Cadiac TCD Notes Flashcards
1
Q
Which murmurs are present in systole
A
‘Flow murmurs’
- Aortic/ pulmonary stenosis
- mitral/tricuspid regurgitation
- Ventricular septal defect
- Aortic outflow tract obstruction
2
Q
Which murmurs occur in diastole
A
- Aortic/ pulmonary regurgitation
- Mitral/ Tricuspid Stenosis
3
Q
Which murmurs are continuous
A
Patent ductus arteriosis (only happens in children)
4
Q
What are the gradings of murmurs
A
Grade one: barely audible
Grade two: soft, but easily heard
Grade three: loud
Grade four: associated with a thrill
5
Q
What are the here basic shapes of murmurs?
A
Crescendo-decrescendo
Decrescendo (often in diastole)
Uniform
6
Q
When does Aortic regurgitation happens?
A
Diastole
7
Q
When does mitral regurgitation happen?
A
Holosytolic
8
Q
When does mitral stenosis happen?
A
Holodiastolic
9
Q
Three most common causes of diabetes
A
Ischaemic
Hypertension
Diabetes (diabetic cardiomyopathy or vis CAD)
10
Q
Name for when breathlessness causes a patient to wake up suddenly in the middle of the night
A
Paroxysmal nocturnal dyspnoea
11
Q
Scale to use to describe heart failure gradings
A
New York Heart Association
Four classes
No symptoms and no limitation in normal activity all the way to severe symptoms at rest
12
Q
Signs of heart failure
A
Pulmonary oedema or pleural effusion Raised JVP Pitting oedema Ascites Tachycardia S3 gallop
13
Q
What sort of diagnosis is heart failure?
A
A clinical diagnosis
- symptoms
- signs
- Objective evidence of structural or functional cardiac abnormalities at rest
ECHO ALONE DOES NOT DIAGNOSE HEART FAILURE
14
Q
Is heart failure a diagnosis or a syndrome?
A
Syndrome not a diagnosis. It is always se on dart or the cause of something
15
Q
Investigations for heart failure
A
Bloods - anaemia and b12 can be a cause U+E TFT as hyper and hypo can be a cause Glucose for diabetes
BNP
- normal levels rule out heart failure
- provides prognostic information
- RAISED IS NOT SPESIFIC
CXR for pulmonary effusions and oedema
16
Q
Uses of Echocardiogram in HF
A
Provides info on ejection fraction - normal is 60%
Helps look at ateology
Valves
Chamber size - dialated atrium
17
Q
HF with preserved LV function
A
EF >45%
18
Q
HF with LV systolic dysfunction
A
EF <45%
19
Q
AF ECG
A
No P waves
Irregularly irregular
20
Q
What does LVH on ECG suggest?
A
Hypertension, aortic stenosis, HOCM
21
Q
Treatment of heart failure with impaired systolic function?
A
Diuretics ACE inhibitors B-Blockers Aldosterone receptor antagonists Devices: CRT/ ICD
22
Q
Treatment of heart failure with preserved LV function
A
Diuretics
Treatment of co-morbidities
23
Q
Three ways that ACE-I help HF
A
Inhibit LVH and remodelling
Inhibit vasoconstriction
Decrease water and salt retention
24
Q
Which BBlockers is not licensed for heart failure?
A
Atenolol
25
What does ICD stand for?
Implantable cardia defibrillators, which treats sudden cardiac death
26
Why are LFTs important when investigating heart failure?
Pulmonary congestion can cause associated liver congestion
27
What is atrial myxoma?
A tumour in the atrium
28
What do you hear in mitral stenosis?
Mid diastolic rumbling murmur
Loudest at apex with bell of stethoscope
Loudest with patient rolled onto left
29
Long rumbling murmur in kids
Patient foramen ovale
30
What type of calcium channels are in the heart?
L type calcium channels
31
What is early after depolarisation or EAD?
Abnormal depolarisation and following action potentials after normal repolarisation has happened
Causes long QT syndrome
32
What are the signs of infective endocarditis?
- Petechiae
- Splinter haemorrhages
- Oslr nodes
- Janeway lesions
- Roth spots
33
How do you diagnose infective endocarditis?
Duke Criteria
| Two major or one major plus three minor or five minor
34
When is BCNEI most likely?
After antibiotics
35
Chain of clinical investigations following symptoms of AF?
Feel pulse, if irregular:
Do an ECG, if AF:
do TTecho or TOecho
36
What is the clinical scoring system for stroke risk?
CHA2DS2-VASC
37
What is the clinical scoring system for bleeding risk?
HAS-BLED
38
When do you not give anti stroke medication in AF?
If under 65 and no risk factors of CHA2DS2-VASC
39
What do you do if AF and CHA2DS2-VASC great than or equal to 2?
Give anti coagulation medication e.g apixaban, dabigatran, wafrin, rivaroxiban
40
If high stroke risk and AF but anti coagulation isn't possible what should you do?
Consider left atrial appendage
41
What do you give for suitable patients in New or reversable AF with no HF?
Give rate control drugs. Beta blockers or calcium channel blockers
42
If paroxysmal or persistant AF and risk factors for stroke what do you give?
Dronedarone
43
What value of BNP rules out heart failure?
less than 100ng/L
44
What should you do next if you suspect heart failure in a patient with BNP over 100ng/L?
Perform TTecho for cardiac abnormalities
45
Flow chart for acute HF
once diagnosed by TTecho give diuretics if acute
Once stable give beta blockers unless second or third degree heart blocker or cardiogenic shock
Restart or start BB in LVD once IV diuretics no longer needed.
46
What do you give in HF if reduced LV ejection fraction?
ACE-I and aldostrone antagonist
47
What should you monitor after enitial treatment of acute HF?
HR, BP, U+E, renal function
48
What is the new clinical measure for heart failure?
NT-proBMP
49
If proBMP over 2000?
urgent referral for TTecho
50
If proBMP less than 400
Dx HF unlikely
51
What can cause low levels of proBMP?
Obesity, african, afro-carrib, diuretics, ACE-I, BBlockers, ARBs, MRAs
52
What can cause a high level of BMP?
old age, LVH, tachycardia, hypoxemia, renal dysfunction (eGFR less than 60), COPD and sepsis
53
What medication should you avoid in HF with reduced EF?
verapamil, diltazem
54
What medication is contraindicated in liver failure?
amiodarone
55
What do you have to do in AF before cardioversion to rule out clots?
TTecho
56
what do you give for AF with HF?
Digoxin
57
When can't you give DOACs?
renal insufficiency
58
How long do you give anti coagulation for after AF cardiovascular
four weeks
59
If there is a thrombus in AF how long do you give hep/warf before cardioversion?
FOur weeks
60
What type of diuretic is strongest?
Loop diuretics
61
If HF with LVEF less than 35% with no left bundle branch block
Give ICD
62
If HF with LVEF less than 30% with LBBBlock what do you do?
cardiac resynch thrapy or CRT
63
How to diagnose ST elevation in 12 lead ECG
>/= 1mm ST elevation in leads II and III
64
Ejection systolic murmur heard loudest in the aortic area radiating to the carotids. Answer:
Aortic stenosis
65
Mid-diastolic rumbling murmur, heard best with the bell of the stethoscope at the apex with the patient in the left lateral position. Answer:
Mitral stenosis
66
Pansystolic murmur heard loudest at the apex of the heart radiating to axilla. Answer:
Mitral regurgitation
67
Early diastolic murmur heard best at the left 4th intercostal space with the patient sat forward in expiration. Answer
Aortic regurgitation
68
Secondary prevention of ACS
```
aspirin
a second antiplatelet if appropriate (e.g. clopidogrel)
a beta-blocker
an ACE inhibitor
a statin
```
69
Once MONA has been used for ACS, if a ECG shows NSTEMI what should you give patients STAT?
LMWH
70
Differential for hypotension, arrhythmias or pulmonary oedema?
silent MI - common in diabetes and elderly
71
ECG leads in inferior infarcts
Leads II, III and AVF.
72
ECG leads in lateral infarct
AVL and V5-V6
73
ECG leads in anterior infarcts
V2-V4
74
ECG changes posterior infarct
all R waves, ST depression in V1 and V2
75
Investigations for MI
```
ECG
Troponins
CXR
FBC
Serum urea and electrolytes
Lipids - 12 hours from onset window
Glucose
```
76
Time window for MI thrombolysis
12 hours from onset
77
What drugs should patients be on post MI
```
Asperin
Second antiplatelet
ACE-I
B blockers
Statins
Aldosterone antagonist if heart failure with reduced ejection fraction
```
78
If post MI with heart failure with reduced ejection fraction, what additional drug can be given?
Aldosterone antagonist e.g eplerenone 25mg/day
79
Type of MI associated with post bradycardia?
Acute inferior wall MI
80
Treatment for ventricular tachycardia?
I.V amiodarone if vagal vagal fail
81
Anti hypertensives you can use in pregnancy
Methyl dopa
Labetalol
Nifedepine
82
Side effects of calcium channel blockers
Flushing
Ankle swelling
Headache
83
Side effects of ACE I
cough
| hyperkalaemia
84
Side effects of Thiazide type diuretics
Hyponatraemia
Hypokalaemia
Dehydration
(thiazide leads to hypos)
85
Side effects of A2RB
Hyperkalaemia
86
Stage one hypertension
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
87
Stage two hypertension
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
88
Severe hypertension
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
89
If there is a difference in BP in both arms, which one should be used?
Higher BP arm
90
If there are higher and lower readings for BP from both arms, which reading should you use?
Lowest
91
Signs of phaeochromocytoma in hypertension
labile or postural hypotension, headache, palpitations, pallor and diaphoresis
92
When to medically treat stage two hypertension
; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater
93
Age of patient for consideration of secondary cause of hypertension
Less than 40 years
94
Which thiazide diuretics to use in hypertension
chlorthalidone or indapamide
95
define treatment resistant hypertension
Higher than 140/90 after three drugs, add forth drug and consider referral
96
Step four hypertension treatment if potassium < 4.5 mmol/l
spironolactone
97
step four hypertension treatment if potassium >4.5
add higher-dose thiazide-like diuretic treatment
98
BP targets in hypertension
Age < 80 years 140/90 mmHg 135/85 mmHg
| Age > 80 years 150/90 mmHg 145/85 mmHg
99
Define pre-eclampsia
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
100
Most common reason for hypertension in children
Renal paranchymal disease (80%)
101
Most common cause of secondary hypertension
Primary hyperaldosteronism
102
NICE recommend the following blood pressure targets for diabetics:
if end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
otherwise < 140/80 mmHg
103
Idiopathic intracranial hypertension management
Weight loss, diuretics e.g. acetazolamide and topiramate
104
Which type of calcium channel blockers are safest to use in heart block and heart failure?
Nifedipine, amlodipine, felodipine as they are dihydropyridines
105
Which calcium channel blocker can't be used with beta blockers due to causing heart block and heart failure?
Verapamil
106
What blood pressure medication can cause gout
thiazide diuretics
107
Three drugs that cause hypertension
combined oral contraceptive pill
corticosteroids
ciclosporin
108
Pulmonary hypertension and the JVP
a large A wave in the JVP
109
Causes of raised ICP by drugs
lithium
corticosteroids
isotretinoin
