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Finals > Cardio > Flashcards

Cardio Flashcards

1
Q

Really generally why does aortic regurg occur?

A

Disease of the aortic valve or distortion/dilation of the aortic root and ascending aorta

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2
Q

What are the causes of aortic regurgitation?

A

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

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3
Q

Features of aortic regurgitation

A
  • early diastolic murmur
  • collapsing pulse
  • wide pulse pressure
  • quincke’s sign (nailbed pulsation)
  • De musset’s sign (head bobbing)
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4
Q

Quincke’s sign

A

Nail bed pulsation

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5
Q

De musset’s sign

A

Head bobbing

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6
Q

Investigation aortic regurgitation

A

echocardiography

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7
Q

What are the indications for valve replacement in patients with AR

A
  • symptomatic AR
  • asymptomatic AR with LV systolic dysfunction
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8
Q

Symptoms aortic stenosis

A
  • chest pain
  • dyspnoea
  • syncope/presyncope
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9
Q

Murmur aortic stenosis

A

Ejection systolic murmur, radiating to the carotids

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10
Q

Features of aortic stenosis

A
  • narrow pulse pressure
  • slow rising pulse
  • soft/absent S2
  • S4
  • thrill
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11
Q

What are the causes of aortic stenosis

A
  • degnerative calcificaiton
  • bicuspid aortic valve
  • willilams syndrome
  • post rheumatic disease
  • HOCM
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12
Q

Management of aortic stenosis

A
  • asymptomatic then observe
  • symptomatic then valve replacement
  • asymptomatic but valvular gradient >40mmHg and features such as left ventricular systolic dysfunction then consider surgery
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13
Q

What are the options for aortic stenosis surgery?

A
  • 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
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14
Q

Mitral valve regurgitation risk factors

A
  • female
  • lower body mass
  • age
  • renal dysfunction
  • prior MI
  • prior mitral stenosis or valve prolapse
  • collagen disorders
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15
Q

What are the causes of mitral regurgitation

A
  • 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
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16
Q

Features of mitral regurgitation

A
  • pansystolic murmur
  • apex, radiates to the axilla
  • S1 may be quiet, in severe cases may have widely split S2
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17
Q

Management of mitral regurgitation

A
  • 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
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18
Q

Narrow QRS tachycardia management (stable)

A
  • 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
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19
Q

Broad complex tachycardia stable management

A
  • amiodarone 300mg IV over 10-60 minutes
  • if ineffective then synchronised DC shock up to 3 times
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20
Q

What are the causes of mitral stenosis?

A

Rheumatic fever

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21
Q

Features of mitral stenosis

A
  • dyspnoea
  • haemoptysis
  • mid-late diastolic murmur
  • loud S1
  • opening snap
  • low volume pulse
  • malar flush
  • atrial fibrillation
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22
Q

What is the management of mitral stenosis?

A
  • if they have associated AF then anti-coagulate with warfarin
  • asymtpomatic: regular echo
  • symptomatic: percutaneous mitral balloon valvotomy or mitral valve surgery
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23
Q

What are the causes of ejection systolic murmur?

A

Louder on expiration:
- aortic stenosis
- hypertrophic obstrucive cardiomyopathy

Louder on inspiration
- pulmonary stenosis
- atrial septal defect

  • teratology of fallot
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24
Q

What are the causes of a holosystolic (pansystolic murmur)

A
  • mitral/tricuspid regurgitation
  • ventricular septal defect
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25
Q

Early diastolic murmur

A
  • aortic regurgitation
  • graham- steel murmur
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26
Q

Mid-late diastolic murmur

A
  • mitral stenosis
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27
Q

Coronary artery anterior STEMI

A

Left anterior descending

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28
Q

Coronary artery inferior STEMI

A

Right coronary

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29
Q

Coronary artery lateral STEMI

A

Left circumflex

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30
Q

Initial drug therapy in ACS

A
  • aspirin 300mg
  • oxygen if SATs<94%
  • morphine if severe pain
  • nitrates (caution if hypotensive)
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31
Q

What is the STEMI criteria?

A
  • 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
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32
Q

In a confirmed STEMI, when should PCI be offered?

A
  • 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
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33
Q

What kind of stent for PCI

A

Drug eluting

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34
Q

Access for PCI

A

Radial is preferred to femoral

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35
Q

When should a patient be offered fibrinolysis?

A
  • 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
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36
Q

Further antiplatelet prior to PCI

A
  • aspirin +
  • prasugrel if not taking an oral anticoagulant
  • if taking an oral anticoagulant then clopidogrel
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37
Q

What should patients undergoing fibrinolysis be given

A

Antithrombin drug

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38
Q

Coronary artery anterolateral stemi

A

Left coronary artery

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39
Q

What are the types of myocardial infarction?

A
  • 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
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40
Q

Secondary prevention for ACS

A
  • aspirin 75mg once daily
  • another antiplatelet (ticagrelor or clopidogrel) for 12 months
  • atorvastatin
  • ace inhibitor
  • atenolol
  • aldosterone antagonist
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41
Q

Management of NSTEMI

A
  • 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

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42
Q

Which patients with NSTEMI or unstable angina should have coronary angiography

A
  • immediate: if clinically unstable (hypotensive)
  • within 72 hours: patients with a GRACE score of >3%
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43
Q

Killlip class 1

A

No clinical signs of heart failure

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44
Q

Killip class 2

A

Lung crackles, S3

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45
Q

Killip class 3

A

Frank pulmonary oedema

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46
Q

Killip class 4

A

Cardiogenic shock

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47
Q

What are the poor prognostic factors following ACS

A
  • 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
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48
Q

What is acute pericarditis?

A

inflammation of the pericardial sac, lasting less than 4-6 weeks

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49
Q

Causes of acute pericarditis

A
  • viral infection
  • tuberculosis
  • uraemia
  • post myocardial infarct
  • radiotherapy
  • connective tissue disease
  • hypothyroidism
  • malignancy (lung cancer, breast cancer)
  • trauma
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50
Q

Features of acute pericarditis

A
  • chest pain: pleuritic, relieved by sitting forwards
  • non productive cough
  • dyspnoea
  • flu like symptoms
  • pericardial rub
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51
Q

ECG pericarditis

A
  • widespread ECG changes
  • saddle shaped ST elevation
  • PR depression (most specific ECG marker)
52
Q

Investigation for suspected pericarditis

A
  • ECG
  • Transthoracic echo
  • bloods: inflammatory markers, troponin
53
Q

Management of pericarditis

A
  • 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
54
Q

Medical management of angina

A
  • 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)
55
Q

What do NICE adivse regarding nitrate tolerance

A

If experiencing tolerance then use asymmetric dosing regime to maintain a daily nitrate free time of 10-14 hours

56
Q

TIA antiplatelets

A
  • clopidogrel lifelong
57
Q

Associations of aortic dissection

A
  • hypertension
  • trauma
  • bicuspid aortic valve
  • marfans/ehlers-danlos
  • turners/noonans
  • pregnancy
  • syphilis
58
Q

Features of aortic dissection

A
  • chest/back pain typically maximal at onset
  • pulse deficit (weak or absent, or difference in BP >20mmHg systolic between the arms)
  • aortic regurg
  • hypertension
59
Q

What are the classifications of aortic dissection?

A
  • type A: ascending aorta, 2/3 of cases
  • Type B: descending aorta, distal to the left subclavian origin
60
Q

Investigation for aortic dissection

A
  • 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
61
Q

Management of type A dissection

A
  • surgical
  • BP target 100-120 systolic
62
Q

Management of a type B dissection

A
  • conservative management
  • bed rest
  • reduce the blood pressure with IV labetalol to prevent progression
63
Q

How to assess features of a murmur

A
  • site
  • character
  • radiation
  • intensity / grade
  • pitch
  • timing
64
Q

Murmur grades

A
  • 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
65
Q

What are the three major complications for mechanical heart valves?

A
  • thrombus formation
  • infective endocarditis
  • haemolysis causing anaemia
66
Q

CHADSVASC

A
  • congestive heart failure
  • hypertension
  • Age ≥75 (2), 65-74 (1)
  • Diabetes
  • Stroke or TIA
  • Vascular disease
  • Sex - woman
67
Q

Anticoagulation for cardioversion in AF

A
  • if onset is less than 48 hours then heparin
  • if greater than 48 hours then anticoagulate for at least 3 weeks
68
Q

Chemical cardioversion

A
  • amiodarone
  • flecainide if no structural heart disease
69
Q

Which patients should get rhythm control for AF?

A
  • reversible cause of AF
  • new onset AF (within 48 hours)
  • heart failure caused by AF
  • symptoms ongoing despite rate control
70
Q

Immediate cardioversion for AF

A
  • AF present for less than 48 hours
  • life threatening haemodynamic instability
71
Q

Cardioversion choice when delayed cardioversion

A

Electrical is recommended

72
Q

Score for risk of bleeding in AF for those on anticoagulation

A

ORBIT
O- older age (75+)
R- renal impairment (GFR<60)
B- Bleeding previously
I- Iron
T- taking antiplatelet medication

73
Q

First degree heart block

A

PR interval >0.2 seconds

74
Q

Second Degree heart block

A
  • 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
75
Q

Third degree heart block

A

No association between P and QRS waves

76
Q

What can raise levels of BNP?

A
  • heart failure
  • myocardial ischaemia
  • valvular disease
  • chronic kidney disease
77
Q

What are the side effects of beta blockers?

A
  • bronchospasm
  • cold peripheries
  • fatigue
  • sleep disturbance, including nightmares
  • erectile dysfunctions
78
Q

What are the contraindications to beta blockers?

A
  • uncontrolled heart failure
  • asthma
  • sick sinus syndrome
  • concurrent verapamil use: may precipitate severe bradycardia
79
Q

Buergers disease features

A
  • Extremity ischaemia
  • superficial thrombophlebitis
  • raynauds
80
Q

Becks triad

A

Cardiac tamponade
- hypotension
- raissed JVP
- muffled heart sounds

81
Q

What are the features of cardiac tamponade?

A
  • beck’s triad
  • dyspnoea
  • tachycardia
  • absent y on JVP
  • pulsus paradoxus (abnormally large drop in BP during inspiration)
  • ECG: electrical alternans
82
Q

What is the management of cardiac tamponade?

A

Urgent pericardiocentesis

83
Q

What decreases BNP levels?

A
  • obesity
  • diuretics
  • ACEi
  • Beta blockers
  • ARBs
  • aldosterone antagonists
84
Q

NYHA class 1

A
  • no symptoms
  • no limitations: ordianry physical exercise does not cause undue fatigue, dyspnoea, or palpitations
85
Q

NYHA class 2

A
  • mild symptoms
  • slight limitation of physical activity: comfortable at rest
    but ordinary activity results in fatigue/dyspnoea
86
Q

NYHA class III

A
  • moderate symptoms
  • marked limitation of physical activity, comfortable at rest
87
Q

NYHA class IV

A
  • severe symptoms
  • unable to carry out any physical activity without discomfort
  • symptoms at rest
88
Q

What is the mechanism of clopidogrel?

A

Antagonist of P2Y12 adenosine diphosphate ADP receptor, inhibiting the activation of platelets

89
Q

Features of coarctation of the aorta

A
  • 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)
90
Q

Features of complete heart block

A
  • syncope
  • heart failure
  • bradycardia
  • wide pulse pressure
  • JVP: cannon waves in S1
91
Q

Features of constrictive pericarditis

A
  • dyspnoea
  • right heart failure
  • JVP shows prominent x and y descent
  • pericardial knock: loud s3
  • kussmauls sign is positive
92
Q

What are the causes of dilated cardiomyopathy?

A
  • idiopathic
  • myocarditis
  • ischaemic heart disease
  • peripartum
  • hypertension
  • iatrogenic
  • substance abuse
  • genetic predisposition
  • infiltrative e.g. haemochromatosis, sarcoidosis
93
Q

Features of dilated cardiomyopathy

A
  • Heart failure
  • systolic murmur
  • S3
  • balloon appearance of the heart
94
Q

Management of eisenmenger’s syndrome

A

Heart-lung transplant

95
Q

Which valve is most commonly affected in infective endocarditis?

A

Mitral valve

96
Q

Most common cause of infective endocarditis

A

Staphylococcus aureus

97
Q

Infective endocarditis associated with dental procedure

A

Streptococcus viridans

98
Q

Infective endocarditis following valve surgery

A
  • Staph epidermidis
  • after 2 months, most likely is staph aureus
99
Q

What is the modified duke criteria?

A

Infective endocarditis can be diagnosied if pathological criteria positive, or 2 major criteria, or 1 major and 3 minor, or 5 minor criteria

100
Q

Duke pathological criteria

A

Positive histology or microbiology of pathological material obtained at autopsy or cardiac surgery

101
Q

Major criteria duke

A

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

102
Q

Minor criteria duke

A
  • 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
103
Q

Vascular phenomena infective endocarditis

A

major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions (non-tender) , petechiae or purpura

104
Q

Immunological phenomena infective endocarditis

A

glomerulonephritis, Osler’s nodes (tender), Roth spots

105
Q

Initial therapy for infective endocarditis

A
  • amoxicillin if native valve
  • if penicillin allergic, MRSA or severe sepsis then vancomycin and gent
  • if prosthetic valve: vancomycin+rifampicin + low dose gent
106
Q

What are the indications for surgery for infective endocarditis

A
  • severe valvular incompetence
  • aortic abscess
  • infections resistant to antibiotics/fungal infections
  • cardiac failure refractory to standard medical treatment
  • recurrent emboli after antibiotic therapy
107
Q

What are the post MI complications?

A
  • 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
108
Q

How long after MI left ventricular free wall rupture

A

1-2 weeks

109
Q

Presentation of left ventricular free wall rupture

A

Acute heart failure secondary to cardiac tamponade:
- raised JVP
- pulsus paradoxus
- diminished heart sounds

110
Q

Presentation of dressler’s syndrome

A
  • fever
  • pleuritic pain
  • pericardial effusion
  • raised ESR
  • 2-6 weeks post MI
111
Q

Presentation of acute mitral regurg post MI

A
  • acute hypotension
  • pulmonary oedema
112
Q

Features of takayasu arteritis

A
  • 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
113
Q

Management of takayasu’s arteritis

A

Steroid

114
Q

Features of takotsubo cardiomyopathy

A
  • chest pain
  • features of heart failure
  • ECG: st elevation
  • normal angiogram
115
Q

Management of takotsubo cardiomyopathy

A

Majority improve with supportive treatment

116
Q

What is the management of tosades de pointes?

A

IV magnesium sulphate

117
Q

Causes of a long QT interval

A
  • congenital
  • antiarrhythmics
  • tricyclics
  • antipsychotics
  • chloroquine
  • erythromycin
  • hypothermia
  • subarachnoid haemorrhage
  • hypocalcaemia, hypokalaemia, hypomagnesaemia
118
Q

ECG features wolff parkinson white

A
  • short PR interval
  • wide QRS with slurred upstroke (delta wave)
  • left axis deviation if right sided accessory pathway
119
Q

When should beta blockers be stopped in heart failure?

A
  • heart rate <50
  • second or third degree heart block
  • shock
120
Q

What is the investigation of choice for suspected aortic dissection?

A

CT aortic angiogram

121
Q

Warfarin target mechanical aortic valve

A

3

122
Q

Warfarin target mechanical mitral valve

A

3.5

123
Q

What is an early sign of LVF?

A

Gallop rhythm with S3

124
Q

Posterior MI on ECG

A

tall, broad R waves, ST depression and tall upright T waves

125
Q

Cardiac tamponade on ECG

A

Electrical alternans (alternating QRS amplitude)

126
Q
A

Finals (37 decks)

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