Cardio Flashcards
Mx of unstable angina
Aspirin + Clopidogrel
LMWH
GTN Spray
Standard treatment of STEMI/STEMI
MONAC
Morphine
Oxygen
Nitrates
Aspirin
Clopidogrel
Occlusion of which vessel can lead to heart block
RCA
(located by SA and AV nodes)
What is negative in RAD
Lead I
What is negative in LAD
Lead II (& Lead III)
Causes of syncope?
Vasovagal (fainting)
Orthostatic
Cardiovascular: arrhythmia, aortic dissection, ACS
Slow rising pulse
Aortic stenosis
Most common causes of aortic stenosis
Calcific degeneration
Congenital bicuspid valve
Signs of mitral stenosis
Palmar erythema
Malar Flush
Left parasternal heave
Stigmata of endocarditis
Loud S1 – closing snap of stenosed mitral valve.
Loud P2- secondary to pulmonary HTN
Most common cause of Mitral stenosis
Rheumatic fever (90%)
Mx of mitral stenosis
Observation
Percutaneous balloon mitral valvuloplasty
Surgical repair/replacement
Scar present if valvular replacement
Median sternotomy scar
How to differentiate the sound of an aortic or mitral valve replacement
Remember that the 1st heart sound is closure of the mitral valve and 2nd heart sound closure of the aortic valve.
So a metallic click just before the carotid pulse is a mitral valve replacement and just after the carotid pulse is an aortic valve replacement.
(Listen over both areas for intensity of the click)
Sx of HOCM
Jerky pulse
Large A waves in JVP
Ejection systolic murmur radiating to the apex
Differentials for Ejection systolic murmur
Aortic stenosis
Pulmonary Stenosis
Aortic sclerosis
HOCM
ASD
Differentials for pansystolic murmur
Mitral regurgitation & Tricuspid regurgitation.
VSD ASD
Differentials for diastolic murmur
Aortic regurg
Pulmonary regurg
Mitral stenosis
Tricuspid stenosis
Causes of aortic stenosis
Calcific degeneration (commonest)
Congenital bicuspid valve, post rheumatic fever & IE
Causes of aortic regurg
IE, aortic dissection, rheumatic fever, bicuspid aortic valve, Marfan’s
Causes of mitral regurg
IE, rupture of chordae tendinae (post-MI), Marfan’s
Valve problem associated with carcinoid syndrome
Tricuspid stenosis
Indications for a median sternotomy
Aortic aneurysm/dissection
Mechanical valves
Heart transplant
Coronary artery bypass graft
Thymectomy
Signs of LVF
Fatigue
Exertional dyspnoea
Orthopnoea + PND
Nocturnal cough (± pink, frothy sputum)
Signs of RVF
↑JVP + jugular venous distension
Tender smooth hepatomegaly
Pitting oedema
Ascites
Chronic heart failure classification
*New York Classification**
1. No breathlessness
2. Breathless on moderate exertion
3. Breathless on mild exertion
4. Breathless at rest
Heart failure Ix
Bloods: FBC, U+E, NT-proBNP, lipids, glucose
CXR
ECG
ECHO: the key Ix
Heart failure Ix
Bloods: FBC, U+E, NT-proBNP, lipids, glucose
CXR
ECG
ECHO: the key Ix
Chronic Heart Failure Mx
Beta Blocker + ACEi + Loop diuretic
2nd add spironolactone
3rd consider ivabradine
Narrow pulse pressure
Aortic stenosis
Causes of aortic stenosis
Age-related senile calcification
Bicuspid aortic valve
Rheumatic heart disease
Clinical Symptoms of Severe AS
Angina: 50% dead in 5yrs
Syncope: 50% dead in 3yrs
Dyspnoea: 50% dead in 2yrs
AS Ix
ECG
Echo
AS Mx
MDT approach
Optimise CV risk: statins, anti-HTN, DM, anti-plat
Sx: valve replacement ± CABG
Causes of AF
IHD
Rheumatic heart disease
Thyrotoxicosis
Hypertension
RA
Ix of AF
ECG
Bloods:
FBC: pneumonia, sepsis
U+E: ↓K
TFTs: ↓TSH, ↑fT4
Troponin
D-dimer: PE
CXR
Echo
dDx for irregulary irregular pulse
AF
Multiple ventricular ectopics
Clinical Distinction: Exercise pt.
AF: pulse stays irregularly irregular
VE: ↑ HR → regular pulse
↓ diastole time closes window for ectopics
IE diagnostic criteria
Duke criteria:
2 major
1 major + 3 minor
All 5 minor
MAJOR:
+ve blood cultures (2 separate cultures)
Endocardial involvement: +ve echo: vegetation, abscess, dehiscence or new valvular regurgitation
MINOR:
Predisposition: cardiac lesion, IVDU
Fever >38
Emboli: septic infarcts, splinters, janeway lesions
Immune: GN, Osler nodes, roth spots, RF
blood cultures not meeting major criteria
Causes of impalpable apex breat (4)
COPD
Obesity
Pericardial effusion
Dextrocardia
Fx of Pulmonary HTN
^JVP
Left parasternal heave
Loud P2
Pulsatile hepatomegaly
Peripheral oedema
Heart sounds (S1-4)
S1: mitral valve closure
S2: aortic valve closure
S3: rapid ventricular filling of dilated left ventricle
S4 atrial contraction against a stiff ventricle
Causes of aortic regurgitation
Bicuspid aortic valve
Rheumatic heart disease
Autoimmune: Ank spondylitis, RA
Connective tissue: Marfan’s, Ehler’s Danlos
Acute:
Infective endocarditis
Type A aortic dissection
Murmur standard Ix and Mx
Ix: ECG, CXR, Echo + Doppler
Bloods: FBC, U&E, Lipids, glucose, BNP
Mx: MDT approach: GP, cardiologist, dietician
Optimise CV risk: statins, anti-HTN, DM, anti-plat
Regular monitoring
Diagnosis of Rheumatic fever
Jones Criteria
2 major, 1 major + 2 minor
Major Criteria (CASES)
Pancarditis
Arthritis
Subcut nodules
Erythema marginatum
Sydenham’s chorea
Minor criteria
Prolonged PR interval (not if carditis is a major)
Arthralgia (not if arthritis is a major)
Fever
↑ESR or ↑CRP
Prev rheumatic fever
Ix of Rheumatic fever
Bloods: FBC, ESR, ASOT
ECG
Echo
Rheumatic fever Tx
Bed rest until CRP normal for 2 wks
Benzylpenicillin 0.6-1.2 IM for 10 days
Analgesia; carditis/arthritis: aspirin/NSAIDs
Add oral pred if CCF, cardiomegaly, 3rd degree block
What pulse sign would you see in pt with HOCM?
Pulsus bisferiens - biphasic pulse, is a cardiac cycle with two peaks, a small one followed by a strong and broad one
Complications of valve replacement
Acute failure of valve e.g. breakage
Chronic failure of valve e.g. stenosis, incompetence
Infective endocarditis
Anaemia
AF
Thromboembolism
