Cardio Flashcards
What is Heart Failurw
Inability of CO to meet body’s metabolic demands despite maintained venous pressures
How do you classify HF
LOW OUTPUT (low EF: EF<40)
or
HIGH OUTPUT (normal EF)
What are causes of low output HF
LHF:
- HTN
- IHD
- cardiomyopathy
- valve disease / regurg
RHF:
- secondary to LHF (congestive cardiac failure)
- IHD, cardimyopathy
What are symptoms of chronic LHF
dyspnoea
orthopnoea
PND
fatigue
what are sx of acute LHF
dyspnoea
wheeze
cough
pink frothy sputum
what are sx of RHF
swollen ankles
increased weight
fatigue
anorexia, nausea
what are signs of LHF
bibasal crackles, S3 gallop
if acute: cyanosis, pulsus alternans
what are signs of RHF
raised JVP
hepatomegaly
ascites
pitting oedema
How can yoou classify LHF?
New York Heart Association Classificationo
1- no limit on activity
2- comfortable at rest, dyspnoea on ordinary activity
3- dyspnoea on less than ordiinary activity
4- dyspnoea at rest
What ix for acute HF?
Bloods: FBC U&EE LFT CRP Gluc LIpids TFT
ABG, trop, BNP
CXR
ECG
Echo (assess ventricular dysfunction)
How d you manage HF if haemodynamically stable?
BASHeD heart
- BB (if low EF, OR loop diuretiic if preserved EF) + ACEi
- BB + ACEi + aldosterone antagonist
- Specialist
- Hydralazine + nitrate
- DIgoxin
- Ivabradinie
- sacubitri-valsartan
What is AF?
irregularly irregular pulse
What are sx of AF
dyspnoea
chest pain
fatigue
dizziness
syncope
What are AF findings on ECG
irreg irreg
absent P wave
– atrial flutter = sawtooth
How can you split causes of AF, and what are they
CARDIAC
- IHD
- rheumatic heart disease
- cardiomyopathy
- sick sinus
- pericarditis
SYSTEMIC
- hyperthyroid
- infection
- alcohol
RESP
- PE
- bronchial cancer
what is the first key split in AF management pathway, and what are conditions for each
RHYTHM vs RATE control
RHYTHM CONTROL if:
- AF is reversible
- coexistent HF (caused by AF)
- new onset AF
RATE CONTROL if:
permanent AF
How do you RHYTHM control someone?
<48h: DC cardiovert (3 synchronous shocks) > pharm cardiovert (fleicanide or amiodarone)
> 48h from onset of AF: anticoag for 4 weeeks before cardioverting
THEN LONG TERM BETA BLOCKER
How do you rate control someone
Beta blocker or CCB
Second line: digoxin
Third line: amiodarone
When do you give fleicanide or amiodarone for DC cardioversion
Fleicanide: young, no structural heart disease
Amiodarone: old, structural heart disease
What else must you do in someone with AF
CHADS VASC SCORE vs HAS-BLED risk
to determine stroke risk compared to risk of bleeding
if low: aspitrin
if high: warfarin
what are symptoms of infectious endocarditis
• Fever with sweats/chills/rigors
• Malaise, fatigue
• Weight loss
• Arthralgia
• Myalgia
• Confusion
• Skin lesions
• Ask about recent dental surgery or IV drug use
what are signs of infectious endocarditis
FROM MS JANE
Fever
Roth spots on retina
Osler’s nodes (tender nodules on finger/toe pads)
Murmur (new, regurgitant)
Microscopic haematuria (due to damage to kidneys)
Splenomegaly (due to emboli damage to spleen )
Janeway lesions (painless macules on the palms which blanch on pressure)
Anaemia
Nail clubbind and haemorrhage (splinter)
Emboli
What ix do you do for IE
• Bloods
o FBC - high neutrophils, normocytic anaemia
o High ESR/CRP
o U&Es
o rheumatoid factor positive
• Urinalysis
o Microscopic haematuria
o Proteinuria
• Blood Culture - with microscopy and sensitivities as well
• Echocardiography - Transthoracic or transoesophageal (produces better image)
What classifications do you use for IE
DUKES classification - 2 majors OR 1 major + 3 minor OR 5 minors
What mx do you give for IE
Abx 6 weeks (initially IV > PICC line)
start broad spec (amox + gent), then guided by culture results
What is pericarditis
inflammation of pericardium
What are causes of pericarditis
Vascular: post-MI, Dressler
Infection - viral (cocksackie, HIV), TB, mumps
Trauma
AI (, SLE,)
Metabolic (Uraemia)
Inflamm (sarcoid, scleroderma)
What are sx of periicarditis
– explain the type of pain
Pleuritic chest pain (sharp, central., radiatimg to shoulders, relieved by sitting forward)
Non productive cough
Dyspnoea
Flu like sx
What is audible on ascultation in pericarditis
pericardial RUB
What is finding on ECG in periicarditis
widespread saddle shaped ST elevation
MANAGEMET OF periciarditis
NSAID + colcichine
How do you assess for cardiac arrest?
Shout for help. Does this patient have a DNACPR?
Call 2222
A- Head tilt chin life, ask someone to hold jaw thrust
B- Look, listen and feel for signs of life, Breathing, chest movement
C- check central pulse
what are shockable rhythms
VF, pulseless VT
What are non-shockable rhythms
pulseless electrical activity, asystole
What do you do once you have ascertained no breathing and no central pulse
COMMENCE CPR 30 chest compressions : 2 rescue breaths via bag valve mask
Call 2222 for cardiac arrest
Continue CPR until crash team arrive with resus trolley
What do you do once crash team arrive
Place defib pads on chest, look at rhythm
What do you do for shockable rhythm
Stand clear - Defib max 1x (150J)
Reassess - if no change, Continue CPR for 2 minutes
repeat shock
You can repeat this cycle (CPR-shock) max 3 times
then continue CPR + give adrenaline 1mg IV + amiodarone 300mg IV
Restart CPR 2mins > rhythm check > shock – with adrenaline after alternate shock
What do you do for PEA/Asystole
continue CPR
Give 1mg Adrenaline IV
Secure airway with LMA /igel – otherwise hold jaw thrust
CPR for 2 mins > reassess > give adrenaline at alternate reassesses
What do you do if patient has spontaneous return of circulation
Send to ITU
Document
Debrief
Datix
what symptoms do you get with stable angina
chest pain on exertion relieved by rest
what is the pathophysiology of stable angina
mismatch in oxygen supply and demand to myocardium
due to constricted coronary
what is the first line ix for stable angina
CT coronary angiography CTCA
(but check renal function first as it requires contrast)
using this look at CALCIUM SCORE
what is management for stable angina
CONSERVATIVE: lifestyle changes
MEDICAL:
1. BB/CCB + GTN spray
—– use nonDHP CCB e.g. verapamil / diltaziem
- BB + CCB + GTN spray
—– use DHP CCB with BB (otherwise total HB!!!) eg nifedipine - AAA (Aspirin, ACEi, Atorvastatin)
what is definition of HTN
SBP > 140 and / or DBP >90 on three separate occasions
How can you divide causes of HTN
Primary (essential/idiopathic)
Secondary
- renal (RAS, PKD, CKD)
- endocriine (hyperthyroid, cushing’s, Conn’s, phaeo)
- cardiovascular (aortic coarct)
what is aortic coarctation
congenital narrowing of the aorta
where does aortic coarctation usually occur, and how does this result in different signs?
- usually AFTER left subclavian artery > radiofemoral delay
- rarely BEFORE left subclavian > radioradial delay
what are complications of aortic coarctation
upper extremity HTN
LV hypertrophy
malperfusion of abdomen and LL
how do you diagnose and tx aortic coarct
echo
CT / MR angio
Tx: angioplasty or surgery
when do you need to admit someone with hypertension?
when BP >180/110
will usually present with signs of deterioration e.g. retinal haemorrghage, papilloedema, confusion, AKI, chest pain etc
what do we define as severe HTN
BP > 180/110
what medication do you need to give first line for HTN
if <55 and not afrocarribean: ACEi or ARB
if >55 or afrocarrib: CCB
what med do you give second line for HTN
add the one you weree not giving before or thiazide-like diuretic
SO:
if <55 and not afrocarribean: (ACEi or ARB) + (CCB or thiazide-like diuretic)
if >55 or afrocarrib: CCB + (ACEi or ARB or TLD)
what med do you give third line for HTN
ACEi or ARM + CCB + TLD
what med do you give first line for HTN if pt had T2DM, regardless of demographiocs
ACEi or ARB
if black, give ARB only
what investigations do you do for HTN
exclude secondary causes
ambulatory BP monitoring > if declined / white coat syndrome, monitor at home
What is the cause of rheymatic fever
group A beta haemolytic strep e.g. S Pyogenes»_space; SCARLET FEVER
antibodies cross react with myosin, muscle glycogen and VSMC
can cause long term damage
What are signs and symptoms of ACUTE rheumatic fever + typical pt
in children 5-15yo
pharyungeal infection > latent interval of 2-6 weeks
then: polyarthritis (tender joints, swelling), pericarditis (endocarditis, myocarditis, pericarditis),
later (up to 6 months later) sydenam’s chorea
What is sydenham’s chorea
St vitus dance - involuntary movements
what criteria do you use for rheymatic fever dx
JONES CRITERIA
Explain Jones criteria
- Evidence of Group A infection + throat culture + / rapid strep antigen +
2a. 2 majors
2b. 1 major + 2 minors
what are major criteria for Jones Cit
CASES
Carditis
Arthiris
Subcut nodules
Erythema marginatum
Sydenams chorea
What are minor crit for Jones
FRAPP
Fever
Raised ESR or CRO
Arthralgia
Prolonged PR
Previous RF
How o you manage Rh F
Acutely (attack lasts 3 months)
- bed rest
- analgesia (NSAID, aspirin)
- phenoxymethylpen QDS 10/7
what is Rh F prophylaxis
Once monthly IM benzathine pen
OR
BD PO 250mg phenoxymethylpen
What is a AAA
localised enlargement of the abdominal aorta
- diameter > 3cm or >50% normal
WHat are RF for AAA
- male
- FH
- smoking, HTN, hypercholesteraemia
- connective tissue disease
What are symptoms for unruptured AAA
unruptured: asymptomatic
What are signs for unruptured AAA
pulsatile lateral expansile mass
abdominal bruits
what are sx of ruptured AAAA
pain in abdo/ back, sudden and severe
syncope
shock
what additional sign may be visible on the abdomen in ruptured triole A
Grey turner (retroperitoneal bleeding9
what investigation must you get in suspected AAA q
BLloods: FBC, clotting, LFT, UE, X match
Imaging: USS (if unruptured), CTA with contrast if ruptured
How do you manage a ruptured AAA
volume resus, anaglesia, VTE prophylaxis
EVAR (endovascular aneurysm repair)
what is the genetic inheritance of HOCM
Autosomal DOMINANT
1 in 500
How does HOCM happen?
defect in gene for contractile protein > diastolic dysfunction> LV hypertrophy > decreased compliance > decreased CO
What shows up on HOCM bippsu
myofibrillar hypertrophy with chaotic and disorganised fashion myocytes
signs and sx of hocum
often asymptomatic
suden deathh in family
exertional: dyspnoea, angina, syncope
examiination: jerky carotid pulse, large A waves, double apex beat
what two ix must you get for HOCM
Echo
ECG
What are HOCM findings on Echo
MR SAM ASH
Mitral regurg
Systolic anterior motion of anterior miitral valve leaflet SAM
Asymmetric hypertrophy ASH
Management of HOCM
ABCDE
Amiodaroe
beta blocker / verapamil for sx
cardioverter defib
dual chamber pacemaker
endocarditis prophylaxis
what is cor pulmonale
pulmonary heart disease
presenting as RV HYPERTROPHY and RV DILATION
why does cor pulmonale occur?
due to:
- pumonary HTN (either primary or COPD, interstitial lung disease)
what are signs of cor pulmonale
due to backup of blood into systemic venous system:
- ascites
- jaundice
- hepatomeg
- raised JVP
due to difficulty in allowing blood to reach lungs:
- SOB
- wheeze
how do calcium channel blockers work
reduce calcium uptake into cell > vascular smooth muscle relaxaton> decreases systemic vascular resistance > lowers HTN
give an example of a CCB
Amlodipine
give an example of an ARB
losartan
candesartan
give an example of an ACEi
ramipril
enalapril
what are DVLA rules for driving after MI
Stop driving for:
- 1 week if angioplasty was successful, no further procedures
- 4 weeks if angioplasty was unsuccessful, if they had an MI with no angioplasty, CABG surgery
How do you identify orthostatic hypotension
3-2-1 drop:
3 minutes of standing, then a drop of 20/10 in BP
what can cause long QT syndrome
Congenital
Drugs
Endocrine (hypocalcaemia, hypokalaemia, hypomagnaesaemia)
Vascular (MI, myocarditis
what congenital conditions can cause long QT
jervell-Lange Nielsen syndrome (deafness)
Romano-Ward syndrome (no deafness)
What drugs can cause Long QT
METH CATS
Methadone
Erythromycin
Terfenadine
Haloperidol
Clarythromycin
Amiodarone
TCA
SSRI
what is the danger of long QT
leads to VT > death
What is torsade de pointes and how do you manage it
a type of VT
Manage with IV magnesium sulphate
what type of drug should you start in HF if EF is <30%
SGLT2 inhibitor
what is cardiac tamponade
Buildup of fluid in pericardial sac > compression of heart
What are causes of cardiac tamponade
vascular (MI, rupture, aortic dissection)
infection
trauma (incl cardiac surgery)
Malignancy
Inflamm (pericarditisi)
what is Becks triad
Triad that identifies cardiac tamponade (cardiac tamponade generally occurs with pericarditis)
- low BP
- high JVP
- muffled heart sounds
what is special feature of Cardiac Tamponade?
PULSUS PARADOXUS (BP drops by 10mmHg with every inspiration)
how do you manage cardiac tamponade
pericardiocentesis
which beta blocker offers prognostic benefit in heart fsailure
CARVEDILOL
what condition does JVP have an absent A wave=
AF
whayt condition has a heaving apical pulse
aortic stenosis
what murmur has a WATERHAMMER PULSE
Aortic regurg (also called Corrigan’s opulse)
What murmur has a TAPPING APEX BEAT?
Mitral stenosis (sound is made as the valve shuts - because it is so stiff)
what are pacemakers for?
PACING OUT THE HEART
- SA node pathology
- AF
- HF
What are Implantable Cardioverter Defibrillators for
Shocking the heart into feasible rhythm
used for tachyarrhythmias
What causes CANNON A WAVES?
Complete heart bloc (due to synchronous contractions of atria and ventricles)
what is pulmonary HTN
RAISED pulmonary artery pressure
so an umbrella term for conditions which cause increased pressure in the pulmonary artery
causes of pulmonary HTN - categories
- Pulmonary artery obstruction (PE, or rarely an intravascular tumour)
- lung disease (COPD, interstitial lung disease> cause backflow)
- Left heart disease (LVD, valve disease, cardiomyopathy)
- Pulmonary arterial HTN in absence of other causes (iaatrogemic, RF connective tissue diseases)
What bacterium causes ACUTE IE, and who is this common in ?
S aureus – IVDU
what valve does S aureus affect and why
tricuspid valve - as is the first reached from systemic circulation
What bacterium causes chronic IE, and from where does it come
Strep viridans
from brushing your teeth
what valve does S viridans affect and why
Mitral valve - because it is a much weaker and less quantity of bacterium, so it only affects already damaged valve !!
what is the chadsVASC score component
CHF
HTN
Age >= 75
Diabetes
Stroke
Age >=65
Sex Category (female)
Age and Stroke are worth 2 points
how do you treat pericarditis / dressler’s post MI?
NSAIDs
what is dresslers and how does it occur
post MI – 6 weeks
because myocardium has been damaged > you have made autoantibodies to it
what condition for a long time after an MI causes prolonged ST elevation?
left ventricular aneurysm
what is QRISK used for
Scoring system
for 10 year risk of developing cardiovasc disease
What are the parameters of QRisk for which different treeatments are employed?
QRISK >10% = high risk of CVD = high dose statin
QRISK <10% = lifestyle modification
when do you need to treat HTN
> 140/90 if >80 + end organ damage, CVD, CKD, diabetes, QRisk >10
in everyone else treat if >160/100
give an example of a thiazide like diuretic
indapamide
what are major and minor criteria for Duke’s (IE)
Major: BE
Bacteraemia, Echo findings
Minor: FEVEER
Feever
Echo findings other
Vascular phenomena (emboli, splinter haemorrhages, janeway lesions)
Evidence of immune involvcement (Osler nodes, Roth spots, RF)
Evidence of microbio envolvement (+ve culture)
RF: IVDU, heart condition
