Cardio Flashcards
Really generally why does aortic regurg occur?
Disease of the aortic valve or distortion/dilation of the aortic root and ascending aorta
What are the causes of aortic regurgitation?
Chronic - valve disease:
- rheumatic fever
- calcific valve disease
- connective tissue disease
- bicuspid aortic valve
Chronic - aortic root:
- bicuspid aortic valve
- spondyloathropathies
- hypertension
- syphilis
- marfans, ehler danlos
Acute - valve
- infective endocarditis
Acute aortic root
- aortic dissection
Features of aortic regurgitation
- early diastolic murmur
- collapsing pulse
- wide pulse pressure
- quincke’s sign (nailbed pulsation)
- De musset’s sign (head bobbing)
Quincke’s sign
Nail bed pulsation
De musset’s sign
Head bobbing
Investigation aortic regurgitation
echocardiography
What are the indications for valve replacement in patients with AR
- symptomatic AR
- asymptomatic AR with LV systolic dysfunction
Symptoms aortic stenosis
- chest pain
- dyspnoea
- syncope/presyncope
Murmur aortic stenosis
Ejection systolic murmur, radiating to the carotids
Features of aortic stenosis
- narrow pulse pressure
- slow rising pulse
- soft/absent S2
- S4
- thrill
What are the causes of aortic stenosis
- degnerative calcificaiton
- bicuspid aortic valve
- willilams syndrome
- post rheumatic disease
- HOCM
Management of aortic stenosis
- asymptomatic then observe
- symptomatic then valve replacement
- asymptomatic but valvular gradient >40mmHg and features such as left ventricular systolic dysfunction then consider surgery
What are the options for aortic stenosis surgery?
- surgical aortic valve replacement (low/med risk pts)
- transcatheter AVR (high risk patients)
- balloon valvuloplasty: children with no aortic valve calcification, critical aortic stenosis but not fit for valve replacement
Mitral valve regurgitation risk factors
- female
- lower body mass
- age
- renal dysfunction
- prior MI
- prior mitral stenosis or valve prolapse
- collagen disorders
What are the causes of mitral regurgitation
- Post MI/coronary artery disease: papillary muscles or chordae tendinae affected
- mitral valve prolaspe: leaflet of valve deformed
- infective endocarditis: vegetations stop valve closing properly
- rheumatic fever (inflamed valve)
- congenital
Features of mitral regurgitation
- pansystolic murmur
- apex, radiates to the axilla
- S1 may be quiet, in severe cases may have widely split S2
Management of mitral regurgitation
- medical management: nitrates, diuretics, positive inotropes, intra-aortic balloon pump to increase output
- if in heart failure: ACEi, beta blockers, spironolactone
- acute severe regurg: surgery
Narrow QRS tachycardia management (stable)
- vagal manoeuvres
- adenosine 6mg rapid IV bolus, then 12, then 18
- if ineffective then verampamil or beta blocker
- if ineffective then synchronised DC shock up to 3 times
Broad complex tachycardia stable management
- amiodarone 300mg IV over 10-60 minutes
- if ineffective then synchronised DC shock up to 3 times
What are the causes of mitral stenosis?
Rheumatic fever
Features of mitral stenosis
- dyspnoea
- haemoptysis
- mid-late diastolic murmur
- loud S1
- opening snap
- low volume pulse
- malar flush
- atrial fibrillation
What is the management of mitral stenosis?
- if they have associated AF then anti-coagulate with warfarin
- asymtpomatic: regular echo
- symptomatic: percutaneous mitral balloon valvotomy or mitral valve surgery
What are the causes of ejection systolic murmur?
Louder on expiration:
- aortic stenosis
- hypertrophic obstrucive cardiomyopathy
Louder on inspiration
- pulmonary stenosis
- atrial septal defect
- teratology of fallot
What are the causes of a holosystolic (pansystolic murmur)
- mitral/tricuspid regurgitation
- ventricular septal defect
Early diastolic murmur
- aortic regurgitation
- graham- steel murmur
Mid-late diastolic murmur
- mitral stenosis
Coronary artery anterior STEMI
Left anterior descending
Coronary artery inferior STEMI
Right coronary
Coronary artery lateral STEMI
Left circumflex
Initial drug therapy in ACS
- aspirin 300mg
- oxygen if SATs<94%
- morphine if severe pain
- nitrates (caution if hypotensive)
What is the STEMI criteria?
- clinical symptoms consistent with ACS for ≥20 minutes with persistent ECG features in ≥2 continguous leads of:
- 2.5mm ST elevation in leads V2-3 in men under 40 or ≥2mm elevation in men over 40
- 1.5mm ST elevation in V2-3 in women
- 1mm ST elevation in other leads
- new LBBB
In a confirmed STEMI, when should PCI be offered?
- if the presentation is within 12 hours of symptom onset and PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given
- in a patient who has received fibrinolysis whose ECG fails to show resolution of the ST elevation
What kind of stent for PCI
Drug eluting
Access for PCI
Radial is preferred to femoral
When should a patient be offered fibrinolysis?
- should be offered within 12 hours of symptom onset if primary PCI cant be delivered within 120 minutes of the time fibrinolysis could have been given
Further antiplatelet prior to PCI
- aspirin +
- prasugrel if not taking an oral anticoagulant
- if taking an oral anticoagulant then clopidogrel
What should patients undergoing fibrinolysis be given
Antithrombin drug
Coronary artery anterolateral stemi
Left coronary artery
What are the types of myocardial infarction?
- Type 1: traditional MI due to ACS
- Type 2: increased demand or reduced supply of oxygen
- Type 3: sudden cardiac death or cardiac arrest suggestive of an ischaemic event
- Type 4: MI associated with PCI, coronary stenting and CABG
Secondary prevention for ACS
- aspirin 75mg once daily
- another antiplatelet (ticagrelor or clopidogrel) for 12 months
- atorvastatin
- ace inhibitor
- atenolol
- aldosterone antagonist
Management of NSTEMI
- GRACE score to decide on PCI or angiography
- Aspirin 300mg stat dose
- Ticagrelor 180mg
- Morphine
- antithrombin (fondaparinux)
- Nitrate (GTN)
Oxygen if sats less than 94
Which patients with NSTEMI or unstable angina should have coronary angiography
- immediate: if clinically unstable (hypotensive)
- within 72 hours: patients with a GRACE score of >3%
Killlip class 1
No clinical signs of heart failure
Killip class 2
Lung crackles, S3
Killip class 3
Frank pulmonary oedema
Killip class 4
Cardiogenic shock
What are the poor prognostic factors following ACS
- age
- development or history of heart failure
- peripheral vascular disease
- reduced systolic blood pressure
- killip class
- initial serum creatinine concentration
- elevated initial cardiac markers
- cardiac arrest on admission
- ST segment deviation
What is acute pericarditis?
inflammation of the pericardial sac, lasting less than 4-6 weeks
Causes of acute pericarditis
- viral infection
- tuberculosis
- uraemia
- post myocardial infarct
- radiotherapy
- connective tissue disease
- hypothyroidism
- malignancy (lung cancer, breast cancer)
- trauma
Features of acute pericarditis
- chest pain: pleuritic, relieved by sitting forwards
- non productive cough
- dyspnoea
- flu like symptoms
- pericardial rub
ECG pericarditis
- widespread ECG changes
- saddle shaped ST elevation
- PR depression (most specific ECG marker)
Investigation for suspected pericarditis
- ECG
- Transthoracic echo
- bloods: inflammatory markers, troponin
Management of pericarditis
- majority outpatient
- if fever >38 or elevated troponin then inpatient
- treat any underlying cuase
- advise avoiding any stenuous physical activity until symptom resolution and normalisation of inflammatory markers
- NSAID and colchinine if acute idiopathic or viral pericarditis until symptom resolution and normalisaton of inflammatory markers
Medical management of angina
- Aspirin
- statin
- beta blocker or calcium channel blocker (if remains symptomatic add the other but never verapamil and beta blocker due to risk of complete heart block)
What do NICE adivse regarding nitrate tolerance
If experiencing tolerance then use asymmetric dosing regime to maintain a daily nitrate free time of 10-14 hours
TIA antiplatelets
- clopidogrel lifelong
Associations of aortic dissection
- hypertension
- trauma
- bicuspid aortic valve
- marfans/ehlers-danlos
- turners/noonans
- pregnancy
- syphilis
Features of aortic dissection
- chest/back pain typically maximal at onset
- pulse deficit (weak or absent, or difference in BP >20mmHg systolic between the arms)
- aortic regurg
- hypertension
What are the classifications of aortic dissection?
- type A: ascending aorta, 2/3 of cases
- Type B: descending aorta, distal to the left subclavian origin
Investigation for aortic dissection
- Chest X ray shows widened mediastinum
- CT angiography of the chest abdomen and pelvis (investigation of choice) : false lumen= key finding
- Transoesophageal echocardiography if unstable
Management of type A dissection
- surgical
- BP target 100-120 systolic
Management of a type B dissection
- conservative management
- bed rest
- reduce the blood pressure with IV labetalol to prevent progression
How to assess features of a murmur
- site
- character
- radiation
- intensity / grade
- pitch
- timing
Murmur grades
- Grade I: difficult to hear
- Grade II: quiet
- Grade III: Easy to hear
- Grade IV: easy to hear with a palpable thrill
- Grade V: audible with a stethoscope barely touching the chest
- Grade VI: audible with stethoscope off the chest
What are the three major complications for mechanical heart valves?
- thrombus formation
- infective endocarditis
- haemolysis causing anaemia
CHADSVASC
- congestive heart failure
- hypertension
- Age ≥75 (2), 65-74 (1)
- Diabetes
- Stroke or TIA
- Vascular disease
- Sex - woman
Anticoagulation for cardioversion in AF
- if onset is less than 48 hours then heparin
- if greater than 48 hours then anticoagulate for at least 3 weeks
Chemical cardioversion
- amiodarone
- flecainide if no structural heart disease
Which patients should get rhythm control for AF?
- reversible cause of AF
- new onset AF (within 48 hours)
- heart failure caused by AF
- symptoms ongoing despite rate control
Immediate cardioversion for AF
- AF present for less than 48 hours
- life threatening haemodynamic instability
Cardioversion choice when delayed cardioversion
Electrical is recommended
Score for risk of bleeding in AF for those on anticoagulation
ORBIT
O- older age (75+)
R- renal impairment (GFR<60)
B- Bleeding previously
I- Iron
T- taking antiplatelet medication
First degree heart block
PR interval >0.2 seconds
Second Degree heart block
- Mobitz type 1: progressive prolongation of the PR interval until a dropped beat occurs
- Type 2: PR interval is constant but P wave is often not followed by a QRS complex
Third degree heart block
No association between P and QRS waves
What can raise levels of BNP?
- heart failure
- myocardial ischaemia
- valvular disease
- chronic kidney disease
What are the side effects of beta blockers?
- bronchospasm
- cold peripheries
- fatigue
- sleep disturbance, including nightmares
- erectile dysfunctions
What are the contraindications to beta blockers?
- uncontrolled heart failure
- asthma
- sick sinus syndrome
- concurrent verapamil use: may precipitate severe bradycardia
Buergers disease features
- Extremity ischaemia
- superficial thrombophlebitis
- raynauds
Becks triad
Cardiac tamponade
- hypotension
- raissed JVP
- muffled heart sounds
What are the features of cardiac tamponade?
- beck’s triad
- dyspnoea
- tachycardia
- absent y on JVP
- pulsus paradoxus (abnormally large drop in BP during inspiration)
- ECG: electrical alternans
What is the management of cardiac tamponade?
Urgent pericardiocentesis
What decreases BNP levels?
- obesity
- diuretics
- ACEi
- Beta blockers
- ARBs
- aldosterone antagonists
NYHA class 1
- no symptoms
- no limitations: ordianry physical exercise does not cause undue fatigue, dyspnoea, or palpitations
NYHA class 2
- mild symptoms
- slight limitation of physical activity: comfortable at rest
but ordinary activity results in fatigue/dyspnoea
NYHA class III
- moderate symptoms
- marked limitation of physical activity, comfortable at rest
NYHA class IV
- severe symptoms
- unable to carry out any physical activity without discomfort
- symptoms at rest
What is the mechanism of clopidogrel?
Antagonist of P2Y12 adenosine diphosphate ADP receptor, inhibiting the activation of platelets
Features of coarctation of the aorta
- infancy: heart failure
- adult: hypertension
- radio-femoral delay
- mid systolic murmur, maximal over the back
- apical click from the aortic valve
- notching of the inferior border of the ribs (not seen in young children)
Features of complete heart block
- syncope
- heart failure
- bradycardia
- wide pulse pressure
- JVP: cannon waves in S1
Features of constrictive pericarditis
- dyspnoea
- right heart failure
- JVP shows prominent x and y descent
- pericardial knock: loud s3
- kussmauls sign is positive
What are the causes of dilated cardiomyopathy?
- idiopathic
- myocarditis
- ischaemic heart disease
- peripartum
- hypertension
- iatrogenic
- substance abuse
- genetic predisposition
- infiltrative e.g. haemochromatosis, sarcoidosis
Features of dilated cardiomyopathy
- Heart failure
- systolic murmur
- S3
- balloon appearance of the heart
Management of eisenmenger’s syndrome
Heart-lung transplant
Which valve is most commonly affected in infective endocarditis?
Mitral valve
Most common cause of infective endocarditis
Staphylococcus aureus
Infective endocarditis associated with dental procedure
Streptococcus viridans
Infective endocarditis following valve surgery
- Staph epidermidis
- after 2 months, most likely is staph aureus
What is the modified duke criteria?
Infective endocarditis can be diagnosied if pathological criteria positive, or 2 major criteria, or 1 major and 3 minor, or 5 minor criteria
Duke pathological criteria
Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery
Major criteria duke
Blood cultures:
- two positive blood cultures showing typical organisms
- persistent bacteraemia from two blood cultures taken >12 hours apart or three or more if the pathogen is less specific e.g. staph aurues
- positive serology for coxiella, bartonella, chalmydia psittaci
- positive molecular assays for specific gene targets
Evidence of endocardial involvement
- positive echocardiogram
- new valvular regurgitation
Minor criteria duke
- predisposing heart condition or IVDU
- microbiological evidence not meeting major criteria
- fever >38
- vascular: major emboli, splenomegaly, clubbing, splinter haemorrhage, janeway lesion, petechia or purpura
- immunological: glomerulonephritis, osler nodes, roth spots
Vascular phenomena infective endocarditis
major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions (non-tender) , petechiae or purpura
Immunological phenomena infective endocarditis
glomerulonephritis, Osler’s nodes (tender), Roth spots
Initial therapy for infective endocarditis
- amoxicillin if native valve
- if penicillin allergic, MRSA or severe sepsis then vancomycin and gent
- if prosthetic valve: vancomycin+rifampicin + low dose gent
What are the indications for surgery for infective endocarditis
- severe valvular incompetence
- aortic abscess
- infections resistant to antibiotics/fungal infections
- cardiac failure refractory to standard medical treatment
- recurrent emboli after antibiotic therapy
What are the post MI complications?
- cardiac arrest due to VF
- cardiogenic shock
- chronic heart failure
- tachyarrhythmia, VF/VT
- bradyarrhythmia (AV block: more common if inferior MI)
- pericarditis: in 1st 48 hours
- dresslers: 2-6 weeks post MI , fever, pleuritic pain, pericardial effusion and raised ESR
- LV aneurysm: persistent ST elevation and left ventricular failure
- Left ventricular free wall rupture (1-2 weeks after)
- ventricular septal defect
- acute mitral regurgitation
How long after MI left ventricular free wall rupture
1-2 weeks
Presentation of left ventricular free wall rupture
Acute heart failure secondary to cardiac tamponade:
- raised JVP
- pulsus paradoxus
- diminished heart sounds
Presentation of dressler’s syndrome
- fever
- pleuritic pain
- pericardial effusion
- raised ESR
- 2-6 weeks post MI
Presentation of acute mitral regurg post MI
- acute hypotension
- pulmonary oedema
Features of takayasu arteritis
- systemic features of vasculitis
- unequal blood pressure in the upper limbs
- carotid bruit and tenderness
- absent or weak peripheral pulses
- upper and lower limb claudication on exertion
- aortic regurg
Management of takayasu’s arteritis
Steroid
Features of takotsubo cardiomyopathy
- chest pain
- features of heart failure
- ECG: st elevation
- normal angiogram
Management of takotsubo cardiomyopathy
Majority improve with supportive treatment
What is the management of tosades de pointes?
IV magnesium sulphate
Causes of a long QT interval
- congenital
- antiarrhythmics
- tricyclics
- antipsychotics
- chloroquine
- erythromycin
- hypothermia
- subarachnoid haemorrhage
- hypocalcaemia, hypokalaemia, hypomagnesaemia
ECG features wolff parkinson white
- short PR interval
- wide QRS with slurred upstroke (delta wave)
- left axis deviation if right sided accessory pathway
When should beta blockers be stopped in heart failure?
- heart rate <50
- second or third degree heart block
- shock
What is the investigation of choice for suspected aortic dissection?
CT aortic angiogram
Warfarin target mechanical aortic valve
3
Warfarin target mechanical mitral valve
3.5
What is an early sign of LVF?
Gallop rhythm with S3
Posterior MI on ECG
tall, broad R waves, ST depression and tall upright T waves
Cardiac tamponade on ECG
Electrical alternans (alternating QRS amplitude)
