cardio Flashcards
A 35-year-old lady presents to cardiology for investigation of a pansystolic murmur. She has hypermobility of large and small joints bilaterally and marked striae on her abdomen and chest.
What is the most likely cause of this murmur?
mitral regurgitation
Widespread joint hypermobility along with skin changes indicated by striae should make you think of a collagen disorder - these findings are commonly present in Ehlers-Danlos syndrome.
Mitral valve prolapse and mitral regurgitation are associated with Marfan’s and Ehlers-Danlos syndromes. Mitral regurgitation would produce a pansystolic murmur as described in the stem.
In what scenario would you expect a MI to present without chest pain?
If the patient is elderly or diabetic
You suspect pulmonary hypertension, what feature would support your Dx on auscultation of the chest?
loud second heart sound
A 59-year-old man attends a cardiology outpatient clinic 4 weeks after sustaining a myocardial infarction (MI). He reports feeling a little more tired than previously and has felt his heart racing occasionally. He denies any cough, fever, or chest pain. He has a past medical history of hypertension and hypercholesterolaemia.
On examination, he has bibasal crackles and is noted to have a third and fourth heart sound. His ECG is reported as ST elevation in the precordial leads alongside some well-formed Q waves.
What is the most likely diagnosis?
Left ventricular aneurysm
ST elevation usually returns to normal after 2 weeks and T waves become inverted - prolonged ST elevation suggests LVA.
LVA occurs due to incomplete reperfusion of LV post-MI and transmural scar formation causes impaired conduction and contractility.
What vein is usually used for a CABG?
saphenous vein - longest vein in the body
other options: internal thoracic artery (internal mammary artery), radial artery
What medical conditions increase the risk of atherosclerosis?
- diabetes
- HTN
- CKD
- inflammatory conditions (RA)
- Atypical antipsychotic meds
What are the complications of atherosclerosis?
- angina
- MI
- TIA
- Stroke
- peripheral artery disease
- chronic mesenteric ischemia
If a Px presents with erectile dysfunction - what tests should you do?
indicates arterial disease
- lipid profile
- BP
- Q-risk score (% px will have a MI or stroke in the next 10 years - if >10% should be started on atorvastatin 20mg)
What is the Mx for coronary artery disease?
conservative: improve diet, lose weight, stop smoking, decrease alcohol intake
medical: statins, aspirin, BB, ACEi
surgical: PCI or CABG
Describe PCI
- catheter in brachial or femoral artery
- feed up to coronary arteries via xray guidance and injecting contract to highlight areas of stenosis
- Areas of stenosis treated with balloon dilatation and stented
What are the stages of a CABG procedure? `
- Cardiopulmonary bypass: Takes deoxygenated blood from the VC or RA and passes it through a machine that oxygenates it and removes the CO2. Herapin is used to prevent blood clots.
- Cardioplegia: Heart needs to be still. High K solution is delivered to coronary circulation which causes it to stop. Cardioplegia is stopped following surgery. May result in arrhythmias.
- CABG: pedicled graft - proximally attached to original site but changing where it supplies or free graft - completely separated from original site and reattached to new area.
Free grafts are attached directly to the aorta with the other end attached to the coronary artery distal to the diseased part of artery to avoid the stenosis.
What is intimal hyperplasia?
Process where the tunica intima layer of the vein thickens due to the increased pressure, causing stenosis of the vessel. Arterial grafts are less affected by this so can make better grafts
How long does it take to recover from a CABG?
Discharged after approx. 1 weeks and gradually build up exercise tolerance for ~3 months
2 most serious complications of CABG procedure ?
- death
- stroke
What would a midline sternotomy scar suggest?
- aortic or mitral valve replacement
- CABG
What is the life span of bioprosthetic valve?
~10 years
What is the life span of a mechanical heart valve?
What is a con of mechanical heart valves?
> 20 years
lifelong anticoagulation of warfarin (*INR range 2.5-3.5)
What is the most favourable metallic heart valve?
St Jude valve - two tilting discs - bileaflet valve - least risk of thrombosis formation
Complications of mechanical heart valves?
- thrombosis formation - stroke
- infective endocarditis
- haemolysis - break down of RBC in valve causing anaemia
What valve would have been replaced if you heard a click in the place of S1 ?
S1 - mitral valve
S2 - aortic valve
What is a TAVI and when would you do one ?
transcatheter aortic valve implantation
done is severe aortic stenosis when px is too high risk of open heart valve replacement.
Done via a catheter - inflate balloon - insert bioprosthetic valve
What organism usually cause infective endocarditis?
Gram positive cocci
- staph Aureus
- strep viridians
- enterococcus
What are the CF of IE?
- Fever
- new murmur
- splinter haemorrhages, janeway lesions, roth spots, osler nodes, glomerular nephritis
What criteria is used to Dx IE?
modified Dukes
IE Tx?
long course of ABx dependent on organism
what is the screening process for AAA’s ?
All males have an USS at 65
How are AAA’s graded?
<3 cm - normal
3-4.4 - small, rescan in 12m
4.5-5.4 - medium, rescan in 3 m
>= 5.5cm - large, refer within 2 weeks
What features suggest an AAA is likely to rupture?
sumptomatic, diameter >5.5 or rapidly enlarging (>1cm in 1 year)
How is a high risk AAA treated?
elective endovascular repair (EVAR) - stented
What are the CF’s of peripheral arterial disease?
- intermittent claudication
- Px can walk for a predictable distance before symptoms start
- Usually relieved within minutes of stopping
- not present at rest
How would you assess someone you suspect has PAD/intermittent claudication?
- check femoral, popliteal, posterior tibialis and dorsalis pedis pulses
- check ABPIU
- DUPLEX USS - 1st line Ix
- MRA prior to any intervention
How to interpret ABPI:
1 - normal
0.6-0.9 - claudication
0.3-0.6 - rest pain
<0.3 - impending
<0.5 - severe disease
how to Mx PAD:
- Quit smoking
- control co-morbidities (HTN, DM, obesity)
- Statin (80mg atorvastatin) and clopidogrel
- Exercise training
Severe PAD/critical limb ischemia:
- endovascular revascularisation / angioplasty - typically used in short segment stenosis (<10cm)
- surgical revascularisation - typically longer segment >10cm
Last resort: amputation
Other drugs:
naftidrofuryl oxalate: vasodilator
What are the signs of acute limb-threatening ischemia?
6 P's pale pulseless painful paralysed paraesthetic 'perishing with cold'
What are the Cx of acute limb threatening ischemia?
thrombus - ruptured atherosclerotic plaque
Emboli - 2nd to AF
what factors would suggest limb ischemia is due to thrombus?
- pre-existing claudication with sudden deterioration
- no obvious source of emboli
- reduced or absent pulses in contralateral limb
- widespread vascular disease
what factors would suggest limb ischemia is due to emboli?
- sudden onset of painful leg <24hr
- no Hx claudication
- clinically obvious source (AF, recent MI)
- no evidence of PAD
- evidence of proximal aneurysm (AAA, popliteal)
How would you initially Mx limb-threatening ischemia?
ABCDE IV opioids IV unfractionated heparin vascular review Handheld arterial doppler examination
what is the definitive Mx of limb-threatening ischemia?
- Intra-arterial thrombolysis
- surgical embolectomy
- angioplasty
- bypass
- amputation
What are the CF of critical limb ischemia?
1 or more:
- rest pain in foot for >2 weeks
- ulceration
- gangrene
‘hanging leg out of bed at night to relieve pain’
ABPI <0.5
How does superficial thrombophlebitis present?
new painful swelling on leg
‘tender, inflammed ‘worm-like’ mass’
20% of time associated with underlying DVT. Inflammed vein >5cm more liekly to be associated with DVT.
How is superficial thrombophlebitis treated?
USS to exclude concurrent DVT
- Oral NSAIDS
- compression stockings (measure ABPI first to make sure there is no arterial insufficiency)
- LMWH - prophylactic for DVT
Why do varicose veins occur?
incompetent venous valves allow backflow of blood away from the heart. Most commonly in the legs due to reflux in the great saphenous vein and small saphenous vein
What are the RFs for varicose veins?
- increasing age
- female
- pregnancy
- obesity
What brings people to the GP for varicose veins?
mostly cosmetic appearance.
some get aching/throbbing and itching
What complications can arise from varicose veins?
- skin changes
- bleeding
- superficial thrombophlebitis
- venous ulceration
- DVT
Mx of varicose veins?
Conservative:
- leg elevation
- wt loss
- regular exercise
- graduated compression stockings
If significantly symptomatic or complications occur, Tx include:
- endothermal ablation
- foam sclerotherapy
- surgery
A 78-year-old gentleman presents to the emergency department with a 3 hour history of lower back pain. It is achey in nature and a 6/10 on the pain scale. On examination he has some tenderness on his abdomen and loin area. His blood pressure is 100/70 mmHg despite 500ml fluid bolus and his heart rate is 110/min. What’s the most likely diagnosis?
AAA
any elderly men presenting with back pain needs an USS to exclude AAA - especially when haemodynamically unstable
What are the major risk factors for developing an AAA?
HTN and smoking
Rare but important causes of AAA?
- syphilis
- connective tissue diseases (EDS and marfans)
A 77-year-old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration.
> 1.2
Type 2 diabetes may have vessel calcification. This will result in abnormally high ABPI readings. Pain of this nature in diabetics is usually neuropathic and if a duplex scan is normal then treatment with an agent such as duloxetine is sometimes helpful.
what is the triad of Boerhaave syndrome?
vomiting, thoracic pain, subcutaneous emphysema
typically affects middle aged men with a background of alcohol abuse
What ECG changes would you expect to see in an aortic dissection ?
ST elevation in leads II, III, and aVF
