Cardio Flashcards
Describe cardiac tamponade
An accumulation of fluid in the pericardial cavity that reduces cardiac function
Describe the classic clinical features of cardiac tamponade
Beck’s triad:
- hypotension
- raised JVP
- muffled heart sounds
What are the characteristic features of Tetralogy of Fallot?
- right ventricular hypertrophy
- VSD (ventricular septal defect)
- misaligned/overriding aorta
- pulmonary stenosis
What are the features of left sided heart failure?
ABCDE
- alveolar oedema
- Kerley B lines
- cardiomegaly
- dilated upper lobe vessels
- pleural effusion
Also..
- dyspnoea
- reduced ejection fraction
- pulmonary stenosis
What hormone is used to diagnose heart failure? Where is it released from?
BNP (b type natriuretic peptide)
Released from the ventricles (mainly left)
Higher levels = worse prognosis
Describe the pathology of Wolff-Parkinson White
Congenital accessory pathway between the atria and ventricles
Causes atrioventricular re entry tachycardia
No slowing of conduction… therefore, AF can very quickly deteriorate to VF
What the the ECG changes seen in Wolff-Parkinson white?
- delta waves (wide QRS complex, with a slurred uptake)
- short PR interval
- axis deviation to the opposite side of the accessory pathway…
What can cause an ejection systolic murmur that is louder on expiration?
- aortic stenosis
- hypertrophic obstructive cardiomyopathy
What can cause an ejection systolic murmur that is louder on inspiration?
- pulmonary stenosis
- atrial septal defect
What kind of murmur does VSD cause?
Pan systolic murmur, harsh in character
Describe the murmur heard in mitral / tricuspid regurgitation
Pan systolic
High pitched, ‘blowing’ in character
What causes late systolic murmur?
- mitral valve prolapse
- coarctation of the aorta
Describe the murmur heard in aortic regurgitation
Early diastolic, high pitched, ‘blowing’ in character
Describe the murmur heard in pulmonary regurgitation
“Graham-steel murmur”
Early diastolic, high pitched, ‘blowing’ in character
Describe the murmur heard in mitral stenosis
Mid-late diastolic
‘Rumbling’ in character
What are the clinical feature of right sided heart failure?
- fatigue
- raised JVP !!
- pitting oedema
- ascites
Describe the first and second line pharmacological treatment of angina
1 = beta blocker OR cardioselective CCB (verapamil, diltiazem)
2 = beta blocker AND non-cardioselective CCB (nifedipine)
dont combine β blocker with a cardioselective CCB as can cause a systole
Describe the immediate management of STEMI
- dual anti platelets: aspirin + clopidogrel/Ticagrelor/prasugrel
- anticoagulation, via unfractioned heparin
- PCI
Describe the first and second line pharmacological management of chronic heart failure
1st line = ACEi + βblocker
2nd line = add an aldosterone antagonist (mineralcorticoid receptor antagonist) e.g. spironolactone)
In pts who are on medication for chronic heart failure, including ACEi and aldosterone antagonists, what do you need to monitor?
Potassium levels! Both drugs can cause hyperkalaemia
In a pt presenting with high blood pressure for the first time, who is 60 years old and has T2DM, what is your first line pharmacological treatment option?
ACEi or ARB.
Any pt with T2DM should be on this treatment plan instead on CCP, despite their age
In a pt presenting with hypertension for the first time, who is 40 and of Afro-carribbean descent, what is your first line treatment option?
CCB!
No matter the age, pts of Afro-Caribbean descent with hypertension should be put on CCB
At what treatment line can thiazide-like diuretics be introduced for pts with hypertension?
Second line
At what line can Spironolactone be introduced for hypertensive pts?
4th line
At what line can β blockers be introduced for hypertensive pts?
4th line
Stroke prevention in a pt with a metallic heart valve replacement. What drug is preferred?
Warfarin.
DOACs less effective if metallic heart valve in place
What is the pharmacological management of pericarditis ?
NSAIDs + colchicine
Describe the Pathophysiology of aortic stenosis
Narrowing of the aortic valve, either due to degeneration calcification or the presence of a bicuspid aortic valve.
Describe the clinical features of aortic stenosis
- ejection systolic murmur, louder on expiration
- slow rising pulse
- soft/absent S2
- S4
What would be seen on CXR in mitral stenosis?
An enlarged left atrium
What would be heard on auscultation in mitral stenosis?
- Mid/late diastolic murmur, louder on expiration
- loud S1
What are the initial investigations required in suspected infective endocarditis?
- FBC
- blood cultures
- urinalysis
- ECG
Give 3 medical primary care interventions for ischaemic heart disease
- aspirin
- statins
- antihypertensives
Give 3 lifestyle primary care interventions for ischaemic heart disease
- smoking cessation
- dietary advice
- encourage regular exercise
What are the signs / symptoms of a STEMI? (9)
- central, crushing chest pain
- N/V
- light headed / dizzy
- SOB
- sweating
- anxiety / feeling of dread
- palpitations
- pallor
- hypotensive
Describe the effects of RAAS activation
(7)
- anterior vasoconstriction
- increased sympathetic activity
- increased tubular reabsorption of Na+ and Cl-
- increased tubular excretion of K+
- ADH secretion, causing increased H20 retention
- aldosterone secretion, causing increased Na+ retention
- overall, salt and water retention increase the blood pressure !!
What are 6 modifiable risk factors of STEMI?
- smoking
- hypertension
- diabetes
- obesity
- physical inactivity
- poor diet
what are 4 non-modifiable risk factors of STEMI?
- advanced age
- male sex
- family history of coronary artery disease
- previous history of coronary artery disease
Describe the ECG changes seen in 1st degree heart block
Prolonged PR interval
Describe the ECG changes seen in 2nd degree heart block, Mobitz type I
Progressive prolongation of the PR interval, followed by a dropped QRS complex
Describe the ECG changes seen in 2nd degree heart block, Mobitz type II
Intermittently non-conducted P waves.
Non preceded by prolonged PR interval OR followed by shortened PR interval
Describe the ECG changes seen in 3rd degree heart block
No association between P waves and QRS complex…
Atrial rate ~100bpm
Ventricular rate ~40bpm
Define embolism
Blocked vessel caused by a foreign body e.g. blood clot, gas bubble
Define thrombosis
Formation of a blood clot in a blood vessel, obstructive blood flow
Define infarction
Death of heart muscle due to reduced or absent blood supply
Define ischaemia
Restricted blood supply to tissues, causing oxygen shortage and therefore reduced cell function
What is the difference between essential hypertension and secondary hypertension?
Essential hypertension is idiopathic, occurring independently of any identifiable cause.
Secondary hypertension occurs as a result of an identifiable cause
List 3 causes of secondary hypertension
- renal artery stenosis
- conn’s syndrome (primary hyperaldosteronism)
- stress
- preeclampsia
- coarctation of the aorta
- pheochromocytoma
How does renal artery stenosis cause secondary hypertension?
Reduced lumen diameter of the renal arteries decreases the afferent arteriole pressure and renal perfusion.
This stimulates renin release, which causes angII and aldosterone release, causing increased renal reabsorption of Na+ and water.
Increased blood pressure via stimulation of RAAS
How does Conn’s syndrome cause secondary hypertension?
Hyper secretion of aldosterone -> renal retention of Na+ and water -> increased blood volume and pressure
How does stress cause secondary hypertension?
Emotional stress activates the sympathetic nervous system
Increased cardiac output and systemic vascular resistance
Increased BP
How does pregnancy cause secondary hypertension?
Increased blood volume!
How does coarctation of the aorta cause secondary hypertension?
Obstruction of the aorta reduced systemic arterial pressure, which activates RAAS.
RAAS works to increase BP
How does pheochromocytoma cause secondary hypertension?
Catecholamine (epinephrine) secretion increased vasoconstriction and cardiac output -> increased BP
ST elevation in leads V3, V4. What aspect of the heart is affected by this MI? Therefore, which artery is most likely affected?
Anterior aspect
LAD
An ECG is taken on someone suspected of suffering a myocardial infarction. They show abnormalities in leads II, III, and aVF.
Which 2 coronary arteries might be implicated?
Right coronary artery OR left circumflex
STEMI showing ST elevation in leads I, aVL, V5-V6
What two arteries are likely to be affected?
Left circumflex or LAD
STEMI showing ST elevation in leads II, III, aVF.
What two arteries might be affected?
Right coronary artery or Left circumflex
What does the left circumflex artery supply?
LA, LV
What does the LAD supply?
RV, LV, intraventricular septum
What does the left marginal artery supply?
LV
What does the right marginal artery supply?
RV, apex
What does the right coronary artery supply?
RA, RV
Describe the acute management of an MI
MONA
Morphine
O2 (if <95%)
Nitrates
Aspirin
Describe the management of a pt with a previous MI
- ACEi e.g. Ramipril
- Dual antiplatelet therapy: Aspirin and Clopidogrel
- Β blocker e.g. Propanolol
- Statin e.g. atorvostatin
In a pt with Px MI, asthma, what medication swap needs to be made?
CCB instead of β blocker
What CXR findings are found in heart failure?
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilation of upper lobe vessels
Effusions
List 3 DD for ST elevation on ECG
STEMI, Pericarditis, Prinzmetal angina
What is the first line management for supra ventricular tachycardia?
Valsalva manouvre
What is the first line investigation in suspected heart failure?
BNP
What is CHA2DS-VASc score used for?
To assess the starting of anticoagulation therapy in pts who have had a stroke
What is HAS-BLED score used for?
Estimates the risk of bleeding in pts who are on anticoagulation meds
What is QRISK3 used for?
Estimates the risk of a pt having a heart attack or stroke in the next 10 years
Describe the symptoms of aortic stenosis
SOB on exertion, angina, syncope
Describe the murmur heard in aortic stenosis
Ejection systolic murmur, crescendo-decrescendo pattern, radiation to the carotids
How is aortic stenosis diagnosed?
Echocardiogram (Doppler echo)
Name 2 risk factors for developing Mitral Valve Stenosis
- Rheumatic fever
- Untreated streptococcus infections
Give 2 RFs for developing mitral valve stenosis
- increasing age
-rheumatoid fever - untreated streptococcus infection
Give 2 characteristic heart sounds of Mitral Valve Stenosis
- Diastolic murmur
- Loud opening S1 snap
What is the gold standard investigation for diagnosing Mitral Valve Stenosis (1 mark)
Echocardiogram
Name 1 class of drug used to manage Mitral Valve Stenosis and give 1 example
- Beta Blockers + example: e.g. bisoprolol/ propranolol etc.
- Diuretics + example: e.g. Furosemide (Salt + loop diuretic) / Bendroflumethiazide (thiazide diuretic) etc.
Name 2 surgical interventions that can be used to treat Mitral Valve Stenosis
- Percutaneous mitral balloon valvotomy
- Mitral valve replacement
What cardiac arrhythmia is often associated with Mitral Valve Stenosis?
Atrial Fibrillation
Aside from IVDU, give 2 other risk factors for Infective Endocarditis
- Old age
- Prosthetic valve
- Congenital heart disease
- Poor dental hygiene
- Skin + soft tissue infection
- IV cannula
- Cardiac surgery
- Pacemaker
What is the name of the criteria used to diagnose Infective Endocarditis?
modified dukes criteria
What is the most common cause of infective endocarditis
Staph aureus
What aspect of chest pain differentiates pericarditis and an MI
Does NOT radiate to the jaws and teeth in pericarditis
Name 2 features elicited on clinical examination that would make you suspect pericarditis
- pericardial rub
- sinus tachycardia
- fever
- effusion signs
What would you expect on an ECG of a pt with pericarditis?
Saddle shaped ST elevation
How long should colchicine be given for in pts who have had acute pericarditis
6-8 weeks
What are the points awarded in CHADSVASc?
Congestive heart failure = 1
Hypertension = 1
Age 75 or over = 2
Diabetes mellitus = 1
Stroke/TIA/thromboembolism = 2
Vascular disease = 1
Age 65-74 = 1
Sex female = 1
Severe aortic stenosis signs
Small volume
Slow rising pulse
What does TIMI stand for?
Thrombolysis in myocardial infarction
What does ST elevation indicate?
Full thickness myocardium involvement
How does MI lead to scar formation?
Lack of oxygen -> necrosis -> formation of granulation tissue
What classic sign might a chest x-ray show in tetralogy of fallot?
Boot shaped heart!!
In an older child, which feature of TOF is squatting during exercise characteristic of?
Right to left shunt
What kind of murmur is caused by patent Decius arteriosus?
Continuous machinery murmur, loudest on S2
Define infarction
Death of heart muscle cells due to reduced/absent blood supply
Which feature of the clinical examination would suggest that the aortic stenosis is now severe?
A small volume and slow rising pulse
GS investigation of aortic stenosis?
Echocardiogram
Commonest cause of myocardial dysfunction leading to heart failure?
Ischaemic heart disease
What drug can be given to reduce the chance of recurrence of pericarditis? How long is it taken for?
Colchicine 1-2mg for the first day. 0.5mg for up to 6 months
What is a common side effect of CCB?
Ankle swelling
What is the first line management for haemodynamilcally unstable AF?
Cardio version with DC shock + anti coagulation
What is the first line management of haemodynamically stable AF?
Βeta blocker + anti coagulation
Why should CCB be stopped in heart failure?
CCB are relatively cardioselective.
Negative inotropes should be stopped as can worsen cardiac failure
What artery supples the AVN in most pts?
Right coronary artery
What is the first and second line management for supra ventricular tachycardia?
1 = modified Valsalva manoeuvre
2 = IV adenosine
Define endocarditis
Inflammation of the endocardium/heart valves due to infection
What is seen on echocardiogram in infective carditis?
Vegetations on the heart valves
Stable angina symptoms
- dyspnoea
- nausea
- sweatiness
- faintness
Stable angina ECG changes?
ST segment depression, T wave inversion
What is the who definition of hypertension?
140/90
Indications of end organ damage in hypertension?
Retinopathy, proteinuria
