Cardio Flashcards
Midline sternotomy scar
- CABG (saphenous vein graft scar present)
- Valvular surgery
Causes of raised JVP
Cardiac
- RHF/Cor Pulmonale
- PE
- RV Infarction
- Constrictive pericarditis
Non-cardiac
- SVCO
Infective Endocarditis signs
Fever
Hands
- Janeway lesions (painless)
- Oslers nodes (painful)
- Splinter haemorrhages
Face
- Roth spots (ophthalmoscopy)
Heart
- Murmur
- In IVDU, Tricuspid regurgitation
- Otherwise, Mitral regurgitation
Abdomen
- Splenomegaly
What is S3 + causes
Extra heart sound due to rapid ventricular filling in a compliant ventricle
Causes
- Normal/physiological in young patients <40
- High output states (thyrotoxicosis, anaemia)
- LVF
- Mitral Regurgitation
What is S4 + Causes
Extra heart sound due to vigorous atrial contraction to push blood into a non-compliant ventricle
Causes (anything that causes LVH)
- Hypertension
- Hypertrophic cardiomyopathy
- Aortic stenosis
Aortic Stenosis signs
Narrow pulse pressure Slow rising carotid pulse Heaving apex beat (LVH) Ejection systolic murmur loudest in aortic area radiating to carotids Signs of anaemia
Causes of Aortic stenosis
Age related calcification
Bicuspid aortic valve
Causes of mitral stenosis
Rheumatic heart disease (occurs around 10y after infection)
Austin-flint murmur: Increased LV load due to severe AR
Signs of mitral stenosis
Mitral facies (erythema due to cutaneous vasodilation on the face)
Mid diastolic low rumbling murmur loudest in mitral region with no radiation
Signs of HF (due to LA dilatation)
P Mitrale on ECG (left atrial hypertrophy)
Causes of aortic regurgitation
- Bicuspid aortic valve
- Rheumatic heart disease
- Aortic dissection
- Infective endocarditis
- Connective tissue diseases eg. Marfan’s
Signs of aortic regurgitation
- Quinke’s sign (nailbed pulsation)
- Collapsing pulse
- De Musset’s sign (Head bobbing)
- Corrigan’s sign (Enhanced carotid pulsation)
Early diastolic murmur loudest at LL sternal edge
What is Pulsus Paradoxus + causes
Loss of radial pulse during inspiration due to an inappropriate drop in BP. Occurs in constrictive cardiac diseases:
- Cardiac tamponade
- Constrictive pericarditis
- Restrictive cardiomyopathy
Kussmaul’s sign
Paradoxical rise in JVP associated with constrictive heart disease
Causes of tricuspid regurgitation
RVF
Valve prolapse
Infective endocarditis
Rheumatic heart disease
Risk factors for Infective endocarditis
Valvular disease
- Prosthetic valve
- Valve damage e.g. rheumatic heart disease
Heart disease
- Congenital heart disease
Other
- Poor dentition
- IVDU
Causes and complication of Mitral regurgitation
Rheumatic heart disease
Infective endocarditis
Mitral valve prolapse
Retrograde blood flow across mitral valve increases LV preload, leading to dilatation and HF over time
Presentation of mitral regurgitation
Sx of HF
Dyspnoea
Orthopnoea
PND
Peripheral oedema
Valve surgeries
Open
- Valve repair (normally done for regurgitation)
- Valve replacement (done in stenosis)
- Mechanical valves are lifelong but require
warfarin anticoagulation
- Tissue valves last 10-15y but don’t require
anticoagulation
Transcatheter (for people not suitable for invasive surgery)
- TAVI (guidewire into femoral artery under XR guidance
Indications for CABG
- >50% stenosis PLUS 1 of: ○ Severe angina unresponsive to medical therapy ○ Marked ST depression on exercise ECG ○ Left main stem stenosis ○ Severe triple vessel disease ○ Angina w/ LV dysfunction
Causes of AF
Cardiac
- Ischaemic heart disease
- Valvular heart disease
- Cardiomyopathy
- hypertension
Non-cardiac
- Thyrotoxicosis
- Alcohol
- PE
- Sepsis
Causes of Dilated Cardiomyopathy
Alcohol
Viral infections
Haemochromatosis
Hypertension
Causes of restrictive cardiomyopathy
Amyloidosis
Sarcoidosis
Haemochromatosis
Fibrosis
Heart failure types
HFrEF (EF <40%)
Inefficiency of heart pumping, so stroke volume reduced
HFpEF (EF>40%)
Inefficiency of diastolic heart filling, not pumping
LHF
RHF
CHF
High output vs Low output
High output = increased oxygen demand e.g. anaemia, thyrotoxicosis, pregnancy
NYHA classification of HF
NYHA I: No symptoms with ordinary physical activity
NYHA II: Symptoms with ordinary physical exercise
NYHA III: Symptoms with less than ordinary physical exercise
NYHA IV: Dyspnoea at rest
Signs of HF
Peripheral oedema Raised JVP Displaced apex beat S3 + S4 (gallop rhythm) Hepatomegaly
XR findings in HF
Alveolar oedema Kerley B lines Cardiomegaly Upper lobe diversion Effusions
Mx of chronic heart failure
Conservative
- Exercise programmes
- Smoking cessation
- Low Salt diet
- Fluid restriction
Medical
Drugs to improve symptoms:
- Diuretics
- Long acting nitrates
Drugs to improve prognosis:
- ACEi
- Beta blocker
- Spironolactone
One of SHIC:
Sacubitril-valsartan (if LVEF <35%, replaces ACEi)
Hydralazine + isosorbide (esp. in afrocaribbeans, if ACEI/ARB not tolerated)
Ivabradine
CRT
Reversible causes of cardiac arrest
- Tension
- Trauma
- Thrombin
- Tamponade
- Hypoxia
- Hypokalaemia
- Hypovolaemia
- Hypothermia
MI complications
Dressler’s syndrome (autoimmune pericarditis 6w post-MI)
Arrhythmia (Heart block)
Rupture (Papillary muscle, ventricular septal defect)
Thrombus
Haemorrhage/HF
Valve disease (acute mitral regurgitation)
Aneurysm
Emboli
Re-infarction (use CK-MB instead of troponin)
Pericarditis Ix
Bedside
- Serial ECGs
Bloods
- FBC U&E CRP
- Troponin
Imaging
- Echo (rule out pericardial effusion)
Viral serology
3 types of Post-MI rupture
Papillary muscle rupture = Acute Mitral Regurgitation
Px: Pulmonary oedema, hypotension, new soft PSM
Interventricular septal rupture = VSD
Px = Chest pain, shock, new harsh PSM
LV free wall rupture
Px: HF, cardiac tamponade
Mx of post-MI arrhythmia
Inferior MI = Atropine
Anterior MI = Transcutaneous Pacing then permanent pacemaker
What are the 3 main consequences of an MI? Explain how this then leads to the DARTHVADER complications
- Reduced contractility
○ This means that the heart is not able to pump blood as effectively, possibly leading to cardiogenic shock
○ As you get stasis of blood that is not being moved, this predisposed to clot formation (thrombus) which may embolise to other parts of the body, or cause reinfarction within the coronary vessels- Electrical instability (disorganised ion movements, disrupted electrical conduction)
○ Leads to heart block due to disruption of the SAN and AVN
○ Also leads to arrhythmias such as VF - Tissue necrosis
○ Leads to an inflammatory reaction, which can irritate the pericardium leading to pericarditis
○ Necrosed tissue is more prone to rupture, which may lead to rupture in many areas
§ Papillary muscle rupture: Acute Mitral Regurgitation
§ Ventricular septal rupture: VSD
§ LV free wall rupture: Cardiac tamponade (as blood then accumulates within the pericardium
- Electrical instability (disorganised ion movements, disrupted electrical conduction)
Hypothermia ECG findings
Bradycardia
J waves
QT prolongation
Arrhythmias
Austin flint murmur
Early diastolic Murmur + Mid-diastolic murmur
In severe AR, you get so much backflow of blood that you get a regurgitant jet of high velocity bloodflow through the mitral valve, causing a MDM of Mitral stenosis
Types of pulmonary hypertension
Pulmonary Arterial hypertension
Pulmonary artery obstruction
Chronic lung disease
Left Heart disease
Signs of pulmonary hypertension
Signs of RHF
Peripheral oedema
Raised JVP
Loud S2
Graham Steel Murmur (EDM along L sternal border essentially representing pulmonary regurgitation due to severe pulmonary hypertension)
What is rheumatic fever
Autoimmune condition post Group A strep sore throat
Rheumatic fever features
Major JONES Criteria
Carditis Arthritis Sydenham's Chorea (2-6 months after infection) Erythema Marginatum Subcutaneous nodules
Minor JONES Criteria Fever Raised ESR/CRP Arthralgia Prolonged PR interval Previous RF
Rheumatic fever diagnosis
Evidence of GAS infection, AND: • Throat culture test +ve • Rapid streptococcal antigen test +ve • ↑ ISO titre • Recent scarlet fever
[2a] 2 majors; OR MAJOR: CASES
[2b] 1 major + 2 minors MINOR: FRAPP
Rheumatic fever diagnosis
Evidence of GAS infection, AND: • Throat culture test +ve • Rapid streptococcal antigen test +ve • ↑ ISO titre • Recent scarlet fever
[2a] 2 majors; OR MAJOR: CASES
[2b] 1 major + 2 minors MINOR: FRAPP
Rheumatic Fever Mx
Bed rest
Analgesia
Phenoxymethylpenicillin
Prophylaxis of rheumatic heart disease
Once monthly IM benzathine penicillin OR BD oral phenoxymethylpenicillin
5y if no carditis, 10y if carditis
Indications for aortic valve replacement in AS
Symptomatic
Aortic valve gradient >40mmHg
