Cardio Flashcards
1
Q
Which is the only valve that is normally bicuspid?
A
mitral
2
Q
What carotid character do you get in aortic stenosis?
A
Slow rising
3
Q
Murmur in aortic stenosis
A
Ejection systolic
4
Q
Sequelae of aortic stenosis?
A
Concentric LVH due to higher pressure needed to open valve
Heart failure
Lack of blood to end organs
+turbulent flow
+microangiopathic haemolytic anaemia- haemoglobinuria
5
Q
3 cardinal symptoms of aortic stenosis
A
syncope
angina
dyspnoea
6
Q
Does a mechanical or bio valve last longer?
A
Mechanical
7
Q
Alternative to valve replacement in AS?
A
Balloon valvuloplasty
8
Q
50% aortic regurg caused by whaT?
A
Aortic root dilation
9
Q
What causes aortic root dilation?
A
Idiopathic
aortic dissection
aneurysm
Syphilis
Marfan’s/ED
10
Q
Murmur aortic regurg?
A
Early decrescendo diastolic
11
Q
What finding do you get in aortic regurg o/e?
A
Large pulse pressure leading to hyperdynamic circulation
12
Q
Why do you get a large pulse pressure in aortic regurg?
A
Blood volume in ventricle is increased so higher SV so systolic BP high
Blood volume in aorta is decreased so in diastole get a low BP
13
Q
What are the signs of hyperdynamic circulation
A
waterhammer pulse
bounding pulse
Head bobbing
Quincke’s sign- pulsating fingernail capillary beds
14
Q
Other sequelae of aortic regurg?
A
Eccentric LVH
15
Q
Most common cause of mitral regurg
A
prolapse of valve
16
Q
What causes mitral valve prolapse?
A
Myxomatous degeneration of the papillary muscles (e.g. due to Marfan’s/ED)
17
Q
Which valve leaflet’s chordae tendinae are most likely to rupture in mitral prolapse
A
posterior
18
Q
Symptoms of mitral prolapse
A
mostly asymptomatic
19
Q
Murmur of mitral prolapse?
A
Systolic murmur with a mid systolic click
20
Q
What manoeuvres can change the mitral prolapse murmur?
A
Squatting increases venous return so click is later (more space for the valve to move in) and murmur shorter
Standing/valsalva makes the click earlier and murmur longer
21
Q
What are other causes of mitral regurg?
A
Damage to papillary muscles post MI
LHF leading to LV dilation
Rheumatic fever
22
Q
Murmur of (non prolapse) mitral regurg
A
Pansystolic ‘blowing’ murmur
23
Q
Sequelae of mitral regurg
A
LHF- extra work is created for the heart as the blood keeps draining back- LA and LV volume overload - eccentric hypertrophy –> HF
24
Q
Most common cause mitral stenosis
A
Rheumatic fever
25
What is rheumatic fever
antibodies post strep-A throat infection
Commissural fusion of the valve
26
Murmur in mitral stenosis
Systolic snap and diastolic rumble
27
Sequelae of mitral stenosis
High pressure can = atrial dilation
Backs up into pulmonary circulation- pul oedema and dyspnoea
Pul HTN- strain on RH --> RVH --> RHF
Increased risk AF and therefore thrombus risk
Can also get dysphagia
28
Malar flush is sign of which valve disease?
Mitral stenosis
29
What pulse pressure do you get in AS?
Narrow
30
Radio-radial and radio-femoral delay are sign of what?
Coarctation of the aorta
31
Left sided murmurs (M&A) are louder on
Held expiration
32
Right sided murmurs (T&P) are louder on
Held inspiration
33
What could a pansystolic murmur indicate
Mitral regurg
VSD
Tricuspid regurg
34
would a VSD murmur alter on position/breathing?
No
35
When is a tricuspid regurg louder?
Held inspiration sitting forwards
36
What sign do you get in tricuspid regurg?
large V waves on JVP
37
What do large A waves mean on JVP?
Anything that makes blood flow RA to RV more difficult e.g. RVH (due to pulmonary HTN or pulmonary stenosis) or tricuspid stenosis
38
What do absent A waves mean on JVP
AF
39
How is heart failure diagnosed?
Framingham criteria- 2 major OR 2 minor + 1 major
40
What can be used as a measure of prognosis in heart failure?
Ejection fraction
41
What categories can heart failure be split into?
Normal ejection fraction
Reduced ejection fraction
42
what is 'congestive' heart failure?
Both R and L ventricles
43
Pulmonary oedema is a sign of which sided heart failure?
Left
44
Why does LHF lead to RHF?
pulmonary hypertension
45
What are signs of RHF?
Peripheral oedema
Hepatic congestion
(systemic venous congestion)
46
What is the role of BNP in heart failure?
To stratify patients in primary care
>2000 refer to cardio 2ww
400-200 non urgent referral
<400 consider alt dx
47
What does BNP do physiologically?
body's natural defence against hypervolaemia- natriuresis, diuresis and vasodilation
48
Does a normal CXR exclude heart failure?
No
49
5 xray findings of heart failure?
Alveolar oedema (bat wing)
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Pleural effusion
50
Which heart failure patients get an echo?
All w susp heart failure
51
How is heart failure classified?
NYHA - how much functional limitation
52
What is the most common arrhythmia that heart failure patients develop?
AF
53
What dietary change is made in severe heart failure?
Fluid restriction to <1.5L/day
54
What are the two main drugs you give in heart failure?
ACEi and beta blocker- start at different times (use clinical judgement about which you start first.)
55
Mechanism of ACEi in heart failure treatment?
Vasodilation, reduces afterload and fluid retention- slows LV disease progression and improves neuroendocrine abnormalities
56
Mechanism of beta blockers in heart failure?
reduce afterload + HR (so tackles arrhythmias)
57
3 cardio C/Is to beta blockers
2/3rd degree heart block
Sick sinus syndrome
Sinus bradycardia
58
What other drugs could you consider for symptom control in heart failure?
Diuretics for fluid overload. Once improved may be able to maintain euvolaemia with fluid and salt restriction.
Digoxin if refractory to other Rx
Amiodarone if arryth
CCB
59
Do diuretics improve LT outcome in heart failure?
No only spironolactone does
60
What type of diuretic is first line in heart failure?
Loop
61
Which CCBs can you use in heart failure?
Amlodipine only
62
Which drugs should be avoided in heart failure?
TCAs
Li
NSAIDs
Corticosteroids
QT prolonging Rx
Flecainide (an antiarrhythmic)
63
Is the treatment for diastolic HF the same?
No - ionotropic effect is the aim
Early CCBs ± B blockers
Avoid diuretics and strong vasodilators
Caution ACEi
64
What is diastolic heart failure?
AKA preserved ejection fraction
LV is stiff so can't fill properly in diastole leading to reduced amount of blood going to body.
Symptoms of HF with normal ejection fraction
65
How does acute heart failure occur and what can it lead to?
Due to e.g. MI/arryth
Lead to cardiogenic shock
66
Alternative to ACEi if heart failure pt can't tolerate ACEi?
ARB
67
Can you give ACEi in valvular heart disease?
Avoid unless specialist input
68
name the layers of the wall of the heart and pericardium
Endocardium
Myocardium
Epicardium (surface of heart + visceral layer pericardium)
Pericardial space (lubricant)
Parietal layer pericardium
Fibrous pericardium
69
Where do the coronary vessels drain into?
Coronary sinus in the RA
70
What prevents backflow in AV valves? (mitral and tricuspid)
Valve leaflets attached to papillary muscles via the chordae tendineae
71
What has higher resistance systemic or pulmonary circulation?
Systemic
72
Name the three layers of blood vessels
Tunica intima
Tunica media
Tunica externa
73
Which layer of the blood vessel contains smooth muscle and elastin?
Media
74
What additional structure do large blood vessels have in their tunica externa?
Vasa vasorum (own blood vessels)
75
What layers do capillaries have?
tunica intima ± basement membrane
76
Blood flow =?
volume/time
Q
77
Velocity of blood =?
Distance/time
Or flow/area (Q/A)
V
78
What is mean arterial pressure?
1/3 SBP + 2/3 DBP
79
What is Reynold's number?
How laminar/turbulent blood flow is
80
What are two features unique to skeletal muscle cells?
Multinucleated
Sarcoplasm contains myofibrils
81
What is in a myofibril?
Sarcomere containing thick myosin filaments and thin actin filaments
82
CO=?
SVxHR
83
Normal CO?
about 5L/min
84
How much blood in a human body?
About 5L
85
How do you work out SV?
End diastolic vol - end systolic vol
86
ejection fraction = ?
stroke volume/end diastolic volume
87
What is normal ejection fraction?
Around 50-65%
88
Which organ receives the most blood per gram?
Kidneys
89
cardiac work =?
mean aortic pressure x stroke volume
90
Does cardiac work correlate well with cardiac output?
No e.g aortic stenosis- lot of work for little output.
91
What is preload?
Ventricle wall stress at the end of diastole
92
What is a law not used in practice to determine wall stress?
Law of Laplace
93
What is a surrogate used for preload?
End diastolic LV volume
94
What is preload affected by?
Venous pressure and rate of venous return
Atrial contraction
Resistance from valves
Ventricular compliance
HR
95
What is afterload?
Ventricle wall stress during systole i.e. the amount of resistance ventricles must overcome during systole.
96
What is afterload affected by?
SVR
Aortic pressure
Valve disease
97
What cells start the action potential in the heart?
Pacemaker cells
98
What is special about pacemaker cells?
Autoarrhythmic
99
Where is the SA node located?
RA
100
Action potentials move ___ through pacemaker cells and ____ through myocytes (fast/slow)
fast
slow
101
How does the action potential reach the other atrium?
Atrial internodal tracts (Bachmann's bundle)
102
How and why does conduction slow at the AV node?
Smaller diameter of cells and slower ion channels (calcium not sodium)
This delay allows the ventricles to fill
103
Does the action potential move quickly or slowly through the His-Purkinje system? Why?
Quick so that there is a co-ordinated contraction
104
What is the firing rate of the SA node
60-100 BPM
105
What if the SA node fails to fire?
Then other parts of the heart take over pacing- other parts of atria > AV node > ventricular pacemaker cells (each has a slower and slower rate)
(ectopic foci)
106
Where is the AV node?
RA just inferior to coronary sinus
107
what is the carotid sinus?
Major baroreceptor site at the base of the internal carotid artery just superior to the bifurcation of the common carotid
108
How do cardiomyocytes contract?
Small amount of calcium influx from neighbouring cell
Enters T tubules to allow it to go deep into the cell
Binds to ryanodine receptors on sarcoplasmic reticulum
Even more calcium released
Calcium binds to Troponin C which is attached to tropomyosin
(tropomyosin is draped around actin to cover the myosin head binding sites)
When calcium binds this moves the tropomyosin to expose the binding site
Myosin-actin cross bridge formed--> power stroke --> contraction
109
Big box in ECG = how long?
0.2s
110
Small box in ECG = how long?
0.04s
111
How to calculate rate on ECG
300 divided by number big squares
OR
Number of R waves on strip x 6 (strip is 10s)
112
In which leads is T wave inversion normal?
III, aVR, V1
113
What ECG change might be seen in stable angina?
Widespread ST depression
114
What ECG changes are seen in an NSTEMI?
ST depression
T wave inversion
115
Difference between ischaemia and infarct
Infarct when cell death occurs due to ischaemia
116
ECG changes in STEMI (transmural infarct)
T wave inversion
Hyperacute T waves
ST elevation
Pathological Q waves
117
What is the criteria for ST elevation on ECG
>1mm in 2 adjacent leads except V2 and V3 where must be >2mm
118
Other causes of ST elevation
Coronary artery vasospasm
LVH
Pericarditis
119
Pathological Q waves in V1 and V2- infarct location?
Septal
120
Pathological Q waves in V3 and V4 - infarct location?
Anterior
121
Pathological Q waves in V3-6, I and aVL - infarct location?
Anterolateral wall
122
Which lead is not a reliable one to look at for pathological Q waves?
aVR
123
Causes of pathological Q waves other than STEMI?
LBBB
WPW
124
How long does it take for each ECG change to resolve post STEMI?
ST elevation days
T wave inversion weeks/months
Pathological Q waves stay for longer
125
What would a large P wave in V1 and 2 (and II, III, aVF)
RA enlargement
126
What are the ECG signs of RV hypertrophy?
Dominant R wave in V1 and dominant S wave V5/6
R axis deviation
Narrow QRS (i.e. not due to RBBB)
127
Main ECG signs LVH
Deep S wave V1 and v big R wave V5/6. Add up to >35mm
128
Additional ECG signs in LVH
R wave duration longer (>50ms)
ST elevation V1
ST depression V5/6
T wave inversion V5/6
129
What do bifid P waves in Lead II and biphasic P waves in lead V1 mean?
LA enlargement
130
What is it called when blood flow to a muscle increases disproportionately due to vasodilation in those blood vessels?
(functional) hyperaemia
131
What are the two ways total peripheral resistance is controlled
Intrinsic and extrinsic factors
132
What are the intrinsic controls of total peripheral resistance?
1. Level of metabolites in the surrounding tissue- adenosine and CO2 = vasodilation of arterioles
2. Autoregulation: BP decrease = arteriole dilation
3. Active hyperaemia: increased organ perfusion as required when it is more active
133
What is the extrinsic control of total peripheral resistance
Sympathetic NS and endocrine system control vascular smooth muscle contraction
134
What type of blood vessel is the primary site of vascular resistance?
Arterioles
135
What is the Starling equation (basically)
fluid movement is based on hydrostatic pressure and oncotic pressure
Also includes a filtration co-efficient which = the water permeability of the capillary wall
136
Left coronary artery splits into which arteries?
Left anterior descending
Left circumflex
137
Right coronary artery splits into what?
Right marginal
Posterior descending
138
What are the four cardiac veins?
Great
Middle
Small
Anterior
139
Which cardiac vein bypasses the coronary sinus and drains straight into the RA?
Anterior
140
With which artery does the great cardiac vein run?
LAD
141
With which artery does the middle cardiac vein run?
PDA
142
With which artery does the small cardiac vein run?
R marginal
143
With which artery does the anterior cardiac vein run?
right coronary
144
ST elevation in leads V1-4- where is the infarction and which artery?
Anterior/septal
LAD
145
ST elevation in leads V5,6 I and aVL- where is the infarction and which artery?
Lateral
Left circumflex
146
ST elevation in leads II, III, aVF- where is the infarction and which artery?
Inferior
RCA
147
ST depression in leads V1-4- where is the infarction and which artery?
Posterior
PDA/RCA
148
Mnemonic to remember reciprocal changes in ST elevation?
PAILS (arrow under the L)
149
What is R wave progression?
V1 has a deeper S wave and v small R wave, as you move along to V6 there is a more and more dominant R wave and a smaller S wave
150
Sensitivity/specificity of BNP?
Sensitive but not specific
Useful in ruling out HF but positive can = a lot of things.
151
If suspect an inferior MI what can you do to check?
Right sided leads ECG
ST elevation in V4R (5th ICS MCL) is high sens and spec for RV MI.
152
IF suspect posterior MI what can you do to check?
Posterior leads (V7,8,9)
