Cardio Flashcards
What’s type A aortic dissection
Ascending aorta
2/3 cases
What’s type B aortic dissection
Descending aorta
1/3 of cases
What’s DeBakey’s type 1 aortic dissection
Originates in ascending aorta
Propagates to at least aortic arch
Possibly beyond it
What is DeBakey’s type 2 aortic dissection
Originates in and is confined to ascending aorta
What is DeBakey’s type 3 aortic dissection
Originates in descending aorta
Rarely extends proximally
Can extend distally
Management of type A dissection
Surgical management
Maintain BP over 100mmHg
Management of Type B aortic dissection
Conservative
Bed rest
Reduce BP with IV labetalol
Features of mitral stenosis
Dyspnoea
Haemoptysis
Mid-late diastolic murmur (best heard in expiration)
Loud S1
Opening snap
Low volume pulse
Malar flush
AF
Management of mitral stenosis
With AF as well - warfarin used with moderate/severe
Can use DOAC’s
Asymptomatic - regular echos
Symptomatic - percutaneous mitral balloon valvotomy or surgery
What is LBBB
Cardiac conduction abnormality due to slow or absent conduction through left bundle. Means left ventricle takes longer to fully depolarise. Wide QRS complexes.
Can be due to MI, HTN, cardiomyopathy
What is ventricular tachycardia
Broad complex tachy originating from a ventricular ectopic focus. Can go to VF.
What are the two types of VT?
Monomorphic - from MI
Polymorphic - torsades, long QT
Management of VT
Adverse signs - low bp, chest pain, heart failure - immediate cardioversion
Meds - amiodarone, lidocaine, procainamide
NEVER VERAPAMIL
What creates heart sound S1
Closure of mitral and tricuspid valves
When is S1 soft?
Long PR
Mitral regurg
When is S1 loud?
Mitral stenosis
What causes S2 heart sound?
Closure of aortic and pulmonary valves
When is S2 soft?
Aortic stenosis
What causes S3?
Diastolic filling of ventricle
Heard in LVF, constrictive pericarditis and mitral regurg
What causes S4?
Atrial constriction against a stiff ventricle
When is S4 heard?
Aortic stenosis
HOCM
HTN
Drug management of angina pectoris
Aspirin and statin if not CI
Sublingual GTN for attacks
Beta blocker or calcium channel blocker
If only ccb then verapamil or diltiazem
If in combination with bb then amlodipine or nifedipine.
Only add 3rd drug if waiting for PCI or CABG
3rd drugs - long acting nitrate, ivabradine, nicorandil, ranolazine
How does Flecainide work?
Blocks the Nav1.5 sodium channels in the heart
How does bisoprolol work
Blocks beta one adrenergic receptors in heart muscle
How does procainamide work
Induces rapid blocking of batrachotoxin activated sodium channels rapidly
What is S3 also known as?
Gallop rhythm
Aetiology of acute pericarditis
Viral infections - coxsackie
TB
Uraemia
Post MI - early (1-3d) fibrinous, late (weeks-months) Dressler’s
Radiotherapy
Connective tissue disease - SLE, RA
Hypothyroidism
Malignancy - lung and breast
Trauma
Features of acute pericarditis
Chest pain, pleuritic, relieved by sitting forwards
Non productive cough, dyspnoea, flu like symptoms
Pericardial rub
Acute pericarditis investigations
ECG changes - global and widespread not territories, saddle shaped ST elevation, PR DEPRESSION
TTE
Bloods - inflammatory markers, trop
Management of acute pericarditis
Majority as outpatient unless high risk (fever, raised trop)
Treat underlying cause
Avoid strenuous physical activity
Combination of NSAID’s and colchicine with idiopathic or viral
Common bugs of endocarditis
S aureus
S epidermidis if <2 months post valve surgery
Pathophysiology of arrhythmogenic right ventricular cardiomyopathy
Autosomal dominant
Right ventricular myocardium is replaced by fatty and fibrofatty tissue
Presentation of arrhythmogenic right ventricular cardiomyopathy
Palpitations
Syncope
Sudden cardiac death
Investigations of arrhythmogenic right ventricular cardiomyopathy
ECG - V1-3 anomalies, usually TWI,
Echo changes subtle - enlarged hypokinetic right ventricle
MRI to show fibrofatty tissue
Management of arrhythmogenic right ventricular cardiomyopathy
Drugs - sotalol
Catheter ablation
ICD
What’s Naxos disease
Autosomal recessive form of arrhythmogenic right ventricular cardiomyopathy
Triad of ARVC, palmoplantar keratosis, woolly hair
Congenital causes of Long QT syndrome
Jervell-Lange-Nielsen syndrome (included deafness)
Romano-Ward syndrome (no deafness)
Drug causes of prolonged QT interval
Amiodrarone, Dora lol
TCA’s, SSRI’s
Methadone
Chloroquine
Terfenadine
Erythromycin
Haloperidol
Ondansetron
Other causes of long qt interval
Electrolyte - hypocalcaemia, hypokalaemia, hypomagnasaemia
Acute MI
Myocarditis
Hypothermia
Subarach
MI complications
Cardiac arrest.
Cardiogenic shock
Chronic heart failure
Tachyarrhythmia
Bradyarrhythmia
Pericarditis
Left ventricular aneurysm
Ventricular septal defect
Acute mitral regurg
Why does cardiac arrest mostly happen after MI
Developing ventricular fibrillation
Common tachyarrhythmias after MI
Ventricular fibrillation
Ventricular tachycardia
Which bradyarrhythmia follows MI?
AV block follows inferior MI
What is Dressler’s syndrome and when does it occur?
2-6 weeks after MI
Pericarditis
Fever, pleuritic pain, pericardial effusion and raised ESR.
Treat with NSAID’s
Describe ventricular septal defect after MI
Occurs in first week
1-2% of patients
Acute heart failure and pan systolic murmur
Echo is diagnostic
Urgent surgical correction
Describe acute mitral regurgitation
More common with infero-posterior infarction and may be due to ischaemia or rupture of papillary muscle
Acute hypotension & pulmonary oedema
Early to mid systolic murmur
Treat with vasodilator therapy then surgery
When do you get a slow rising/plateau pulse?
Aortic stenosis
When do you get a collapsing pulse
Aortic regurgitation
Patent ductus arteriorsus
Hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Describe bisferiens pulse and when is it seen
‘Double pulse’ - two systolic peaks
Seen in mixed aortic valve disease
When do you get a jerky pulse??
HOCM
When do you get pulsus paradoxus
Severe asthma
Cardiac tamponade
When do you get pulsus paradoxus?
Severe Asthma
Cardiac Tamponade
Describe Eisenmenger’s syndrome
Reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension.
Occurs when an uncorrected left-to-right leads to a remodelling of the pulmonary microvasculature causing obstruction and pulmonary hypertension
What is Eisenmenger’s syndrome associated with
Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Features of Eisenmenger’s
Original murmur may disappear
Cyanosis
Clubbing
Right ventricular failure
Haemoptysis, embolism
Management of Eisenmenger’s
Heart-lung transplantation
When are ejection systolic murmurs louder on inspiration?
Pulmonary stenosis
Atrial septal defect
When are ejection systolic murmurs louder on expiration?
Aortic stenosis
HoCM
When are pansystolic murmurs herd
Mitral/tricuspid regurgitation - tricuspid louder during inspiration
Ventricular septal defect (harsh in character)
When do you get late systolic murmurs?
Mitral valve prolapse
Coarctation of aorta
When do you get early diastolic murmurs?
Aortic regurgitation (high pitch and blowing)
Graham-Steel murmur - pulmonary regurg
When do you get mid-late diastolic murmurs
Mitral stenosis (rumbling)
Austin-Flint murmur (severe aortic regurgitation)
When do you get a continuous machine-like murmur
Patent ductus arteriosus
Features of cardiac Tamponade
Becks triad -
Hypotension, Raised JVP & Muffled heart sounds
Other -
Dyspnoea & Tachycardia
Absent Y on descent of JVP
Pulsus paradoxus, Kussmaul’s
ECG - electrical alternans
Management of cardiac Tamponade
Urgent pericardiocentesis
What are the centrally acting antihypertensives?
Methyldopa - pregnancy
Moxonidine - essential HTN when conventional therapy failed
Clonidine - alpha-2 adrenoreceptors in vasomotor centre
What is the most common cardiac tumour?
Atrial myxoma
Where do you normally find atrial myxoma
Most in left atrium
Commonly attached to fossa ovalis
More common in females
Features of atrial myxoma
Systemic - dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
Emboli
Atrial Fibrillation
Mid diastolic murmur - tumour plop
Echo - pedunculated heterogenous mass
Which sign best indicates severe calcified aortic stenosis
Displaced apex beat
Which features of a broad complex tachycardia suggests VT rather than SVT
AV dissociation
Fusion or capture beats
Positive QRS concordance in chest leads
Marked left axis deviation
History of IHD
lack of response to adenosine or carotid sinus massage
QRS > 160ms
What is the role of dipyridamole?
Antiplatelet used in combination with aspirin after ischaemic stroke or TIA
How does dipyridamole work?
Inhibits phosphodiesterase elevating cAMP which reduce intracellular calcium
Reduced cellular uptake of adenosine and inhibition of thromboxane synthase
Features of severe MS
Length of murmur increases
Opening snap becomes closer to S2
Features of cholesterol embolism
Eosinophilia
Purpura
Renal failure
Livedo reticularis
Causes of cholesterol emboli
Secondary to vascular surgery or angiography
Also - severe atherosclerosis
Management of torsades de pointes
IV mag sulf
What is torsades de pointes
A form of polymorphic ventricular tachycardia associated with long QT interval.
May lead to VF then sudden death
Management of HOCM
Amiodarone
Beta blockers or verapamil
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis
Drugs to avoid in HOCM
Nitrates
ACEi
Inotropes
HOCM inheritance pattern
AD
1 in 500
Defect in genes encoding contractile proteins
Anteroseptal region ECG changes and artery involved
V1-V4
Left Anterior Descending
Inferior region ecg changes and artery involved
II, III & aVF
Right coronary
Anterolateral region ecg changed and artery involved
V1-V6, I & aVL
Proximal left anterior descending
Lateral region ecg changes and artery involved
I, aVL +/- V5-6
Left circumflex
Posterior region ecg changes and artery involved
V1-3
Left circumflex (also right coronary)
Horizontal ST depression
Upright T waves
Broad R waves
Dominant R wave in V2
ECG features of hypokalaemia
U waves
Small or absent T waves (occasionally inversion)
Prolonged PR interval
ST depression
Long QT
What is Ebstein’s anomaly
Congenital heart defect with low insertion of tricuspid valve resulting in large atrium and small ventricle
What is Ebstein’s anomaly associated with
Patent Foramen Ovale or Atrial Septal Defect
Wolff-Parkinson White syndrome
Clinical features of Ebstein’s anomaly
Cyanosis
Prominent ‘a’ wave in distended JVP
Hepatomegaly
Tricuspid regurgitation- pansystolic murmur, worse on inspiration
RBBB - widely split S1 and S2
Causes of ST depression on ecg
Secondary to abnormal QRS (LVH, LBBB, RBBB)
Ischaemia
Digoxin
Hypokalaemia
Syndrome X
Features of Takayasu’s arteritis
Systemic features of vasculitis - malaise, headache
Unequal blood pressure in upper limbs
Carotid bruit and tenderness
Absent or weak peripheral pulses
Upper and lower limb clarification on exertion
Aortic regurgitation
What is Takayasu’s arteritis associated with
Renal artery stenosis
Management of Takayasu’s arteritis
Steroids
Investigations into Takayasu’s arteritis
Vascular imaging of arterial tree either MRA or CTA
Features of aortic stenosis
Chest pain
Dyspnoea
Syncope/pre syncope
Murmur - ESM, radiates to carotids, decreases following valsalva
Features of severe aortic stenosis
Narrow pulse pressure
Slow rising pulse
Delayed ESM
Soft/absent S2
S4
Thrill
LVH
Causes of aortic stenosis
Degenerative calcification
Bicuspid aortic valve
William’s
Post-rheumatic disease
Subvalvular - HOCM
Fabry’s, SLE, Uraemia
Management of aortic stenosis
Valve replacement if symptomatic
Which anti hypertensive drugs need to be used cautiously in aortic stenosis?
Beta blockers
