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Phase 2 > Cardio > Flashcards

Cardio Flashcards

1
Q

What is the intrinsic rate of the SA node?

A

60 - 100 BPM

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2
Q

What is the intrinsic rate of the AV node?

A

40 - 60 BPM

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3
Q

What is the intrinsic rate of the ventricular cells?

A

20 - 45 BPM

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4
Q

What is the intrinsic rate of the ventricular cells?

A

20 - 45 BPM

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5
Q

Describe the impulse conduction pathway

A

SAN -> AVN -> Bundle of His -> Bundle branches -> Purkinje fibres

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6
Q

One small box on ECG = ?

A

0.04 seconds
(40 milliseconds)

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7
Q

One large box on ECG = ?

A

0.20 seconds (horizontally)
0.5 mV (vertical)

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8
Q

Cardiac output (L/min) =

A

Stroke volume (L) x HR (BP)

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9
Q

Define total peripheral resistance

A

The total resistance to slow in systemic blood vessels from start of aorta to vena cava

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10
Q

What vessels provide the most resistance?

A

Arterioles

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11
Q

What is Starling’s Law?

A

Force of contrition is proportional to end diastolic length of cardiac muscle fibres
i.e. more ventricle fills, harder it contracts

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12
Q

What is S1?

A

Mitral and tricuspid valve closure

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13
Q

What is S2?

A

Aortic and pulmonary valve closure

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14
Q

What is S3?

A

In early diastole during rapid ventricular filling
Normal in children and pregnant women
Associated w/ Mitral Regurg and heart failure

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15
Q

What is S4?

A

“Gallop” in late diastole
Produced by blood forced into stiff hypertrophic ventricle
Associated w/ LV hypertrophy

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16
Q

Key presentation of peripheral arterial disease

A

6 Ps

Pain
Pulseless
Pallor
Perishingly cold
Paraesthesia
Paralysis

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17
Q

Symptoms of PAD

A

Intermittent claudication

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18
Q

Ix PAD

A

Colour Duplex USS - shows vessels and blood flow within

Ankle Brachial Pressure Index (ABPI) -
highest ankle systolic pressure / highest brachial systolic pressure
Normal = 1 - 1.2
PAD = ≤ 0.9 (below 0.4 is severe - rest pain)

If thinking of intervention,
MRI/CT angiography - identify stenosis and quality of vessels

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19
Q

Tx PAD

A

Lifestyle changes - to minimise risk of MI and relieve symptoms
e.g. stop smoking, treat HTN, lower cholesterol, improve diet, exercise

Anti-platelet therapy - Clopidogrel (P2Y12-i)

If severe :
percutaneous transluminal angioplasty or surgery

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20
Q

Describe the stages of chronic limb ischaemia

A

stage 1 - asymptomatic
stage 2 - intermittent claudication
stage 3 - rest pain/nocturnal pain
stage 4 - necrosis/gangrene

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21
Q

Complications of PAD

A

Acute limb ischaemia
∴ loss of limb

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22
Q

Key presentation of peripheral venous disease (DVT)

A

Red, swollen, warm limb
Dull achy contact pain

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23
Q

Ix DVT

A

Wells score - to assess likelihood

If DVT likely - venous ultrasound
If DVT unlikely - D-dimer first

GS : Venous ultrasound
If unavailable, CT scan

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24
Q

Tx DVT

A

If proximal, ANTI-COAG! for 3 months (unless CI)
DOACs, warfarin, heparin
Apixaban, rivaroxaban

If distal, check local protocol.
In UK, start anticoag unless ↑ risk of bleeding or if DVT < 5cm

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25
Q

What type of patients will need a tailored approach of treatment for DVT?

A

Pregnant, cancer, renal impairment patients

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26
Q

Complications of DVT

A

Pulmonary embolism

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27
Q

If a DVT patient present with marked swelling, significant pain and cyanosis, what should you suspect?

A

Phlegmasia cerulea dolens
IMMEDIATE TREATMENT - life and limb threatening !!!

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28
Q

Which artery? Hip/buttock pain

A

Aortic or iliac artery

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29
Q

Which artery? Thigh pain

A

Common femoral artery

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30
Q

Which artery? Upper 2/3rd of calf pain

A

Superior femoral artery

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31
Q

Which artery? Lower 2/3rd of calf pain

A

Popliteal artery

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32
Q

Which artery? Foot pain

A

Tibial or peroneal artery

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33
Q

Other signs/symptoms of PAD

A

Bruit - ‘Whooshing sounds’ when stethoscope over iliac arteries
Buerger’s test
Absent pulses
Ulcer’s don’t fully heal

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34
Q

Define HTN

A

Clinical BP - 140/90
At home - 135/85

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35
Q

Causes of 1st degree heart block

A

LEV’s disease (aka Lenegre’s)
IHD - scar tissue from myocyte death
Myocarditis
Hypokalaemia
AVN blocking drugs e.g. beta blockers, CCBs, Digoxin

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36
Q

Define 1st degree Heart Block

A

Delayed AV conduction but still makes it to ventricles
Prolonged PR interval > 0.22s

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37
Q

Key presentation of 1st Degree Heart Block

A

ASYMPTOMATIC!
no treatment required

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38
Q

Describe 2 places where electrical energy can be blocked

A
  1. AVN or Bundle of His = AV block
  2. Lower conduction system = BBB
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39
Q

Causes of 2nd Mobitz Type 1 heart block

A

AV node blocking drugs e.g. BB, CCB, Digoxin
Inf. MI

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40
Q

Define 2nd Mobitz Type 1 Heart Block

A

Atrial impulses fail to reach the ventricles
Progressive PR interval prolongation until beat is ‘dropped’ and P wave fails to conduct
PR wave then returns to normal

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41
Q

Key presentation of 2nd Mobitz Type 1 heart block

A

Light-headedness, dizziness, syncope

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42
Q

Causes of 2nd Mobitz Type 2 heart block

A

Block at intra-nodal level
Ant. MI
Mitral valve surgery
SLE, Lyme disease
Rheumatic fever

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43
Q

Key presentation of 2nd Mobitz Type 2 heart block

A

Dyspnoea, postural hypotension, chest pain, syncope

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44
Q

Describe 2nd Mobitz Type 2 heart block

A

PR interval is CONSTANT (NO PROLONGATION)
QRS intervals widened and dropped

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45
Q

State the causes of 3rd degree Heart Block

A

Structural heart disease
IHD e.g. acute MI
HTN
Endocarditis, Lyme disease

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46
Q

Describe 3rd degree heart block

A

COMPLETE dissociation between atria and ventricles i.e. P waves completely independent of QRS complex

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47
Q

What is a Narrow-complex escape rhythm?

A

QRS complex less than 0.12 seconds
Implies block originates in Bundle of His ∴ region of block lies more proximally in AV node

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48
Q

Tx 3rd degree heart block

A

IV atropine
Permanent pacemaker insertion

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49
Q

Tx 2nd degree heart block

A

If severe enough, permanent pacemaker insertion

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50
Q

What is Broad-complex escape rhythm?

A

QRS > 0.12 s
Block indicated to be Below His, more distal in His-Purkinje system

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51
Q

What can often occur with Broad-complex escape rhythm B?

A

Dizziness, Blackouts

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52
Q

Causes of Right Bundle Branch Block

A

PE
IHD
Atrial-ventricular septal defect

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53
Q

Causes of Left Bundle Branch Block

A

IHD
Aortic valve disease

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54
Q

Describe Right Bundle Branch Block

A

Right bundle no longer condutcs
∴ ventricles don’t receive impulses at same time, spread from left to right instead
∴ late activation of RV

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55
Q

How is a RBBB seen on an ECG?

A

Deep S wave in leads 1 and V6
Tall late R wave in lead V1

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56
Q

RF for PE

A

Age
DVT
Surgery within last 2 months
Bed rest > 5 days
Previous venous thromboembolic events
FHx

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57
Q

Why is there a difference in treatment between proximal and distal DVTs?

A

Proximal has a chance of PE, stroke etc
Bigger risk

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58
Q

Describe Virchow’s triad

A
  1. Vessel injury
  2. Venous stasis
  3. Activation of clotting system
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59
Q

Ix PE

A

ABCDE assessment
PERC rule if doesn’t meet PERC (PE rule-out criteria), use Wells score
D-dimer

GS : CT pulmonary angiography

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60
Q

Tx PE

A

Anticoag= - rivaroxaban, LMWH
Start O2 if sats < 90%
Thrombolysis - if massive clot

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61
Q

Key presentation of PE

A

If small - asymptomatic
If large - pleuritic pain + other symptoms
If massive - sudden death

Dyspnoea (↑ RR)
Syncope
Dizziness
Leg pain - DVT

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62
Q

Complications of PE

A

Respiratory alkalosis (due to ↑ RR)
Infarction

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63
Q

What can be heard in RBBB?

A

Wide physiological splitting of S2

64
Q

What can be heard in LBBB?

A

Reverse splitting of S2

65
Q

Cause of Infective Endocarditis

A

BACTERIA

Staph. aureus - most common
IVDU, diabetes + surgery
Infects damaged + healthy valves

Strep. viridans - most common in LICs
Dental problems!
Attacks previously damaged valves, low virulence

Staph. epidermis
Prosthetic materials e.g. prosthetic valves

Psuedomonas aeruginosa

66
Q

Describe the pathophysiology of IE

A

Damaged endocardium allows bacteria to thrive.
Creates a prothrombotic millieu
∴ colonisation of thrombus
∴ ↑ Platelet and fibrin deposition
∴ mature infected vegetation

67
Q

Why does damaged endocardium allow bacteria to thrive?

A

Increased platelet and fibrin deposition
They adhere to underlying collagen surface

68
Q

Key presentation of IE

A

Fever, headache, malaise, confusion, night sweats
(non-specific ∴ easily missed)

69
Q

Other signs/symptoms of IE

A

FROM JANE

Fever
Roth spots
Osler nodes
Murmur - usually aortic regurg

Janeway lesions
Anaemia
Nail-bed haemorrhages
Emboli

–
Sepsis of unknown origin
Clubbing
Anorexia
Weight loss
Fatigue
Glomerulonephritis
Haematuria

70
Q

What valves are usually affected with congenital or acquired defects in IE?

A

Left heart valves
More common to be left (mitral and aortic)

71
Q

What valves are usually affected with IVDU cause of IE?

A

Right heart valves

72
Q

Which bacteria causes IE to progress rapidly?

A

Staph. Aureus

73
Q

NEW HEART MURMUR + FEVER =

A

SUSPECT INFECTIVE ENDOCARDITIS

74
Q

Initial Ix IE

A

Duke’s criteria

Blood cultures - 3 sets over 24 hours OR 3 x persistently positive (i.e. 3 cultures 12 hours apart) FROM DIFFERENT SITES.
BEFORE Abx (but don’t delay Tx if sepsis or similar)
also bloods show - ↑ CRP, ↑ ESR, normochromic and normocytic anaemia

CXR - cardiomegaly
ECG long PR interval

75
Q

GS Ix IE

A

2 options :
TTE (transthoracic echo) - less discomfort, low sensitivity, negative TTE doesn’t rule out IE

TOE (transoesophageal) - signif more discomfort, much more sensitive and better at diagnosing!!

76
Q

Describe Duke’s criteria

A

2 major criteria
o Bugs grown from blood cultures
o Evidence of endocarditis on echo, or new valve leak

5 Minor criteria
o Predisposing factors
o Fever
o Vascular phenomena
o Immune phenomena
o Equivocal blood cultures

Definite IE: 2 major / 1 major + 3 minor / 5 minor

77
Q

What are some vascular phenomena of IE?

A

Janeway lesions, major arterial emboli

78
Q

What are some immunologic phenomena?

A

Roth spots, Osler nodes, Glomerulonephritis, Rh factor

79
Q

Tx IE

A

MDT approach
Abx ASAP - organism needs to be identified (and check for prosthetic valve) for specific antibiotic
Prolonged course! (6 weeks)
2 weeks IV, then oral

Treat comps if any

80
Q

What GS treatment should be chosen if a patient has a prosthetic valve?

81
Q

DDx IE

A

SLE
Antiphospholipid syndrome
Reactive arthritis
Meningitis

82
Q

IE complications

A

Arrhythmia
Heart failure
Heart block
Embolisation
Stroke rehab
Abscess drainage

83
Q

What Abx would you use to treat Staphylococcus in IE?

A

Vancomycin and Rifampicin (if MRSA)

84
Q

What Abx would you use for anything other than Staphylococcus in IE?

A

Penicillin - benzylpenicillin and gentamycin (doesn’t work by itself bc can’t get through bacterial cell wall)

85
Q

When might surgery be required in IE?

A

If infection cannot be cured by Abx i.e. returns after treatment

86
Q

What does surgery for IE comprise of?

A

Removal infected devices or removing large vegetations before they embolise

87
Q

Epidemiology of Acute pericarditis

A

M > F
Adults > children

88
Q

Define acute pericarditis

A

Acute inflammation of pericardium with or without effusion

89
Q

Causes of acute pericarditis

A

Viral - *Coxsackie virus B, echovirus, adenovirus, EBV
Bacterial - Mycobacterium tuberculosis
Fungal (rare) - Histoplasma spp. (immunocomp Pxs)

Non-infectious causes -
Autoimmune e.g. RA
Neoplastic e.g. tumours
Metabolic e.g. uraemia
Dressler’s

90
Q

Key presentation of Acute pericarditis

A

Chest pain - severe, sharp, pleuritic
Rapid onset
Might radiate to arm (trapezius ridge)
Relieved by sitting forward, exacerbated by lying down and inspiration

91
Q

Other signs/symptoms of Acute Pericarditis

A

Beck’s triad
Pericardial rub
Signs of effusion
Sinus tachycardia
Dyspnoea
Cough
Systemic disturbance - skin rash, joint pain

92
Q

Ix Acute Pericarditis

A

GS : ECG
Saddle shapped ST elevation - diagnostic
Diffuse ST segment elevation
PR depression

Other :
CXR - cardiomegaly in case of effusion
Echo - confirms effusion
FBC - for troponin, CK etc
D-dimer to rule out PE (but can be raised in both so consult senior if needed)

93
Q

Why is it important to rule out PE?

A

Bc if patient treated with anti-coag, can develop CARDIAC TAMPONADE!!
bc bleeding into pericardial space

94
Q

Tx Acute Pericarditis

A

NSAIDs, Aspirin
Colchicine - for 3 weeks, limited by nausea and diarrhoea but reduces recurrence

95
Q

What is commonly associated with acute pericarditis?

96
Q

DDx Pericarditis

A

MI
Angina
Pleuritic pain
Pulmonary infarction
Pneumonia, GI reflux, peritonitis, aortic dissection

97
Q

What is seen on an ECG with hypothermia?

98
Q

What is commonly associated with Aortic Regurg?

A

Wide pulse pressure
Collapsing pulse
Early-diastolic
Best heard over left sternal edge in 4th intercostal space
Best hear when patient sits forward

  • Du Musset’s sign
    Corrigan’s sign
    Muller’s sign
    Quincke’s sign
99
Q

Describe Aortic Regurg

A

Leakage of blood into LV from aorta during diastole
Due to ineffective coaptation of aortic cusps

100
Q

Causes of Aortic Regurg

A

IE - acute
Rheumatic fever - chronic
Congenital bicuspid aortic valve - chronic
Aortic root dilation

101
Q

Key presentation of Aortic Regurg

A

May be asymptomatic for many years before
Exertional dyspnoea
Palpitations
Angina

102
Q

Other signs/symptoms of Aortic Regurg

A

Orthopnea
Syncope
Paroxysmal nocturnal dyspnea

103
Q

Ix Aortic Regurg

A

ECG - shows LVH, rules out MI
CXR - cardiomegaly, aortic root enlargement

GS : Echo - TTE
TOE better but more invasive, use if suspect aortic dissection

104
Q

Tx Aortic Regurg

A

IE prophylaxis
Vasodilators - ACEi e.g. ramipril
Monitor progression
Surgery if symptoms increase - before LV dysfunction

105
Q

When would you prescribe vasodilators to treat a patient with aortic regurgitation?

A

If patient is symptomatic or has HTN
Otherwise, isn’t effective

106
Q

Define Aortic Stenosis

A

Narrowing of aortic valve resulting in obstruction to LV stroke volume

107
Q

Key presentation of aortic stenosis

A

SAD
Syncope, Angina, Dyspnoea

108
Q

Who commonly has Aortic Stenosis?

109
Q

Describe some key characteristics of Aortic Stenosis

A

Ejection systolic murmur
Crescendo-decrescendo
Soft/absent S2

Prominent S4
Slow rising carotid pulse
Decreased pulse amplitude

110
Q

How would you manage Dressler’s syndrome?

A

High dose aspirin

111
Q

What is adenosine?

A

Bronchoconstrictor

112
Q

When is adenosine contraindicated?

A

2nd and 3rd degree heart block
Decompensated heart failure

113
Q

Causes of aortic stenosis

A

Primarily bc of ageing - calcified aortic valve
Congenital bicuspid aortic valve (more common in men) - more prone to calcification
Rheumatic heart disease (v rare now)

114
Q

3 types of Aortic Stenosis

A
  1. Supravalvular
  2. Valvular
  3. Subvalvular
115
Q

When does calcification happen?

A

As you get older

116
Q

What is the normal area of the aortic valve?

117
Q

When do symptoms of Aortic Stenosis occur?

A

1/4 normal area
(i.e. ~1cm2)

118
Q

In Aortic Stenosis, what is the relationship between loudness of the murmur and severity?

A

Loudness does NOT indicate severity

119
Q

Elderly person w/ chest pain, exertional dyspnoea or syncope =

A

Aortic Stenosis!!

120
Q

Ix Aortic Stenosis

A

ECG - LV hypertrophy
LV strain pattern - depressed ST, T wave inversion (in LV leads)

CXR - LV hypertrophy, calcified aortic valve

GS : Echo - TTE
LV size + functions, doppler derived gradient and valve area

121
Q

DDx Aortic Stenosis

A

Mitral Regurg

122
Q

Tx Aortic Stenosis

A

Surgical aortic valve replacement
OR transcutaneous aortic valve implantation (TAVI)

123
Q

Define Mitral Regurg

A

Backflow of blood from LV to LA during systole

124
Q

Causes of Mitral Regurg

A

Abnormalities of valve, chordae etc
Myxomatous degeneration
Ischaemic mitral valve
Rheumatic heart disease
IE
Papillary muscle dysfunction
DCM

125
Q

RF Mitral Regurg

A

Females
Lower BMI
Advanced age
Renal dysfunction
Prior MI

126
Q

Describe the characteristics of Mitral Regurgitation

A

Pansystolic murmur at apex, radiates to axilla
Soft S1
Austin flint murmur at apex
Systolic ejection murmur
Diastolic blowing murmur at L sternal border

127
Q

Ix Mitral Regurg

A

ECG - may show LAH, LVH, AF. NOT diagnostic
CXR - LA enlargement, central pulmonary artery enlargement

GS : Echo - LA and LV size and function
Valve structure assessment
TOE is very helpful

128
Q

Key presentation of Mitral Regurg

A

Exertional dyspnoea, fatigue, lethargy, palpitations, symptoms of heart failure

129
Q

Tx Mitral Regurg

A

IE prophylaxis

Vasodilators - ACEi (hydralazine or ramipril)
HR control for AF - BB (atenolol), CCB, digoxin
Anti-coag for AF/flutter e.g. rivaroxaban
Diuretics for fluid overload - Furosemide

130
Q

Monitoring for Mitral Regurg

A

Do a follow-up echo

Mild - 2-3 years
Mod - 1-2 years
Severe - 6-12 months

131
Q

Indications for surgery in Mitral Regurg

A

ANY symptoms at rest OR exercise

If asymptomatic, if ejection fraction < 60%
OR if new onset AF

132
Q

Define Mitral Stenosis

A

Obstruction of LV inflow, prevents proper filling during diastole

133
Q

How many cusps in mitral valve?

134
Q

Normal mitral valve area

135
Q

Symptoms of Mitral Stenosis occur when

A

Mitral valve area < 2 cm2

136
Q

Cause of Mitral Stenosis

A

Rheumatic heart disease

obvs bc of rheumatic fever
∴ Untreated Strep infection is a RF !

137
Q

Epidemiology of Mitral Stenosis

138
Q

Key presentation of Mitral Stenosis

A

Symptoms present years/decades after rheumatic fever
Progressive dyspnoea

139
Q

Other signs/symptoms of Mitral Stenosis

A

Haemoptysis
Oedema
Malar flush
Palpitations
R HF

140
Q

Describe the characteristics of Mitral Stenosis

A

Diastolic murmur, heard when Px lying on left side in held exp
Longer murmur = more severe !!!
Loud S1
Most prominent at apex

141
Q

Ix Mitral Stenosis

A

ECG - AF, LAV
CXR - LAV, Pulmonary oedema, calcified mitral valve (maybe)

GS : Echo
Assesses mitral valve mobility, gradient and mitral valve area

142
Q

Tx Mitral Stenosis

A

Rate control - BB, digoxin
Diuretics - furosemide

Percutaneous mitral balloon valvotomy (less invasive) or surgical mitral valve replacement

143
Q

Why does medical therapy not prevent progression of Mitral Stenosis?

A

Because it is a mechanical problem

144
Q

Define heart failure

A

Inability of the heart to deliver blood and ∴ O2 that is required of the metabolising tissue of the body
Syndrome, not a disease

145
Q

Prognosis of heart failure

A

25-50% of patients die within 5 years of diagnosis

146
Q

RF of heart failure

A

65 +
African descent
M > F
Obesity
Prior MI

147
Q

Cause of Prinzmetal’s Angina

A

Coronary artery spasm

148
Q

Key presentation of Stable Angine

A

Chest pain/discomfort that :

  1. Heavy, central, tight and radiates to arms, jaw and neck
  2. Coincides with exertion/stress
  3. Relieved by rest/GTN spray
149
Q

Key presentation of Pericardial Effusion

A

Obscured apex beat, heart sounds are soft
Pleuritic pain

150
Q

Other signs/symptoms of Pericardial Effusion

A

Kussmaul’s sign - elevated JVP, rises w insp
Tachycardia
Hypotension
Chest discomfort
Cardiomegaly
Pulsus paradoxus

151
Q

What is pulsus paradoxus?

A

> 10mmHg decrease on inspiration

152
Q

Complication of Pericardial Effusion

A

CARDIAC TAMPONADE

153
Q

Ix Pericardial Effusion

A

CXR - large globular heart
ECG - low voltage QRS

GS : Echo
echo-free space around heart

154
Q

What is Beck’s triad?

A

Hypotension
Elevated JVP
Quiet heart sounds

155
Q

How would you treat cardiac tamponade?

A

Emergency pericardiocentesis

Phase 2 (24 decks)

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