Cardiac station Flashcards
Cardiac causes of clubbing
Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma
causes of AF
Sepsis, mitral valve stenosis, ischaemic heart disease, thyrotoxicosis, hypertension
Treatment of AF haemodynamically unstable
urgent DC cardioversion
stable AF treatment
rate = if onset >48 hours or uncertain
= b-blockers, rate limiting CCB e.g. diltiazem or digoxin
Rhythm = if reversible cause, <48 hours, heart failure caused by AF
= flecainide, sotalol, amiodarone, AF ablation
CHA2DS2VASC
Congestive HF
hypertension
age >65
diabetes
stroke
vascular disease (MI, PAD, atherosclerosis)
age >75
sex
CHF investigations
Bloods, ECG, CXR
Measure NT-proBNP
<400 = HF unlikely
400-2000 = referral for echo + specialist review 6w
>2000 = referral + review 2w
CHF treatment
1st line = B-Blocker bisoprolol + ACEi ramipril or ARB losartan, furosemide for symptomatic relief from volume overload
2nd line – still symptomatic = mineralcorticoid antagonist = spironolactone
3rd line = specialist = ivabradine, entresto
CHF signs/symptoms
Sob, reduced ET, orthopnoea, peripheral oedema, raised JVP, crackles lung bases
RVF signs
raised JVP, hepatomegaly, pedal oedema, sacral oedema, ascites
LVF signs
pulmonary oedema, tachypnoea, tachycardia
CHF presentation
“Today I examined this gentleman’s cardiovascular system. He had tar staining on his fingers and appeared short of breath. His respiratory rate was 16, and heart rate was 120. He had an irregularly irregular pulse and his JVP was raised at 5cm above the sternal angle. The apex beat was displaced in the 6th intercostal space, anterior axillary line, Heart sounds were normal and there were no added sounds. There were bi-basal fine end inspiratory crackles and peripheral oedema present to the mid thigh” These signs are consistent with congestive cardiac failure secondary to ischaemic heart disease. I would like to take a full history to assess symptoms, and order a CXR”
acute and chronic causes of RVF
Acute = MI, PE, infective endocarditis,
chronic = left ventricular failure, cor pulmonale
Acute and chronic causes of LVF
Acute = MI, Infective endocarditis.
Chronic = ischaemic cardiomyopathy, hypertensive cardiomyopathy, valvular disease
STEMI treatment
1st = primary PCI (<12 hours from onset + <120 mins for PCI)
2nd = fibrinolysis (<12 hours, >120 mins for PCI) = alteplase
Initial management of ACS
Analgesia
Antiemetics
Aspirin 300mg
Oxygen if <94%
GTN infusion if pain, HTN or oedema
NSTEMI
Positive troponin no ECG changes
NSTEMI treatment
aspirin 300mg + fondaparinux
PCI if GRACE score >3% (within 72 hours)
Unstable angina treatment
aspirin 300mg + fondaparinux
reversible MI causes
Hypoxia
hypovolaemia
hypothermia
hypokaelamia or hyperkalamia
hypoglycaemia
Tamponade
tension pneumo
thrombosis
toxins
Broad complex arrythmias
VT
Torsades de Pointes = iV magnesium sulphate
Narrow complex arrythmias
SVT, sinus tachy, AF
Aortic stenosis signs
Slow rising pulse, narrow pulse pressure, Ejection Systolic Murmur, loudest on expiration, radiates to carotids DDx = aortic stenosis, HOCM, mitral regurg Causes = age related = calcification, RHD
AS symptoms (ASH)
angina, syncope, heart failure
AS investigations
ECG, CXR, echo + doppler, coronary angio
AS management
general = MDT, RF modification, QRISK, statin, antiplatelet, HTN, angina
Surgical = open replacement (ball in cage = 3 sounds) (bileaflet = 1 sound)
AS surgery and indications for surgery
TAVI or balloon valvuloplasty
Indications for surgery = symptomatic, CCF, pressure gradient <40%
MR signs
Displaced apex, S1 quiet, pansystolic murmur, radiates to axilla, valvotomy scar, atrial fibrillation also present
severe if displaced/thrusting apex, LVF
MR other DDx
aortic stenosis, VSD
MR management
conservative= MDT, RF mod
Medical = AF = rate/rhythm Reduce afterload = ACEi, B-blocker, diuretics
surgery= repair or replace valve
MR causes
RHD, IE, IHD, Papillary muscle rupture
MR presentation
“Today I examined this gentleman’s cardiovascular system. On general inspection he looked alert and comfortable in bed. He had a normal pulse, and his apex beat was non-displaced. Heart sounds I + II were heard and he had a pansystolic murmur, intensity 3/6, loudest at the apex, which radiated to the axilla. There were bibasal fine end inspiratory crackles and peripheral oedema present to the mid thigh. These are consistent with mitral regurgitation with congestive cardiac failure. I would like to take a history to assess for impact on the patient’s life and request a CXR”
AR signs
Collapsing pulse, head nodding with pulse = De Musset’s sign, Corrigan’s = neck pulses, ejection diastolic murmur at LSE, loudest on expiration
AR DDx
Mitral stenosis
AR management
conservative= MDT, RF mod,
Medical = ACEi + B-blocker, + diuretics,
Surgery = valve replacement
AR causes
IE, rheumatic heart disease, aortic dissection
MS signs
Mid diastolic murmur, Atrial fibrillation
MS differentials
Aortic regurg
MS causes
IE, RHD
MS management
conservative= MDT, RF mod.
Medical = RHD prophylaxis, AF = rate control + DOAC,
Surgery = balloon valvuloplasty
Valve presentation
“I examined this Gentleman’s cardiovascular system. He had a midline sternotomy scar and there was warfarin at the bedside. He had irregularly irregular pulse. There was a metallic click with the first heart sound and the second heart sound was normal. There were no additional sounds and no features of cardiac failure. These signs are consistent with atrial fibrillation and a metallic mitral valve replacement that is functioning well.”
Post CABG signs
tar staining, midline sternotomy scar, scar over left saphenous vein
Post CABG presentation
“Today I examined this gentlemen’s cardiovascular system. He had tar staining on his fingers, a midline sternotomy scar and a scar over his left saphenous vein. Heart sounds were normal with no additional sounds, and there were no features of cardiac failure. These signs are consistent with previous coronary artery bypass graft using the left great saphenous vein”
Vessel used in CABG
Great saphenous = scar on calf
Internal thoracic artery / internal mammary artery = more common
post-CABG management
DAPT = aspirin and clopidogrel for 12 months then aspirin life long
Beta blocker = bisoprolol
ACEi = ramipril or ARB = Losartan
IE
Staph aureus, strep viridians, mitral valve most common, IVDU = tricuspid, fever, murmur, clubbing, petechiae, splenomegaly, haematuria, roth’s spots, Janeway lesions, osler’s nodes
Treatment = amoxicillin and gentamicin
normal cardiac exam presentation
Today I performed a cardiovascular examination of X year old Y.
On general inspection the patient was comfortable at rest, did not seem breathless or in pain and did not have monitoring attached.
On closer inspection of the hands and arms, the patient did not exhibit any stigmata of cardiovascular disease such as splinter haemorrhages or Osler’ nodes.
Extremities were warm with normal capillary refill.
Pulse was regular at Z bpm, and there was no radio-radial delay or collapsing pulse.
On closer inspection of face and chest, no anaemia or scars were identified.
JVP was non raised, and carotid pulse had normal volume and character.
No heaves of thrills were identified and apex beat was non displaced at the mid clavicular line.
On auscultation of the heart, hearts sound I and II were audible with no additional sounds.
Lung bases were clear and there was not sacral or peripheral pitting oedema.
In conclusion this was a normal cardiovascular examination. To complete my examination, I would like to take full history and perform a respiratory examination.
I would like to take a full set of observations, including lying and standing BP, take an ECG reading as well as capillary glucose and take bloods, including FBC, U&Es and LFTs for baseline, and cardiac markers if indicated.
ECG presentation
This is a 12 lead ECG of X year old Y.
It was taken a Z hrs on the date. The quality is adequate, and the calibre is 25mm/s.
The rate is W bpm and regular and there is no/R/L axis deviation.
Every p wave is followed by a QRS complex; thus, this is sinus rhythm.
PR interval is normal, 0.12-0.2 ms, not slurred.
The Q wave is normal (non-pathological).
The QRS complex is narrow (0.8-0.12 ms) and not prolonged. The R waves are equal in size, and there is progression in the chest leads.
The ST interval is normal/elevated/depressed/saddle elevation.
The QT interval is normal/prolonged, the T waves is normal/tall and tented/inverted/biphasic…
In conclusion this is a normal/abnormal ECG…
My main differential is…
What are advantages and disadvantages of tissue heart valves?
- Advantages: No need for warfarin anticoagulation, thus safer in women of child-bearing
age and in the elderly. - Disadvantages: Reduced lifespan of prosthesis compared to mechanical valves, due to
degeneration and calcification.
