitalisation eg Enterococci eg E.faecalis

Bowel malignancy
- strep bovis

soft tissue infection
- esp in diabetes and IVDU and pt with long-standing IV catheters (Staphyloccoci)

Question 8

what are the signs of infective endocarditis

Answer 8

pyrexial
murmur
petechiae (small red or purple spots caused by micro vessel bleed)
Janeway lesion
Osler’s node
splinter haemorrhages
arthritis - assymtric with up to 3 joints affected

Question 9

treatment for infective endocarditis

Answer 9

IV antibiotics depending on causes and culture results

surgery should be done for prosthetic valces, heart failure etc

Question 10

definition of cardiac failure

Answer 10

when heart is unable to supply sufficient cardiac output to meet the body’s need secondary to any structural or functional cardiac disorder

HF can not be the only diagnosis as it is a syndrome occurring as a result of other disease

Question 11

what are the different types of cardiac failure

Answer 11

acute or chronic

systolic and diastolic - systolic (when ventricle not able to contract properly with ejection fraction <40%), diastolic - when ventricle fails to relax and fill normally cuasing inc filling pressure but ejaction fraction >50%

left or right sided (can occur independent or together)
congestive cardiac failure - when both sides failure

low and high output
low - CO dec and fails to rise normally with exertion caused by pump failure
high - CO normal or raise - but there is a clincial picture of heart failure due to abnor elsewhere in the body

Question 12

how common is HF

Answer 12

commonest complication of all form of heart disease

prevalence inc to 10% in >70s

Question 13

who is affected the most by HF

Answer 13

more common in men in younger age groups due to earlier onset of ischaemic heart disease

mainly affect elderly

Question 14

what are the pathogensis of HF

Answer 14

heart/pump problems - heart failure to pump enough –> low CO –> peripheral underperfusion –> compensatory haemodynamic changes

venous return (preload) - affect by the sacromere length at the end of diastolic phase and affected by venous BP and the rate of venous return which in turn affected by venous tone and volume of circulating blood eg mitral regurgitation or fluid overload

outflow resistance (afterload) - the consequence of aortic pressure and pulmonary artery pressure and can be affect by aortic stenosis, hypertension, pulmonary hypertension

Question 15

what can cause heart/pump problem?

Answer 15

heart muscle disease - IHD. cardiomyopathy
restricted filling - constrictive pericarditis, tamponade (compression of the heart by an accumulation of fluid in the pericardial sac)
inadequate heart rate - beta-blocker, heart block, post MI
-ve inotropic drug - antiarrhythmic drugs

Question 16

causes of heart pump failure

Answer 16

IHD - heart muscle disease 
cardiomyopathy 
constrictive pericarditis 
cardiac tamponade 
restrictive cardiomyopathy 
Heart block 
Post-MI
beta-blocker 
antiarrhythmic drug 
SLE 
viral myocarditis 
HIV cardiomyopathy 
amyloidosis

Question 17

causes for preload problem

Answer 17

exercise 
overtransfusion - inc blood volume 
polycthemia - inc blood volume 
sympathetic tone 
arteriovenous fistula

Question 18

causes for afterload problem

Answer 18

systemic HTN
pulmonary HTN
aortic stenosis
aortic insufficiency/regurgitation

Question 19

RF for HF

Answer 19

obesity 
DM 
smoking 
hypertension 
drug absuse alochol abuse

Question 20

symptoms for Left sided heart failure

Answer 20

dyspnoea 
tachycardia 
paroxysmal nocturnal dyspnoea 
fatigue 
orthopnoea 
haemoptysis - sputum forthy and pinlk

Question 21

symptoms for right side heart failure

Answer 21

peripheral sacral oedema

nocturia - fluids from legs returning into bloodstream whilst lying down

Question 22

symptoms of congestive heart failure

Answer 22

paroxysmal nocturnal dyspea 
neck-vein distension 
rales (crackes sounds of the heart) 
radiographic cardiomegaly 
acute pulmonary oedema 
gallop heart sound 
inc central venous pressure 
inc JVP
pulmonary oedema, visceral congestion or cardiomegaly 

nocturnal cough
bilateral ankle oedema
dysponea on ordianry exertion

Question 23

signs of left side heart failure

Answer 23

bi-basal crackles +/- wheeze (cardiac asthma)
pulmonary oedema
central cyanosis
pleural effusion
laterally displaced apex beat
3rd and 4th heart sounds
pulsus alternans (s a physical finding with arterial pulse waveform showing alternating strong and weak beats.)

Question 24

signs of right side heart failure

Answer 24

peripheral/sacral oedema 
ascites 
hepatomegaly 
raised JVP
parasternal heaves - inc RV pressure 
bilateral or RHS pleural effusion

Question 25

differential for heart failure

Answer 25

pneumonia - sputum, consolidation on CXR

Question 26

investigation for heart failure

Answer 26

suspected –> ECG, CXR, BNP –> abnor - echo –> additional diagnostic tests where appropriate

blood tests - FBC, LFT, U+E, cardiac enzyme in acute HF, BNP (Brain Natriuretic Peptide)or N-terminal portion of proBNF

CXR - ABCDE

• alveolar oedema (BAt’s wing)
• interstitial oedema (Kerley B lines)
• cardiomegaly
• upper lobe diversion ( blood vessels of upper lobe as prominent as lower lobe)
• pleural effusion

ECG

Echo 
- cardiac chamber dimension 
systolic and diastolic function 
regional wall motion abnor 
valvular heart disease 
cardiomyopathies

Question 27

management for heart failure

Answer 27

RF reduction –>
ACEi or ARB, beta blocker in selected pts –>
ACEi and beta blocker in all pts +/- dietary sodium restriction, diuretics and digoxin +/- cardiac

resynchronisation if BBB present +/- revasculation, mitral valve surgery +/- consider mDT +/- aldosterone anatgonist –>
inotropes +/- VAD, transplat –>
hospice

Question 28

treatment for heart failure

Answer 28

Diuretics
• Loop diuretics e.g. furosemide, bumetanide, bendroflumethiazide
• Help prevent fluid overload providing symptomatic relief for dyspnoea and improve exercise tolerance
• Potassium-sparing diuretics if predisposition to arrhythmias or pre-existing K+ losing conditions
ACE-I
• Consider in all with LV systolic dysfunction
• Improves symptoms and prolongs life
• Consider ARBs if cough is a problem
Β-blockers
• Decrease mortality
• Additional effects to ACE-i
Spironolactone
• Use in those still symptomatic despite optimal therapy
• Reduces mortality by 30% when in conjunction with the above
Digoxin
• Helps those even in sinus rhythm
• Should be considered when LV systolic dysfunction with signs or symptoms despite above therapy
• Or in those with AF as well
Vasodilators and nitrates
• Use in patients intolerant of ACE-I and ARBs
• Reduces mortality when added to standard therapy in black patients

Question 29

what are the causes of congestive heart failure

Answer 29

LVHF and RVHF combination and hence their causes

also

• severe anaemia - not enough RBC to carry O2
• excessive alcohol consumption - (beri-beri B1 thiamine deficiency)