Cardio Flashcards
Raised JVP, PR depression and ST elevation suggests..
pericarditis
a pansystolic murmur is affecting the ____ or _____ valves?
if the lungs are clear where must the problem be?
mitral or tricuspid
clear lungs - must be tricuspid
the left coronary artery divides into which two arteries?
left anterior descending
circumflex
what area of the heart does the circumflex artery supply?
lateral
left atrium
posterior left ventricle
what parts of the heart does the left anterior descending artery supply?
anterior
anterior left ventricle
anterior septum
what parts of the heart does the right coronary artery supply?
posterior
right atrium and ventricle
inferior left ventricle
posterior septum
symptoms of a heart attack?
central crushing chest pain radiating to jaw/arms palpitations sweating nausea anxiety / feeling of impending doom
ST elevation or _______ is classsified as a STEMI
new left bundle branch block
ECG changes seen in an NSTEMI?
ST depression
Deep T wave inversion
pathological Q wave
troponin is a non specific marker. give 2 situations other than MI when it might be raised:
Chronic renal failure Sepsis Myocarditis Aortic dissection Pulmonary embolism
2 acute treatment for STEMI?
primary PCI if within 2 hrs
thrombolysis if after 2hrs
how does alteplase work?
it is a fibrinolytic
treatment of an NSTEMI?
B – Beta-blockers unless contraindicated
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)
M – Morphine titrated to control pain
A – Anticoagulant: Fondaparinux (unless high bleeding risk)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm
what score is used in NSTEMI to assess whether you need to do PCI?
GRACE
if more than 5% / medium risk, do it
presentation of dresslers syndrome?
2-3 weeks after MI
pericarditis
pericardial rub
pleuritic chest pain
ECG shows global ST elevation and T wave inversion
treatment for dresslers sydndrome?
aspirin
prednisolone
pericardiocentesis
what ECG change in 1st degree heart block?
PR interval is longer than 0.2 seconds
If the QRS waves do not always follow P but the PR interval is constant what is this?
2nd degree heart block
define 3rd degree heart block?
P waves unrelated to QRS
what causes Prinzmetals angina and how does it present?
coronary artery spasm
presents w sudden cardiac pain at rest
treatment/management of prinzmetals angina?
avoid triggers eg smoking, cocaine, hypomagnesium calcium channel blockers (amlodipine) long acting nitrates (ivabradine) GTN avoid beta blockers and aspirin
angina is a mismatch of oxygen demand and supply. give 4 situations when demand is increased?
exercise stress cold hyperthyroid hypertrophy hyper or hypo volaemia tachycardia eating anaemia
gold standard investigation for angina?
CT coronary angiography
side effect of GTN?
headache
1st line prophylactic treatment for angina?
atenolol / propanolol
verapamil
what is ‘dual antiplatelet therapy’?
aspirin
P2Y12 inhibitor eg ticagrelor, clopidogrel
what are the two categories of heart failure?
- reduced ejection fraction (systolic failure) - problem with muscle contraction
- without reduced ejection fraction (diastolic failure) - problem with filling, poor compliance
5 aetiology of heart failure?
ischaemic heart disease hypertension alcohol cardiomyopathy valve disease endocarditis pericarditis respiratory disease drugs that cause arrythmias
what happens in the ‘transition to failure’ when heart failure is developing?
poor CO = low bp
vasopressin – renin – vasoconstriction – hypertension
sodium and fluid retention, because of vasopressin/renin
endothelin released from damaged vessels
= aldsosterone
= sympathetic activation
= apoptosis of myocytes
left sided failure – fluid backs up – right sided failur
clinical presentation of heart failure?
breathless esp when lying tired oedema esp legs cold peripheries hepatomegaly ascites
tachycardia
displaced apex beat
raised JVP
murmur
3 investigations you might do in ?heart failure?
NT - pro - BNP will be raised
Echo - ejection fraction
ECG shows AF
CXR shows pulmonary congestion
what are the 4 severity classes for heart failure?
1 - asymptomatic
2- slight limitation to exercise
3 - severe limitation to exercise
4 - symptoms at rest
what does the ejection fraction need to be to be HFREJ?
40% or less
what is the 1st, 2nd and 3rd line treatment for heart failure with reduced EF?
1st line = ace inhib (or arb) + beta blocker
eg ramipril + bisoprolol
2nd line = swab arb/acei for hydralazine or add spironolactone
3rd line = consider valsartan sacubitril / digoxin / amiodarone
what does ivabradine do?
acts at the SAN to decrease heart rate
sometimes used for heart failure
for heart failure with preserved ejection fraction what is first line?
diuretic
5 risk factors for hypertension?
CKD male age family history increased sympathetic nervous system activity smoking salt obesity alcohol sedentary lifestyle
4 causes of secondary hypertension?
Pregnancy
Endocrine (hyperaldosteronsim, cushigs)
Renal impairment
Medication - steroids, antipsychotics, contraceptives
at what BP is hypertension diagnosed?
140/90
what is stage 2 and stage 3 hypertension?
1 = 140/90 2 = 160/100 3 = 180/120
what BP do you aim for when you have treated it?
140/90 for under 80
130/90 if high risk eg CKD, DM
150/90 if 80 +
first line antihypertensive for caucasian under 65?
ACEi eg -pril
first line antihypertensive for 65+ or afro-carribean?
calcium channel blocker eg amlodipine
what is malignant hypertension?
180/120 +
risk of immediate end organ damage
emergency
what two substances build up as a result of anaerobic metabolism, causing pain?
lactic acid
potassium
apart from pain, give 3 presentations of intermittent claudication?
thin shiny skin
ulceration
temperature difference
hair loss
most common cause of pericarditis?
viral coxsackie HHV8 EBV CMV
IVDU commonly get infective endocarditis from which bacteria?
staph epidermidis
rheumatic fever is caused by what bacteria/illnesses?
group A strep
strep throat
scarlet fever
staph aureus pericarditis usually affects who?
immunocompromised
3 non infective causes of pericarditis?
dresslers sjoren/RA uraemia hypothyroid aortic dissection chronic heart failure amyloidosis
what is tamponade?
a pericardial effusion that is large enough to affect the beating of the heart
what is constrictive pericarditis?
develops from chronic pericardial effusion – fibrosis – heart hasnt got room to beat
what is the pain like in pericarditis?
severe, sharp (not crushing) pleuritic worse when lying best when sitting forward rapid onset left of chest -- upper epigastric//shoulder
apart from pain 3 symptoms of pericarditis?
breathlessness cough hiccups fever tachycardia
in pericarditis what can you hear with the stethoscope?
pericardial rub
on left of sternum with the bell
what 3 things comprise Becks triad and what does it indicate?
hypotension
quiet heart sounds
distended jugular veins
cardiac tamponade
to be diagnosed with pericarditis you need 2 of what 4 features?
Chest pain
ECG changes
Pericardial rub
Pericardial effusion
On the ECG what do you see in pericarditis?
ST elevation, saddle shaped
PR depression
high J point
symmetrical but strange T wave
in pericarditis what will you see on the echo?
pulsus paradoxus
effusion
treatment for pericarditis?
colchicine IV abx rest may need to raise heart rate pericardiocentesis
which valve disease is most common?
aortic stenosis
two things that can cause all valve diseases?
infective endocarditis
rheumatic fever
wide pulse is most commonly associated with which valve disease?
aortic regurg
high at first bc LV very full and need high pressure to expell all blood
low at end bc all the blood has fallen down back into LV
aortic regurg and mitral stenosis both produce diastolic murmurs but what is the difference in the murmur?
aortic regurg - ‘blowing’ murmur at Erb’s point when pt is leaning forward
Mitral stenosis - low pitched murmur at the apex when pt is on their side
They are different because in aortic regug the blood is moving backwards whereas in mitral stenosis the blood is moving forward but slowly
in which valve disease are you most likely to see mitral facies & what are they?
pink-purple patches on the cheeks
mitral stenosis
because this causes the worst pulmonary hypertension
how do you treat mitral stenosis?
beta blockers/digoxin/amiodarone to slow the heart
diuretics
balloon valvectomy or replacement
3 risk factors for infective endocarditis?
abnormal valves prosthetic valve IVDU recent surgery esp heart rheumatic fever septal defect
presentation of infective endocarditis?
new murmur embolic fever sepsis arrythmia heart failure
petechiae
splinter haemorrhage
oslers nodes
janeway lesions
roth spots on fundoscopy
what classifying system is used for the likelihood of infective endocarditis?
Dukes
need 2 major + 1 minor or 1 major + 3 minor
2 things that are in the major Dukes category for infective endocarditis?
pathogen isolated on blood culture
evidence on echo
new valve leak
what are 3 examples of minor Dukes criteria?
IVDU prosthetic valve fever embolic event immune response equivocal blood culture
2 types of echo, which is better?
transthoracic is safer
transoesophageal is more invasive but cleaer
management of infective endocarditis?
IV abx for 6 weeks
what scoring system is used to calculate the risk of developing stroke from AF and what does the score mean about treatment?
CHAD2 Congestive heart failure Hypertension Age over 75 Diabetes S2 - prev stroke or TIA - worth 2 points
score of 0 – aspirin
score of 1 – warfarin or aspirin
score of 2+ – warfarin
if there is primary resistant hypertension, loin pain and haematuria what do you need to be considering?
polycystic kidney disease
what is Kussmauls sign?
increased jugular distention on inspiration
constrictive pericarditis
aetiology of hypertrophic cardiomyopathy?
- primary (primary hypertrophic obstructive cardiomyopathy) - autosominal dominant inheritance eg of a faulty sarcomere gene
- secondary: in response to hypertension or valve defects
what do you see on ECG in hypertrophic cardiomyopathy?
large voltages
inverted T wave
arrythmia
may lead to ventricular tachycardia/VF
treatment for hypertrophic cardiomyopathy? 3
beta blocker or calcium channel blocker to decrease heart rate
amiodarone to stop arrythmia
anticoagulants to stop clotting especially if there is some AF
what is the presentation of dilated cardiomyopathy?
thin overstretched walls are rubbish at contraction so is similar to heart failure arrythmia fatigue dyspnoea tachycardia
what is Naxos disease?
A type of arrythmogenic cardiomyopathy caused by mutation in the genes that make the desmosome
presentation of arrythmogenic cardiomyopathy?
arrythmia
palpitation
syncope
heart failure like when sevvere
what is the ECG like in arrythmogenic cardiomyopathy?
epsilon waves
inverted T
wide QRS in V1-V3
give 2 types of shock caused by decreased cardiac output and what might cause them?
hypovolaemic - eg haemorrhage, burns, diarrhoea, vomiting
cardiogenic - eg MI, myocarditis
Obstructive - eg tamponade, tension pneumothorax
give 2 types of shock caused by decreased systemic vascular resistance?
septic
anaphylactic
neurogenic (eg spinal cord lesion that means the body loses its ability to control BP)
physiological changes in compensated vs decompensated shock?
compensated : increased heart rate, peripheral vasoconstriction and increased resp to maintain BP
decompensated: BP is not maintained and/or the body continues to lose blood and cannot maintain sufficient volume
5 presentations of shock (caused by decreased CO)?
hypoxia tachycardia -- bradycardia as it becomes decompensated Kussmaul breathing / increased resp cold pale peripheries decreased cap refill hypotension confusion weak pulse
signs of anaphylactic/septic shock?
warm flushed pyrexia / rigors vomitting cyanosis pulmonary oedema wheeze (esp anaphylactic)
treatment of shock?
A - maintain airway eg intubate B - give oxygen C - raised legs, give fluid/blood maintain heart rate manage cause - abx / adrenaline / hydrocortisone
the 4 features of tetralogy of fallot?
right ventricular hypertrophy over riding aorta small pulmonary outflow tract ventricular septal defect (PASH - pulmonary aorta septum hypertrophy)
in tetralogy of fallot can you expect cyanosis?
yes
deoxygenated blood can get into the systemic circulation
because right ventricular hypertrophy and poor pulmonary outflow = higher pressure on the right than the left = blood moves right to left
‘fallots spells’ = periods of cyanosis, especially when crying etc
what is the treatment and long term prognosis of tetralogy of fallot?
surgical repair of septa defect
incise pulmonary valve – pulm outflow tract will grow as it is used, no need fo r such hypertrophy of RV anymore, so aorta can move back over
at risk of pulmonary valve regurgitation or arrythmia later in life but generally life normally
in a ventricular septal defect would you expect cyanosis?
only in a large hole
in a small hole the blood will generally move from left (high pressure) to right (low pressure), all this means is that oxygenated blood goes back to the lungs unncessarily
when the hole is large lots of oxygenated blood goes to the lungs, this results in pulmonary hypertension and raises the pressure backing up into the right ventricle, one RV pressure is as high as LV, the blood will flow the opposite way (Eisenmenger) = cyanosis and v bad
prognosis/complications of a small VSD?
buzzing murmur
increased risk of valve defects or infective endocarditis but generally fine
what is the plexiform reaction?
thickening, fibrosis, hypertrophy of pulmonary vessels in response to pulmonary hypertension
treatment options for a large ventricular septal defect?
patch the hole
band the pulmonary artery to decrease the blood flow to the lungs
symptoms & investigation findings (inc a murmur!) of an atrial septal defect?
short of breath on exertion (lungs are full of blood that they have already oxygenated)
pulmonary flow murmur
CXR shows enlarged atria and pulmonary arteries
do you get cyanosis in atrial septal defect?
no, blood flows from left (higher pressure) to right (lower pressure). it would be very unusual for Eisenmengers to develop because the atria have much lower pressure altogether than the ventricles
what is co-arctation of the aorta? how might it present?
narrowing of the aorta
hypotension and formation of collateral vessels in lower body
hypertension in right arm not in left
radio-femoral delay
activation of RAAS and sympathetic systems
how can coarctation of the aorta be repaired? do you always have to repair them?
with a stent or subclavian flap
you need to repair else can cause vascular fragility
what do you see in pulmonary stenosis?
RV hypertrophy
decreased pulmonary blood flow
tricuspid regurgitation
When is JVP raised?
pericarditis
right sided heart failure (not left).
– right sided heart failure = blood cannot get out of the right side into lungs = blood builds up around body. increased systemic blood in veins = raised JVP
would you expect right or left sided heart failure to present with dyspnoea?
left sided
as blood builds up in the left side of the heart
so the blood cannot move from the lungs into the left and instead builds up in the left
NT-pro-BNP is a marker of heart failure but what is it and where does it come from?
brain natriuretic peptide
released from the ventricles when they are stretched
5 signs of left heart failure of an x ray?
Alveolar oedema B Kerley B lines (intersitial oedema) Cardiomegaly Dilated upper lobe vessels E pleural Effusion
SOB thats worse on exertion or lying + coughing pink frothy sputum + fine crackles on ascultation could be?
left sided heart failure
2 times when you would get ST depression and 2 times when you would get ST elevation?
ST depression: NSTEMI, unstable angina
ST elevation: STEMI, pericarditis, prinzmetal angina
what is the difference physiologically between a STEMI and an NSTEMI?
NSTEMI: the infarction does not go all the way across the myocardium
definition of atherosclerosis?
Accumulation of lipids, macrophages, and smooth muscle cells in the intima of large and medium
sized arteries.
what valve do you hear best at the left 2nd intercostal space?
pulmonary
what valve do you hear best at the left 4th intercostal space on the sternal edge?
tricuspid
what valve do you hear best at the left 5th intercostal space on the midclavicular line?
mitral
what drug is NOT a good choice for coronary artery spasm?
beta blockers
an early diastolic decrescendo murmur indicates what?
aortic regurg
side effect of GTN?
headache
