Cardio Flashcards
Top 4 causes of chronic heart failure
Coronary heart disease
Hypertension
Valvular disease
Myocarditis
4 chest signs in L ventricular failure
Displaced apex
S3
Bibasal creps
Wheeze
What is S3?
“Kentucky”
Seen in LV failure when there is rapid ventricular filling
3 conditions which cause heart failure by increasing metabolic demand?
Anaemia
Hyperthyroidism
Pregnancy
CXR features of heart failure
Alveolar shadowing Kerly B lines Cardiomegaly Upper lobe Diversion Fluid in fissures
What on earth are Kerly B lines
Increased pressure in pulmonary circulation —> more fluid in peripheral interlobular septa
normal ejection fraction
approx 60%
Classification of HF severity?
NYHA classification
1) no sx
2) SOB on normal activity
3) Marked limitation of normal activity
4) SOB at rest
Which drugs are best avoided in Mx of HF?
CCBs
1st line Mx of chronic HF
ACEi/ARB + b-blocker + loop diuretic +/- spironolactone
Caution with spironolactone in Mx of chronic HF?
Risk of hypERkalemia, esp as all HF pts are on ACEi
What is S4
active ventricular filling, when atria contracts against a non-compliant ventricle.
ALWAYS pathological + a sign of diastolic failure.
causes of myocarditis
50% idiopathic
1) VIRAL: coxsackie, flu, HIV
2) bacterial: staph, strep
3) drugs: anti epileptics (phenytoin, carbamazepine)
4) Autoimmune: SLE
One form of cyanotic congenital heart disease
Tetralogy of Fallot Pulmonary stenosis RV hypertrophy VSD Overriding aorta
Causes of a collapsing pulse
Aortic regurgitation
Or due to hyper dynamic circulation:
Hyperthyroidism, anaemia, pregnancy
completion of a cardiovascular exam
Hx Basic observations Respiratory exam Drug chart 12 lead ecg
Janeway lesions vs Oslers nodes
JLs: non-tender, flat, palmar surface,
ONs: tender, nodular, on knuckles
Scoring system for Dx of Infective Endocarditis
DUke’s criteria = 2 major/1 major + 3 minor/5minor
Major criteria:
+ve blood cultures w typical organism on 2 occasions
Echo: vegetations or new regurgitation
Minor criteria:
Fever, embolic features, IVDU, predisposing valve/cardiac prob
3 Risk factors for IE
valvular disease
IVDU
Prosthetic valve
Common causative organisms of infective endocarditis?
Acute: staph aureus (in all groups, but esp IVDU)
Subacute: strep viridian’s (esp in native valves w pre-existing damage)
Native valve = strep viridian’s
IVDU = staph aureus
Prosthetic valve = staph epidermis
What is acute rheumatic fever
Aggressive immunological response to Strep pyogenes
Commonly affects mitral valve
- carditis, arthritis, sydenam’s chorea, erythema marginatum, subcutaneous nodules
mx of acute rheumatic fever
Admit + bed rest + IM benpen stat + 10 days of oral penicillin
How does infective endocarditis develop from a pt w history of rheumatic fever
Rheumatic fever –> damaged (mitral) valve
Later in life, after years of bacteraemia there is colonisation of damaged valve + vegetation –> pyrexia
Complications of infective endocarditis
Haematuria!
Thromboses: bowel infarct, splenic infarct, TIA, AKI
Heart block
Heart failure
Causes of aortic regurgitation
Bicuspid aortic valve
Rheumatic valve disease
Autoimmune - ank spond, RhA
CTD - marfan’s, ehlers danlos
Acute: IE, type A aortic dissection
sign of LV strain on ECG?
lateral lead T wave inversion
Key investigation that must be undertaken prior to valve replacement surgery
Cardiac catheterisation to assess coronary arteries
Atrial fibrillation: 1st episode + symptomatic but stable + unknown duration
treat as >48 hours
Rate control (bb or CCB)
Anticoagulation: heparin + warfarin
Rhythm control 3 weeks later (amiodarone or DCCV)
atrial fibrillation: 1st episode + symptomatic + L atrial thrombus found
Rate control
Anticoagulation (heparin + warfarin)
- Rhythm control 3 weeks later (DCCV or amiodarone)
Atrial fibrillation: 1st episode + asymptomatic
Chadsvasc is 0-1: observe for 24 hours (most resolve spontaneously )
Chadsvasc is >=2: anticoagulate + observe for 24 hours
Pacemaker spikes: how to differentiate between atrial and ventricular pacing?
Atrial: spike before p wave
Ventricular: spike before QRS
Ventricular pacing: what does the ECG look like?
pacing spike before QRS
Left ventricular pacing –> QRS morphology similar to RBBB
Pacemakers: what are the indications for a) atrial lead only b) ventricular lead only c) both atrial and ventricular leads
a) atrial lead only: SAN disease in young patients w GOOD AVN conduction
b) ventricular lead only: permanent AFib
c) A+V leads: every one else, esp elderly who are at risk of AV block
ICD - what is it for?
Prophylaxis for patients at risk of VT or VF
- primary prevention in pts of previous arrest/sustained VT
- secondary prevention for HOCM, long QT, congenital heart disease etc
Indication for cardiac resynchronisation therapy
LV dysfunction + broad QRS (i.e. BBB)
In BBB, the impulse travels along intact branch first, before transmitting to the other side –> dysynchronous contraction
What is cardiac resynchronisation therapy
3 leads: in R atrium, R ventricle, L ventricle
Allows synchronised ventricular contraction in response to atrial contraction (the lead in RA detects organised atrial contraction)
Classification of heart block
1st degree: prolonged PR
2nd degree type 1: e.g. 3:1
2nd degree type 2: gradually increasing PR until QRS is dropped
3rd degree: no relationship between p wave + QRS
Causes of heart block
Coronary heart disease (ACS or chronic)
Drugs: beta blocker, adenosine, CCBs,
which electrolytes may be responsible for heart block
Potassium
Calcium
Management of v symptomatic second degree type II heart block
Stop AVN blocking drugs (B-blockers, CCBs)
+ Temporary pacing
(both mobitz type II and 3rd degree heart block are treated this way)
In what scenario can you merely observe heart block?
if Asymptomatic and either 1st degree or 2nd degree type I
Young person - faints a lot
ECG shows long QT.
Next steps?
HUGE risk of VT + VF
Ix: Serum K, Mg, Ca (low levels can cause it)
Echo
24 hour ECG
Mx: beta blockers + ICD
When is shock given in DCCV?
During QRS
Cardiac tamponade - causes
Post MI Post cardiac intervention Pericarditis Malignancy Trauma
Becks traid of cardiac tamponade
Raised JVP
Low BP
Muffled HS
Mx of cardiac tamponade
Pericardiocentesis (echo guidance)
Dukes Criteria for IE
2 major + 1 minor
1 major + 3 minor
5 minor
Major: Echo finding (new murmur)
+ve blood cultures w typical organisms
Minor:
- Emboli: splinter haemorrhage, haematuria, Janeway lesions
- Immuno: Oslers nodes, GNitis
- Fever
- Predisposing <3 condition or IVDU
- +ve cultures of atypical
- Echo w non major criteria
Classification of atrial fibrillation
First episode
Paroxysmal - <7 days
Persistent - >7 days
Permanent - often >1 year, refractory to treatment
Causes of Afib
Heart: MI, IHD, mitral valve path, HTN
Hyperthyroidism
EtOH
pneumonia
Complications of AFIb
Embolism: stroke, TIA
HF: reduced CO
Further remodelling
HASBLED - what is it? what score is considered high ris
Bleeding risk - 3+ is high risk
HTN, renal disease, liver disease, stroke history, bleeding history, wild INR, elderly, EtOH
Afib pharm rhythm control: which agents are used? and in which situs is one preferred?
Flecainide or amiodarone
Amiodarone in structural heart disease
Mx of broad complex tachycardia w no adverse signs
IV amiodarone 300mg over 20-60 mins
then 900mg over 24 hours
Mx of tachycardia w shock/syncope/MI/HF
DC shock!
+ IV amiodarone 300mg over 10-20 mins + repeat shock
Mx of SVT
vagal manœuvres
IV adenosine 6mg bolus, then 12mg then 12mg
Ddx for SVT
atrial fibrillation
atrial flutter
AVNRT
AVRT
Stage 2 HTN
clinic? home?
Clinic: >160/100
Home: >150/95
Diagnosis of rheumatic fever - what are the criteria?
Modified Jones criteria
Major: carditis, arthritis, sydenams chorea, erythema marginatum, subcut nodules
Minor: fever, raised ESR/CRP, long PR interval, arthralgia
Management of rheumatic fever
Admit + bed rest until inflame markers resolve
- IM benpen stat
- 10 day penicillin
- Aspirin as needed
AND secondary Abx prophylaxis
