Cardio Flashcards
NSTEMI Mx
Invasive coronary angiography + angioplasty + stent
CABG
Myocardial CP with negative trop Ix
Pre test probability (GRACE/TIMI) —> high mortality: invasive coronary angiography
Low: CTCA
Functional tests: exercise stress, MIBI scan, stress echo, MRI
Stable angina Rx
10 yr CV event risk >10% - statin
Aspirin
Anti angina (BB, nitrate, CCB, Nicorandil, ranazine, ivabradine)
If symptoms persist on 2x drugs then consider revascularization
Pericarditis with effusion causes
Infective: viral, HIV, TB
Uraemia
Cancer
Autoimmune disease: RA, lupus
Prev trauma / cardiac surgery
Post MI (dressers)
Signs that AS is severe
Soft/delayed S2 (A2) - immobile leaflets & prolonged LV emptying
Delayed ESM
S4
Complications of AS
IE
LV dysfunction
Pulmonary HTN –> RV failure
Conduction problems
DDx ESM
HOCM
VSD
AS/Aortic sclerosis
Flow murmur
CC of AS
Bicuspid (congenital)
Rheumatic
Calcification/Age
Associations:
- coarctation/bicuspid valve
- angiodysplasia - Heydes syndrome
Ix for AS
ECG: ? LVH, conduction issues (long PR)
Bloods: anaemia (Heydes), ESR (IE)
CXR: calcified valve, HF
Echo: mean gradient >40mmHg = severe + reduced LV function
ETT: BP drop + symptomatic
CT: calcification, coronary/peripheral artery patency?
Cardiac catheter: invasive gradients
Mx of AS
ASx: regular review of symptoms + echo to assess gradient/LV function
ASx + LVEF <50% ? surgery
Symptomatic:
- Aortic valve replacement +/- CABG
(low operative mortality: EuroScore I or II)
- TAVI (transcutaneous aortic valve implantation) in high surgical risk EuroScore >20%, frail, prev cardiac surgery
Duke’s Criteria for IE
Major:
- Typical organism in BC x2
- Echo = abscess/vegetation/dehiscence
Minor:
- Fever >38
- Echo suggestive
- Predisposed eg prosthetic valve
- Embolic phenomena
- Vasculitis phenomena (CRP/ESR)
- Atypical organism on BC
2 major
1 major + 2 minor
5 minor
IE - who gets Abx prophylaxis?
Prosthetic valves
Prev IE
Cardiac transplants with valvulopathy
Some congenital heart disease
AR eponymous signs
Corrigons: visible vigorous neck pulsation
Quinckes: nail bed capillary pulsation
De Mussets: visible head nod
Taubes: pistol shot sound over femoral arteries
DDx: collapsing pulse - high flow state - pregnancy, anaemia, thyrotoxic
Causes of AR
Valvular
Biscuspid aortic valve
Endocarditis
Rheumatic Fever
Dilitation
Aortic root dissection (type A)
Marfans
HTN
Aortitis
Ank spond / Vasculitis/ syphillis
Ix of AR
Bloods for IE/vasculitis
CXR: cardiomegaly, pulm oedema
CT: size of aortic root/dissection
Echo: LVEF, LV size, aortic root size, vegetation, jet width
Cardiac catheter pre-op? coronary patency
Mx of AR
HF Mx = ACEI/ARB (reduce afterload)
Regular review of Sx/Echo
Acute (dissection/IE/aortic root abscess) - SURGERY
Aortic root dilation of >5cm
Chronic - SURGERY if:
- Symptoms: reduced ET (NYHA >II)
and/or
- 1) Pulse pressure >100mmHg
- 2) ECG changed on ETT
- 3) LVEF <50%, LV ESD >50mm, >65% LVOT width
Complications of mitral stenosis
Pulm HTN –> RHF
Pulm oedema.
Endocarditis
Embolic complications (high stroke risk if MS + AF)
CC of mitral stenosis
Rheumatic (MCC)
Senile degeneration
IE
Ix of mitral stenosis
Bloods: IE
ECG: p mitrale, AF
CXR: enlarged left atrium, pulm oedema
Echo:
- severe = valve<1cm2, gradient >10mmHg
- left atrial thombus, calcified valve?
- RVF + pulm HTN >50mmHg
Mx of mitral stenosis
AF - rate control + anticoag
HF - diuretic
Mitral valvuloplasty - if valve pliable + not calcified, no atrial thrombus
Mitral valvotomy surgery (open or closed)
Rheumatic fever pathophysiology
= immunological cross-reactivity between group A b-haemolytic streptococcal infection & valve tissue
Rheumatic fever Duckett-Jones diagnostic criteria
proven b-haemolytic streptococcal infection (throat swab, rapid antigen detection, asot)
or
clinical scarlet fever
plus 2 major or 1 major+2minor
major:
- chorea
- erythema marginatum
- subcut nodules
- polyartritus
- carditis
minor:
- raised esr
- raised wcc
- arthragia
- prev `RF
- pyrexia
- prolonged pr interval
Rheumatic fever mx
rest, high-dose aspirin, penicillin
MR complications
AF (LA enlargement)
Pulm oedema (increased left pressure)
Pulm HTN
IE
Embolic complications
CC of MR
Congenital (association with primum ASD)
Acute:
- IE
- Papillary rupture
Chronic:
- Prolapse
- CTD
- Rheumatic fever
- Infiltration (amyloid)
- Dilated LV (functional MR)
- Calcification
Ix of MR
Bloods: IE, CTD
ECG: p mutrale, AF, prev MI (Q wave)
CXR: cardiomegaly, large LA, pulm oedema
Echo:
- Severity: volume of MR jet, LV dilitation, reduced EF
- Cause: vegetation, torn chordae/ ruptured papillae, ASD
Cardiac MRI: volume of MR
Mx of MR
Anticoag - AF/embolic comp
HF: diuretic, BB, ACEI
Percutaneous repair - high surgical risk + symptomatic despite optimal medical Mx
Surgical (preferred) - annuloplasty ring/valve replacement - ideally before HF
CC of TR:
Congenital = Ebsteins anomaly (atrialization of RV + TR)
IE (IVDU)
Functional (MC, dilated RV 2’ to left heart disease)
Implantable device leads –> splint tricuspid valve open
Rheumatic fever
Ix of TR:
ECG: p pulmonale, AF, RV strain
CXR: double right heart border (enlarged RA)
Echo: TR jet, RV dilatation
Mx of TR
HF: Diuretics, b-blocker, ACE I, stockings for oedema
Percutaneous
Surgical valve repair if medical mx fails
Pulmonary Stenosis Assoc
ToF - PS, overiding aorta, VSD, RVH (sternotomy scar)
Noonan’s syndrome (male turners)
Carcinoid syndrome (gut primary with liver mets secreting 5HT into circulation) –> diarrhoea/wheeze/flush + right heart valve fibrosis (TR + PS) - Rx: somatostatin analogue
Pulmonary stenosis Ix
ECG: p pulmonale, RVH, RBBB
CXR: large RA/RV
Echo: severity, RV function, assoc
Mx pulmonary stenosis
Pulmonary valvectomy - gradient >70mmHg or RV Failure
Percutaneous pulmonary valve implant
Surgical repair/replacement
Late complications of prosthetic valves
- Thromboembolus (despite warfarin)
- Bleeding
- Bioprosthetic dysfunction + LV failure
- Haemolysis
- IE –> stap epidermis (early), strep viridans (late)
- AF
Implantable devce complications
Acute
- Local infection
- PTX
- Pericardial effusion /tamponande
Chronic:
- IE
- TR
Indications for an ICD (can be subcutaneous or transvenous)
Primary prevention:
- Familial condition risk of SCD: LQTS, ARVD, Brugada, HCM, congenital
- MI >4wks ago with reduced EF + VT/broad qrs
Secondary prevention:
- Cardiac arrest due to VT/VF
- Sustained VT with compromise / HF
Indications for a CRT
LVEF <35%
NYHA II - IV on optimal medical Mx
Sinus rhythm with broad Qs
Indications for a pacemaker
3s pause
Tachy-brady
Sx mobitz type 2
CHB
CC of constrictive pericarditis
TB - cervical LN
Trauma - sternotomy/post-MI
Tumour
Therapy (radio) - tattoo, thoracotomy
Tissue - CTD: RA, SLE
Ix in constrictive pericarditis
CXR: pericardial calcification, old TB, sternotomy wires
Echo: high signal pericardium, ventricular interdependence (DDx from restrictive cardiomyopathy)
CT/MRI: thickened pericardium, early diastolic flattened septum
Mx of constrictive pericarditis
Medical: diuretics, fluid restriction
Surgery: pericardectomy
ASD signs
Raised JVP
Pulmonary thrill
Pulmonary ESM
Fixed S2
Tricuspid diastolic flow murmur
Signs of deterioration:
- Pulm HTN (RV heave, loud p2, cyanosis, clubbing = Eisenmengers)
- CCF
Types of ASD
Primum = assoc AVSD, cleft mitral valve, downs syndrome
Secondum = MCC
Complications of ASD
Paradoxical embolus
Atrial arrythmia
RV dilititation
Eisenmengers
Ix for ASD
ECG:
- Primum = RBBB + LAD
- Secondum = RBBB + RAD
+ AF
CXR: small aortic knuckle
Echo/MRI: site/size/shunt/anatomy
Mx for ASD - Indications for closure:
Symptomatic: SOB, paradoxical emboli
Significant shunt: Qp : Qs > 1.5 : 1, RV large
Mx for ASD - Contraindications for closure:
severe pulmonary HTN
Eisenmengers
VSD CC
Congenital:
- VSD
- ToF
- PDA
- Coarctation
Acquired:
- Traumatic/post-op
- post-MI
Ix for VSD
ECG: bundle branch block
CXR: pulmonary plethora
Echo/MRI: size/site/shunt/anatomy/assoc
Cardiac catheter
Mx of VSD
- Conservative - MCC small perimebranous VSD close spontaneously
- Percutaneous: Amplatzer device
- Surgical: pericardial patch
Post-infarct VSD:
- Mechanical circulatory support
- Early closure with large patch to allow for further tissue loss and prevent dehiscence
- Heart transplant
What is a Blalock-Taussig shunt?
partially corrects ToF in infancy, by anatomosing sublavian artery (or aorta) to pulmonary artery
= absent radial pulse + thoracic scars
DDx absent radial pulse
Acute:
- embolism
- aortic dissection
- trauma
Chronic:
- atherosclerosis
- coarctarion
- takayasus arteritis
Signs of coarctation
HTN in UL
Prominent UL pulses, weak femoral
Radio-femoral delay
Heaving apex
Systolic murmur to back, loud a2 +/- murmur from assoc lesion
Assoc with coarctation
VSD
Bicuspid aortic valve
PDA
Turners
Intracranial aneurysms
Coarctation Ix
ECG: LVH, RBBB (if VSD)
CXR: notched rib, double aortic knuckle
Echo/CT/MRI: flow/anatomy
Mx coarctation
Percutaneous endovascular aortic repair
Surgical: dacron patch aortoplasty.
Anti-HTN
Longterm surveillance: re-coarctation, aneurysms
What is a PDA
continuity between aorta + pulmonary trunk with LTR shunt (acyanotic)
RF: rubella
signs of PDA
collapsing pulse
thrill in pulmonary region
thrusting apex
continuous machine like murmur loudest below left clavicle
mx of pda
closure - surgery or percutaneously
Assoc with HOCM + signs
Assoc:
- Friedrichs atxia
- Myotonic dystrophy
Signs:
- Jerky pulse
- Double apical impulse (atrial + ventricular contraction)
- Thrill at lower left sternal edge
- ESM +/- assoc mitral valve prolapse
Ix for HOCM
ECG: LVH + strain (TWI)
Echo: asymptomatic septal hypertrophy, LVOT obstruction
Cardiac MRI /Cardiac catheter
Genetic tests - sarcomeric protein mutations
DDx of LVH
Athlete
Hypertensive heart
HOCM
Cardiac amyloidosis
Anderson-Fabry disease
HOCM Mx
ASx: Avoid strenuous exercise, dehydration + vasodilators
Sx + LVOT gradient >30mmHg:
- BB + verapamil –> lower HR (increase filling time) + negative inotrope (reducing force of LVOT compression)
- Cardiac myosin-inhibitors: mavacamten (negative inotrope)
- Pacemaker
- Septl ablation or surgical myomectomy
Refractory = heart transplant
Genetic counselling
HOCM genetics
autosomal dominant
HOCM poor prognosis / indications for ICD
young age at dx
syncope
documented vt / cardiac arrest
fhx of scd
septal thickness >30mm
Burnt out LV (reduced LVEF + fibrosis)
Heart failure causes:
MCC = ischaemia
Structural heart disease (valves/congenital)
Arrythmias
HTN
Post-partum CM
Drugs/Toxins (anticancer)
Endocrine/metobolic:
- Thyroid disease
- Diabetes
- Alcohol - DCM
- Obesity
Infection/infiltration/inflammation
Mx of HF
Treat cause
Medical:
- fluid/salt restrict _ diuretics
- 4 pillars: BB, ARB/ARNI, MRA, SGLT2I
Device:
- ICD/CRT
Surgery:
- Volume reduction surgery - improves LVEDP
- Heart transplant
Indications for heart transplant
Severely impaired LV systolic function, HCM, intractable VT or angina
NYHA III or IV despite optimal medical
CRT/ICD implant
Poor prognosis: CPET <14, markedly high bnp, seattle geart failure model >20% mortality
Cardiac cachexia
Refractory cardiogenic shock despite mechanical support/inotropes
Absolute CI for hear transplant UK
- > 65yo + serious comorbidity
- sespsis/active infection
- incurable malignancy
- psychosocial factors: (smoking/alcohol/drug abuse), poor meds compliance
- irreversible pulmonary HTN
Relative CI for hear transplant UK
BMI >32
DM with end organ damage
severe peripheral vascular / cerebral vascular / lung / kidney disease
BBV
