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Year 3 > Cardio 1 MM > Flashcards

Cardio 1 MM Flashcards

Heart Failure, Infective Endocarditis, Valvular defects, Pericarditis, Myocarditis, Dyslipidaemia

1
Q

What are the 4 types of heart failure?

A
  • Acute vs Chronic
  • Left vs Right
  • High output state vs Low output state
  • Reduced vs Preserved Ejection Fraction
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2
Q

What counts as chronic heart failure?

A

On treatment and unchanged symptoms for at least 1 month

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3
Q

What is high output HF?

A

can’t pump enough blood under higher metabolic demands (NAP MEALS)

  • Nutritional (B1 thiamine deficiency)
  • Anaemia
  • Pregnancy
  • Malignancy
  • Endocrine
  • AV malformations
  • Liver cirrhosis
  • Sepsis
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4
Q

What are risk factors for heart failure?

A
  • DM
  • Dyslipidaemia
  • CAD, MI, Afib, hypertension
  • FHx of HF or sudden cardiac death <40 year olds
  • Cocaine, Alcohol
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5
Q

What can causes of left heart failure be?

A

Valvular: Aortic Stenosis, Aortic Regurgitation, Mitral Regurgitation
Muscular: IHD, Cardiomyopathy, Arrhythmias, Pericarditis
Systemic: Hypertension, Amyloidosis, Drugs, Obesity

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6
Q

What are symptoms of left heart failure?

A

Dyspnoea
o Paroxysmal Nocturnal Dyspnoea
o Orthopnea
o Nocturnal cough
o Pink, frothy sputum

Fatigue, light headedness or history of syncope

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7
Q

What are signs of left heart failure?

A
  • High HR and RR
  • Irregularly irregular heartbeat
  • Displaced apex beat
  • S3 gallop rhythm – can be normal in atheletes
  • S4 (severe heart failure)
  • Murmur (AS, MR, AR)
  • Fine end inspiratory crackles at lung bases (pulmonary oedema)
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8
Q

What can causes of right heart failure be?

A

Lungs: Pulmonary hypertension, PE, Chronic lung disease (ILD, Cystic fibrosis)
Valvular: Tricuspid regurgitation, Pulmonary valve disease

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9
Q

What are symptoms of right heart failure?

A
  • Fatigue
  • Reduced exercise tolerance
  • Anorexia
  • Nausea
  • Nocturia (Fluid retention)
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10
Q

What are signs of right sided heart failure?

A
  • Face swelling
  • Raised JVP
  • TR murmur
  • Ascites, hepatomegaly
  • Peripheral pitting oedema (Sacral + Ankle)
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11
Q

What investigations would you do for heart failure?

A
  1. 12 lead ECG –> Left/Right ventricular hypertrophy
  2. Bloods: NT-proBNP, BNP –> NT-proBNP >300 is probably HF, BNP has a shorter half life.
  3. Imaging: CXR, Transthoracic echocardiogram (to calculate ejection fraction)
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12
Q

What kind of test is BNP?

A

Highly sensitive but not specific

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13
Q

What are the 2 types of heart failure with regards to EF?

A

Reduced ejection fraction: HFrEF is due to systolic dysfunction where heart isn’t pumping enough blood out (<40%)

Preserved ejection fraction: HFpEF is due to diastolic dysfunction where the heart doesn’t fill up properly (>50%)

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14
Q

What can cause systolic dysfunction?

A

Ischaemic heart disease, Dilated cardiomyopathy, Myocarditis, Arrhythmias

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15
Q

What can cause diastolic dysfunction?

A

Hypertrophic obstructive cardiomyopathy, Restrictive cardiomyopathy, Cardiac tamponade and Constrictive pericarditis

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16
Q

What would a CXR show in heart failure?

A
  • Alveolar oedema (fluffiness)
  • Kerley B lines (straight lines on the sides)
  • Cardiomegaly (PA CXR)
  • Dilated upper lobe vessels (cephalization?)
  • Effusions
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17
Q

What criteria is used to diagnose heart failure?

A

Framingham’s Criteria: 2 majors or 1 major + 2 minor

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18
Q

How is chronic heart failure treated?

A

Lifestyle modifications
o ACE inhibitor/ ARB
o Beta blocker
o Diuretic –> Loop diuretic/spironolactone
o Hydralazine + nitrates for Afro-Carribean patients
o Digoxin –> +ve inotrope improves symptoms but not mortality

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19
Q

How is acute heart failure treated?

A
  • Sit patient upright
  • IV loop diuretics: Start with bumetanide (if already on this for chronic, go straight to furo)  Furosemide
  • Oxygen if required
  • Morphine for pain
  • GTN for angina (also reduces systemic pressure)
  • No beta blockers (will slow down heart and potentially cause death)
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20
Q

What are the causes of aortic stenosis?

A
  1. Calcification with age - most common in developed countries
  2. Congenital bicuspid valve predisposing person to development of AS and AR
  3. Rheumatic heart disease
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21
Q

What are clinical features of an aortic stenotic murmur?

A

Ejection systolic murmur heard loudest over the aortic area
Radiates to the carotid arteries
Loudest on expiration and when the patient is sitting forwards

Slow rising pulse with narrow pulse pressure
Non-displaced, heaving apex beat (if present indicates left ventricular hypertrophy)
Reduced or absent S2 (a sign of moderate-severe aortic stenosis)
Reverse splitting of S2: aortic valve closes after pulmonary valve (due to the longer time required for blood to exit the left ventricle)

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22
Q

What is mitral regurgitation caused by?

A

Infective endocarditis
Acute myocardial infarction with rupture of papillary muscles
Rheumatic heart disease
Congenital defects of the mitral valve
Cardiomyopathy

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23
Q

What are clinical features of mitral regurgitation?

A

A pansystolic murmur heard loudest over the mitral area
Radiation of the murmur to the axilla
Loudest on expiration in the left lateral decubitus position

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24
Q

What are causes of aortic regurgitation?

A

Chronic AR can be asymptomatic and unremarkable - can be caused by an actual valvular defect or aortic root dilatation.

Valvular defects:
Congenital bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis

Causes of aortic root dilatation:
Aortic dissection: can result in acute aortic regurgitation
Connective tissue diseases (e.g. Marfan’s syndrome)
Aortitis

25
Q

What are typical clinical features of aortic regurgitation?

A

Decrescendo early diastolic murmur
Heard loudest at the left sternal edge (the direction that the turbulent blood flows) sometimes heard loudest over the aortic area
Austin Flint murmur: a low pitched rumbling mid-diastolic murmur heard best at the apex.

26
Q

What other signs are associated with aortic regurgitation?

A

Corrigan’s sign: visible distention and collapse of carotid arteries in the neck

De Musset’s sign: head bobbing with each heartbeat

Quincke’s sign: pulsations are seen in the nail bed with each heartbeat when the nail bed is lightly compressed

Traube’s sign: ‘pistol shot’ sound heard when stethoscope placed over the femoral artery during systole and diastole

Muller’s sign: uvula pulsations are seen with each heartbeat

27
Q

What are causes of mitral stenosis?

A

Rheumatic heart disease is the most common cause of mitral stenosis.

Other rarer causes include:
Congenital
Left atrial myxoma
Connective tissue disorders
Mucopolysaccharidosis

28
Q

What are clinical signs of mitral stenosis?

A

Low-pitched, rumbling mid-diastolic murmur with an opening click (click heard in mid-diastole when the mitral valve opens)
Murmur is heard loudest over the apex
Loudest in left lateral decubitus position on expiration
Malar flush

29
Q

What causes tricuspid regurgitation?

A

Right ventricular dilatation (e.g. secondary to pulmonary stenosis or pulmonary hypertension)
Rheumatic fever
Infective endocarditis (intravenous drug users are at high risk of endocarditis affecting the tricuspid valve)
Carcinoid syndrome
Congenital (e.g. atrial septal defect, Ebstein anomaly)

30
Q

What is Ebstein anomaly?

A

The Ebstein anomaly (i.e. congenital isolated tricuspid regurgitation) is an abnormal attachment of tricuspid valve leaflets which causes the tricuspid valve to displace downwards into the right ventricle

31
Q

What are features of a tricuspid regurgitation murmur?

A

Pansystolic murmur
Heard loudest over the tricuspid region
Loudest during inspiration

32
Q

What are less pronounced signs of tricuspid regurgitation murmur?

A

Visible/palpable hepatic pulsations
Signs of right-sided heart failure: right ventricular heave, peripheral oedema, hepatomegaly, ascites

33
Q

What are causes of pulmonary stenosis?

A

Congenital: Turner’s, Noonan’s and Williams syndromes. Tetralogy of Fallot (pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect and an overriding aorta).
Rheumatic fever
Carcinoid syndrome

34
Q

What are clinical features of a pulmonary stenosis murmur?

A

Ejection systolic murmur heard loudest over pulmonary area
Loudest during inspiration
Radiates to left shoulder/left infraclavicular region
In severe pulmonary stenosis, the murmur is longer and may obscure the sound of A2

35
Q

What can cause pulmonary regurgitation?

A

Pulmonary hypertension
Infective endocarditis
Congenital valvular heart disease

36
Q

What can cause tricuspid stenosis?

A

Rheumatic fever (most common)
Congenital disease
Infective endocarditis

37
Q

What are clinical features of a tricuspid stenosis murmur?

A

Mid-diastolic murmur (rarely audible)
Loudest at 3rd – 4th intercostal space at the left sternal edge
Loudest during inspiration

38
Q

What investigations and treatments are offered for valvular defects?

A

Investigations: ECG, CXR, Bloods, TTE (to visualise valves for dysfunction)
Treatment:
Valve replacement –> open heart surgery/catheter
Warfarin for life if metalic valves

39
Q

What are outcomes of measuring BP in clinic?

A

If BP > 140/90: Offer ambulatory BP monitoring for 24 hours (ABPM) as can be white coat hypertension

If BP > 180/120: Assess for retinal haemorrhages, confusion, chest pain, signs of HF/AKI (Look for end organ damage)

40
Q

What is classified as stage one hypertension and who is treated for it?

A

Stage 1 Hypertension: >= 135/85

Treat if <80 AND have any of following:
o Target organ damage
o Established CVD
o Renal disease
o Diabetes
o 10 year CV risk >=10%

41
Q

What counts as stage 2 hypertension?

A

> =150/95 - Treat all patients

42
Q

What is the treatment algorithm for someone below 55 or with T2DM?

A
  1. Start on ACE-i/ARB
  2. Then, A+C (calcium channel blocker) or A+D (thiazide like diuretic)
  3. A+C+D
  4. If K+ less than or equal to 4.5mmol/L: Add low dose spironolactone
    If K+ over 4.5mmol/L: Add alpha/beta blocker

If BP not controlled on 4 drugs, specialist review

43
Q

What is the treatment algorithm for someone over 55 with/without T2DM or if they are Black?

A
  1. Start on calcium channel blocker
  2. Then, A (ACE-i/ARB) +C (calcium channel blocker) or A+D (thiazide like diuretic)
  3. A+C+D
  4. If K+ less than or equal to 4.5mmol/L: Add low dose spironolactone
    If K+ over 4.5mmol/L: Add alpha/beta blocker

If BP not controlled on 4 drugs, specialist review

44
Q

What are risk factors for infective endocarditis?

A

Prosthetic valve, post heart transplant, congenital heart disease, IV drug use

45
Q

What organisms cause infective endocarditis?

A

o Staph aureus: Most common + IVDU
o Strep viridans: Dental
o Staph epidermis: Valve surgery <2 months ago
o Strep bovis: Colorectal cancer

46
Q

What are signs of infective endocarditis?

A

o Pyrexia, tachycardia
o New murmur: Mitral > Aortic > Tricuspid > Pulmonary
o Janeway lesions: Painless flat spots
o Osler’s nodes: Painful
o Splinter haemorrhages
o Clubbing
o Poor dentition
o Tricuspid most affected valve in IVDU

47
Q

What would investigations indicate and which ones should be done if infective endocarditis suspected?

A

FBC: Normocytic anaemia, high WCC, high CRP
3 blood cultures 1 hr apart within 24 hours before antibiotic

Transoesophageal echocardiogram: more accurate to pick up on infection plaques around valves

48
Q

How is infective endocarditis diagnosed?

A

Duke’s Criteria [2 major/1 major + 3 minor/5 minor]

Major Criteria:
- Positive blood cultures
- Evidence of endocardial involvement (New murmur/Seen on echo)

Minor Criteria:
- Predisposing heart conditions or IVDU
- Microbiological evidence
- Fever >38
- Vascular phenomena
- Immunological phenomena

49
Q

How is infective endocarditis managed?

A

Empirical antibiotics after blood samples taken unless haemodynamically unstable
Supportive treatment
Targeted antibiotics after culturing
Consider surgery to remove infected tissue

50
Q

What are causes of pericarditis?

A

Inflammation: post Mi, SLE, trauma
Infection: viral, TB, uraemia
Malignancy: malignancy, radiotherapy, anti-cancer drugs

51
Q

What are the forms of pericarditis?

A

Acute pericarditis: new onset inflammation lasting <4-6 weeks
Constrictive pericarditis: impedes normal diastolic filling – late and rare complication of acute pericarditis.

52
Q

What are signs and symptoms of pericarditis?

A

Retrosternal sharp stabbing ache, pleuritic acute onset
Relieved by sitting forwards
Pericardial rub: fresh snow crunching noise heard best over left border of sternum with patient leaning forward at end expiration
If large pericardial effusion then may not hear
Fever, myalgia

53
Q

What investigations would be done for pericarditis?

A

ECG: Wide spread saddle shaped ST elevation [V2-V6 PR depression]
Bloods:
o Troponin to rule out MI
o CRP
o FBC: WCC if infective
o U&E: uraemia
o CXR to eliminate other differentials
Echo

54
Q

How is pericarditis treated?

A

If viral/idiopathic: NSAID + PPI + Colchicine + reduce exercise
If purulent: add antibiotics + pericardiocentesis
If recurrent: consider pericardiectomy (remove part of pericardium)

55
Q

What can cause myocarditis?

A

Infectious: Coxsackie B is most common in EU
Drugs – cocaine
Metals
Radiation

56
Q

What are signs and symptoms of myocarditis?

A

Flu-like prodrome
Chest pain worse on lying down
SOB
Palpitations

57
Q

What investigations are done for myocarditis and what would they show?

A

ECG –> Non specific ST elevation + T wave inversion
Creatine kinase + troponin raised
Endomyocardial biopsy –> Diagnostically good but invasive so not normally performed

58
Q

What is the QRISK score and what is it used to identify?

A

QRISK score: Takens into account following factors to calculate risk of developing CVD in next 10 years + used for primary prevention

59
Q

What does the QRISK score take into account?

A
  • Age, Sex, Ethnicity
  • Smoking, DM, Angina, MI <60, CKD 3/4/5, AF, HNT
  • Cholesterol/HDL ratio
  • BMI

Year 3 (18 decks)

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