Cardio Flashcards
What is a heave
Palpable heart beat- LVH or RVH
Drug prefferred in hypertenisive crises
IV labetalol then sodium nitropusside and diltiazem
Symptoms of WPWS
SOB
Palpitations
Dizziness
What happens in 2nd degree heart block physiology
Some P waves manage to get through
How to treat SVT
Adenosine 6mg then if fails 12mg if that fails repeat
Where is mitral stenosis best heard
Apex when rolled onto left in expiration
What is given after MI to alleviate nausea
IV metoclopramide
Complications post MI
VT Cardiogenic shock Heart blocks Mitral regurg Dresslers syndrome Ventricular septal defect
What is bisoprolol used for
Beta blocker used in AF rate control
Difference between type a and b aortic dissection
type a more proximal in ascending aorta whereas b is more distal in descending aorta
What are the risk factors for rheumatic fever
poverty
overcrowded living quarters
family history of rheumatic fever
D8/17 B cell antigen positivity
Types of ablation
Cryoablation- freezing affected area
Radio frequency ablation- heat on area
What is CHADS VAS score
Congestive heart failure Htn Age 64-74 1 point Diabetes Stroke history or any other VTE 2 points Vascular disease Age >74 2 points Sex- female gets a point
What does a canon a wave suggest
Sustained V tach
What can an ICD do
Monitor ryhtm and rate, if notices abnormality can do 3 things
Pacing
Cardioversion
Defibrillation
What are common signs of rheumatic fever on examination
Heart murmur Chorea erythema marginatum subcutaneous nodules Pansystolic murmur
How long does sydenhams chorea last
1 year
If patient who is a IV drug user has a pansystolic murmur what do you think
Tricuspid regurg
Which veins are varicose veins most commonly found along the distribution of
Long and short saphenous
Long- groin to medial part of calf
Short- popliteal fossa to lateral malleolus
When would you do Abdo US IE
Splenomegaly
ECG diagnosis of irregular QRS and extended QT
Torsades des pointes
What are kerley b lines
small horizontal lines in lower lobes of lungs
Difference in pain between arterial, venous and neuropathic ulcers
Arterial- very painful
Venous- slightly painful
Neuropathic- no pain
How does aortic dissection appear on CXR
Widened mediastinum to right
Blunted aortic notch
Differences between critical limb ischaemia and intermittent claudication
Like stable angina vs unstable
Claudication just on exertion but critical limb ischaemia all the time like at night and rest
Immediate actions when somenoe goes into V fib
Call for help
Start CPR
Cardiac causes of arrythmias
IHD Structural heart changes Cardiomyopathy Pericarditis Myocarditis Aberrant conduction pathways
Causes of sinus tachycardia
Caffeine
Alcohol
Dehydration
Anxiety
Main complication of WPWs
Can go into deadly V fib if go into A fib or flutter
Mid diastolic murmur
Mitral stenosis
Managment of AF BP stable sx started under 48hrs ago
Rate- beta blocker
Rythm- DC or chemical
Stroke risk- DOAC post evaluation
Associated features of neuropathic ulcers
Can get osteomyelitis
MONA BASH
Morphine Oxygen is sats below 94 Nitrates Anti Platelets Beta blockers ACE inhibitors Statin Heparin
Chronic management of A fib
Rate control using rate limiting Ca blocker- if fails digoxin and amiodarone
Rythm control done via cardioversion, flecainide, ablation or IV amiodarone
Anticoagulation with warfarin or heparin- only done if CHADS VAS score above 1
What is treatment for type b aortic dissection
blood pressure control and monitoring
how to exclude MI from angina diagnosis
Troponin
What does cardiomyopathy mean
Heart muscle becoming structurally abnormal in absence of ischaemia etc
What is sydenhams chorea
Movement disorder- irregular, abrupt and rapid involuntary movements
Presentation of mitral stenosis
Pulnomary hypertension leads to dyspnoea, haemoptysis and chronic bronchitis presentation
What is ECG sign of Q wave infarction
Q wave heavily inverted
Criteria for HF
New York Heart failure
1-4
Difference between aspirin and warfarin
Aspirin affects platelets and warfarin clotting factors
What patients can’t adenosine be used in
Asthmatics
What is hypertrophic cardiomyopathy
Marked hypertrophy of left ventricel in absence of an identifiable cause such as HTN or valve disease
What causes pansystolic murmur
Mitral regurg
Tricuspid regurg
Ventricular septal defect
What does bruits over intercostal spaces suggest
Aortic coarctation
Chemical rhythm management of AF
Amiodarone or flecainide
What is important to remember when viewing Echo
Upside down so ventricles are atria
Once you have checked the rythm after a round of CPR what must you always do
Check pulse as could be PEA
How would investigations appear for aortic stenosis
ECG
CXR
ECG
- p mitrale
- LVH
- LBBB or AVN block
CXR
- dilation of aorta
- LVH
What does pericardial friction rub indicate
Pericarditis
Risk factors for emboli
AF
Aneurysm
Treatment for haemodynaimcally unstable sustained v tach
Immediate cardioversion
Follow with amiodarone
Pacemaker
for pericarditis complications how do you differentiate between congestive heart failure and pericardial effusion
In congestive heart failure the pulnomary vasculature will be congested alongside cardiomegaly whereas pulnomary congestion would be absent in pericardial effusion
ECG signs of mitral stenosis
P mitrale as enlarged atrium
Can be signs of AF
What are complications of ICD
Bleeding and infection during insertion
Leads come off requiring future surgery
Damage to left sublcavian
Collapsed lung
Presentation of critical limb ischaemia
Ulcers Gangrene Rest pain Night pain Like unstable angina
What is cause of sudden death in HCM
Arrythmia
What happens to blood pressure in aortic dissection
Hypertensive to begin with but immediately can drop due to haemorrhagic shock
What does mid systolic click suggest
Mitral valve prolapse
What can cause murmur in HCM
Hypertrophy of septum interfering with mitral valve leaflets
What can cause pump failure in relation to HF
Beta blockers
Anti-arrythmics
Heart block
Post MI
Management of A fib acute
DC cardioversion if severe signs shown such shock and myocardial ischaemia
Drugs such as fleicanide
Signs on examination of mitral regurg
Displaced and hyperdynamic apex
Pansystolic murmur radiating to axilla
What is pink cheeks a sign of
Mitral stenosis
What is common auscultation sign for arrythmias
Varied first heart sounds intensity
What does syncope during exercise indicate
Very concerning- condition predisposing to instant cardiac death such as long QT syndrome
What is most common PE ECG finding
Sinus tachycardia
How will chronic stable angina appear on ECG
At rest normal but during exercise will see ST depression
Sign of basal ganglia rhem fever involvement
Sydenhams chorea
Can also get psychiatric
Chronic causes of aortic regurg
Hypertension
Autoimmune- rheumatoid, rheum fever, SLE, seroneg arthrides
Congenital
Connective tissue disorders
What causes fourth heart sound
Ventricular hypertrophy- sound is atria contracting
How will a posterior MI present on ECG
ST depression in V1-3
Examples of valsava manoeuvres
Sticking fingers down throat
Pressing against eyeballs
Dipping face in cold water or swallowing cold drinks/ice
Holding breath and trying to exhale
Investigations for limb ischaemia
ECG
Handheld doppler
ABPI
Angio MRI/CT
What happens in reactive hyperaemia
Massive build up of metabolic waste products
Whats a tapping apex
Palpable apex beat and loud first heart sound
Immediate management of HF
Sit the patient up
15L/min oxygen
Treatment for haemodynalically stable sustained v tach
IV amiodarone
IV sotalol
Pacemaker
Medical management of HF
IV furosemide
GTN
Morphine
What drugs must be avoided in WPWS
Digoxin
Verapamil
Bisoprolol
All block AV conduction
Causes of dilated cardiomyopathy
Idiopathic
Infection- cocksackie B causes myocarditis
Congenital- duchenne muscular dystrophy, haemochromatosis
Alcohol as toxic to myocardium
Drugs- cocaine, chemo
What is good marker of how severe mitral regurg is
Larger the apex
Results of investigations for mitral stenosis
ECG- p mitrale, AF
CXR- pulnomary oedema, left atrial enlargement
Echo- LAD, mitral orificie reduced size
What is brown pigmentation around venous ulcers
Haemodesrin
Who do you see splenomegaly in cardio
Infective endocarditis
What is osteomyelitis
Infection of bone under skin
What is first drug that must be given to patient coming in with ACS and why
Aspirin- stop platelet action
What does increased JVP on inspiration suggest
Constricitve pericarditis
What arrythmia is associated with death in long QT
Torsade de pointes
Most common form of pericarditis
Fibrinous
Range of warfarin dose
2mg-10mg
What are risk factors for aortic dissection
Any connective tissue disorder like Marfans Htn Atherosclerosis Ehlers Danos syndrome Coarctation of aorta Aortic valve defect Patent ductus arteriosus
What is unsustained v tach
Brief and self resolving
Asymptomatic
When present with CAD and LVD is risk factor for sudden death
What system are clotting factors the problem in
Venous
What happens at each HYHFA criteria
1- heart disease but no SOB from undue exercise
2- SOB fine at rest but bad on exertion
3- less than ordinary activities cause SOB
4- SOB present at rest
Signs on examination of aortic regurg
Collapsing pulse Bounding pulse Early diastolic murmur high pitched Wide pulse pressure Quinckes sign De musset
What is DC cardioversion
direct current cardioversion- electrodes applied to chest to restore a normal heart rythm from an abnormal one
How does p mitrale appear
Bifid p wave
How does p pulmonale appear
High p wave
Examples of SVTs
AVRT
AVNRT
Older surgical treatment for stable angina
Coronary artery bypass graft
Investigations for rheumatic fever
Blood cultures
Throat swab
CRP - very heightened
Echo
What are different types of v tach
Sustained vs unsustained
Difference in appearance on CXR between hypertrophied vs dilated LV
On CXR dilated will appear large whereas LVH appears normal
When do you give aspirin
If evidence of atheroma or ischaemia in coronary arteries or carotid
ECG v tach
Wide and bizarre QRS’
HR> 100
At what size are elective abdo aortas operations organised
When above 5.5cm
Investigations for HF
Bloods- BNP
CXR
ECG
Echo
Longer term signs of ischaemia wouldnt see in acute limb ischaemia
Hair loss
Ulcers
What HF medication is likely to have side effect of yellow tinged vision
Cardiac glycosides such as digoxin
What is quinckes sign
Pulsatile nature of aortic regurg means there is bouding pulse so your head almost nods as blood flow reaches it. This can be seen when press nail against surface and the line which is white will move
Causes of mitral stenosis
Rheumatic fever
Endocarditis
Prosthetic valves
What symptoms can limb claudication present with other than pain
Parasthesia
Cold feet
Hair loss
Ulcers
What is done in carotid sinus massage
Rub carotid on side of neck where bifurcation is
How are aortic dissections classified
Type A- ascending aorta
Type B- descending aorta
What can cause mitral regurg
LV dilation Senile calcification Endocarditis Rheumatic fever Cardiomyopathy Connective tissue disorders
What would you give an old inactive patient in AF
Digoxin
Anti-coagulate
Important investigations in WPWS
TSH
Echo
Treatment for unsustained v tach
If no underlying heart condition no treatment needed however if is one then ICD needed and amiodarone secondary to this
What could cause sudden death in young healthy person during exercise
HCM
What is the name of second part of second heart sound
Pulmonary
What presents with syncope, SOB on exertion and angina
Aortic stenosis
When are left sided valve problems more common
In high oressure systems
Symptoms of A fib
Palpitations
Stroke
Irregular pulse
Dose of aspirin if carotid artery ischaemia or atheroma evidence
300mg
STEMI management is dependant upon what
If symptoms started 12 hours ago or less
2 problems that can occur at any time following MI
AF
HF or LVD
Symptoms for atrial flutter
Palpitations Exercise intolerance Confusion and dizziness Chest pain SOB
Procedure for any sustained v tach
Pacemaker
Common presentation of HCM
Normally no symptoms but can be angina dyspnoea or syncopal attacks
What is an ICD
Implanted cardiac defibrillator
An ICD is placed under the skin to monitor your heart rate, with thin wires connecting it to the heart. An ICD constantly monitors your heart rhythm through the electrode and try and correct any abnormalities it notices
1 st degree heart block physiology
Ischaemia at AV node means slowing of beats getting through
What type of aortic dissection produces unequal pulses
Proximal to left subclavian artery
Main risk factors for PAD
smoking – the most significant risk factor
type 1 diabetes and type 2 diabetes
high blood pressure
high cholesterol
What is used to rate control a patient in AF
Beta blocker
What is buergers test
Hold patients leg up in air for 2 minutes and look for pallor. Then when patient hangs legs over the bed will see in positive buergers the affected leg going from pallor to very red back to pinkiness
First investigation for ACS
ECG- is ST elevation?
Very notable sign of mitral stenosis murmur
Very loud S1
Differences in accessory pathway WPWS
Can be antegrade so from atria to ventricles- known as orthodromic.
Or can be exclusively retrograde and go from ventricles to atria- antidromic
Why does inferior STEMI show up on leads II,III and AvF
Leads II, III direction of travel is downwards to feet
What is treatment for type a aortic dissection
cardiothoracic surgical intervention
What are other changes seen in MI ECG
Reciprocal ST depression
T wave inversion
Complications of v tach
Asystole
Sudden cardiac death
V fib
Why does ischaemia predispose to V fib
Myocardium more excitable
In leg ischaemia what will what will ABPI be
Less than .7
What is 4th HS indicative of
Atrial contraction against stiffened ventricle normally from HTN
Minor criteria for IE
Predisposition such as IV drug user
Fever over 38C
Vascular signs
Immunological signs
Causes of diastolic HF
Restrictive ardiomyopathy
Constrictive pericarditis
Tamponade
LVH
What is multifocal sinus tachycardia caused by
COPD hypoxia
What is the inheritance of hypertrophic cardiomyopathy
Autosomal dominant
What is sustained v tach
Longer than 30s Symptomatic Haemodynamically unstable Life threatening Can lead to v fib
Why do you get aortic regurg with aortic dissection
Any dilation or ripping of aorta immediately to aortic valve will cause regurg
Reference range for uncomplicated DVT warfarin dose
2-3
What is a pericardial friction rub
Upon auscultation hear a murmur with 1 systolic and 2 diastolic sounds
Signs on examination of aortic stenosis
Narrow pulse pressure
Slow rising pulse
Ejection systolic murmur which radiates to carotids
Most common complication of VSD
Endocarditis
What is a U wave
Small deflect after T wave seen in hypokalaemia
2 different physiological types of v tach
Focal and reentry
what condition can deceivingly elevate troponin
Myopericarditis
What causes tapping apex beat normally
Mitral stenosis
What is atrial flutter
Circulatory or oscillatory atrial impulses around the atria which occasionally stimulates the AVN
When is pericardial rub best heard
At left sternal border leaning forward on expiration
5 cardinal signs of rheum fever
Pancarditis Arthrits Sydenhams chorea Erythema nodosum Subcut nodules
When do you see cannon waves at JVP
Third degree HB
what is treatment for pericarditis
NSAIDS
Drugs preferred in WPWS and why
Amiodarone
Flecainide
Have less blockage on AV node
What does history of IV drug user and recent dental surgery indicate in SBAS
Infective endocarditis
Largest cause of death post MI
Cardiogenic shock
What system are platelets the problem in
Arterial
Differences between dry and wet gangrene
Dry occurs in arterial obstruction whereas wet is when bacteria the site normally post venous obstruction
Investigations for mitral regurg
CXR
ECG
Echo
What drug has no evidence for post MI use
Omega 3
Where are venous ulcers normally on leg
Lower third of leg between mallelous and lower calf
Important question to ask for patient with murmur
Rheumatic fever when a child
features of marfans
raised palate
lens dislocation
arachnodactily
How long after does troponin actually become elevated for in MI
12 hours therefore not a good acute investigation
How does a flutter appear on ECG
Saw tooth baseline
When are cannon waves seen
3rd degree HB
What drugs should be given for stable angina
Nitrates- GTN or ISMN
Beta blocker- atenolol
Aspirin
Statin- simvastatin
Is CPR always required in V fib
Yes as pulseless
What difference in BP between both arms would be significant
20mmHg
What is PND
Paroxysmal nocturnal dyspnoea- awake every couple of hours short of breath
What is hypertension defined as
BP >140/90
Symptoms of aortic regurg
Exertional dyspnoea
Orthopnoea
PND
Rarer- palpitations, syncope, angina
What indicates Left bundle branch block other than William
Prolonged QRS complexes
Medication given for after MI
Clopidogrel Bisoprolol Aspirin 75mg Atorvastatin Ramipril
When are mitral murmurs heard best
When rolled on side
Characteristics of venous ulcers
Shallow
Irregular shape- can be champagne shaped
Fibrinous material at ulcer bed
Flat or steep margin elevation
What happens to EF in systolic and diastolic HF
HF preserved in diastolic but less than 40 in systolic
What is main life threatening issue of ACS immediately
Ventricular arrythmia
What can be done to diagnose a tachyarrythmia when in tachycardia
Carotid sinus massage
Valsava
IV adenosine
What does p mitrale suggest
Left atrial enlargement
What is flow chart of progression to limb ischaemia
Pale, cool and hair less to Ulcer and gangrene to 6Ps
What valve causes first heart sound
Mitral (slightly tricuspid)
Where is DVT normally managed
In the community
What 4 rythm abnormalities can cause cardiac arrest
V fib
Asystole
Pulseless ventricular tachycardia
Pulseless electrical activity (electrical activity and no cardiac output)
What causes BBBs normally
IHD
Differences in auscultation for chronic and acute rheumatic fever
Acute- pansystolic mitral regurg
Chronic- diastolic mitral stenosis
Investigations for aortic stenosis
CXR
ECG
Echo
What is problem with warfarin in MI treatment
Is long acting and produces a pro thrombotic state initially
What can be trauma cause of limb ischaemia
Compartment syndrome
Associated findings of venous ulcers
Lipodermofibrosis Lipodermatosclerosis Brown pigment Telengiectasia Normal cap refill
Treatment rheumatic fever
Bed rest
Antibiotics
What is rheumatic fever
Acute rheumatic fever is an autoimmune disease that may occur following group A streptococcal throat infection. It affects the heart and joints mainly
Risk factors for SVT
Underlying cardiac issues such as IHD, cardiomyopathy
Hyperthyroidism
Excessive alcohol and caffeine consumption
What decides whether you cardiovert a patient or just slow their ventricular rythm
If they are fit and healthy then you will want to cardiovert as slowing ventricular rythm still leaves you with a reduced CO
How many blood cultures needed for IE
3
What tachycardia is caused by WPWS
Atrioventricular re-entry tachycardia
Where are neuropathic ulcers generally found
Under any calluses or pressure points on foot such as plantar aspect of first or fifth MTP joint
ECG abnormality infective endocarditis
Heart block
Mangement of AF BP stable Sx started over 48 hours ago
Rate control and anti-coagulate for 3 weeks then come back
Signs on examination of mitral stenosis
Malar flush
Tapping apex beat
Mid diastolic murmur
Thrill
ECG finding for WPW syndrome
Delta wave- depolarisation occurs early so R wave starts early missing out Q wave so is upstroke from p wave immediately.
PR interval also shorter
What does a mid systolic click followed by a late systolic murmur heard at apex indicative of
Barlow syndrome
Signs of RHF as opposed to LHF
LHF lung related so orthopnoea, SOB, PND, pinky sputum
RHF pre lung related so ascites, oedema, anorexia and epistaxis
Test used to determine sats pressure of heart chambers
Left and right heart catherterisation
Pain character in intermittent claudication
Cramping
What is a thrill
Vibration felt over a valve- indicates turbulent flow
How does abdominal aortic aneurysm present
With back pain once the aneurysm gets so big it begins to press on the lumbar spine- acute onset think ruptured
Why does patients leg go very red in buergers test after hanging them off table
Reactive hyperaemia
What must be considered when deciding what drug to give for chemical cardioversion in
If structural damage give amiodarone
How to evaulate whether patient should be started on a DOAC to reduce stroke risk
Combine both CHAD-VASC and HAS-BLED and determine whether risk of clot outweighs that of bleeding
What are varicose veins caused by
Incompetent venous valves
What condition are roth spots seen in
IE
What is main cause of hospital deaths following MI
Cardiogenic shock- especially if present long after
What is wolff-parkinson white syndrome
Congenital heart defect where have an accessory pathway joining atria and ventricles which bypasses AVN resulting in early ventricular depolarisation before purkinjie fibre pathway.
Echo findings IE
Vegetations
Abcess
Abcess prosthetic valve
Vascular signs IE
Mycotic emboli
Janeway lesions
Observation signs of aortic regurg
Quinckes sign
Nodding head
What are causes of RHF
Lung disease leading to cor pulmonale
Pulmonary stenosis
How can lower limb purpura suggest AAA
Aneurysms have turbulent flow so leads to embolic formation
What pain can ruptured abdominal aorta present with
Any abdominal pain anywhere even loin to groin pain
what do kerley b lines suggest
pulnomary oedema
What is management of NSTEMI
Give fondaparinaux and GRACE score risk stratification. If low risk then medical management however if high risk do angiography
What is used to monitor warfarin dose
INR
Modern day surgical treatment for stable angina
Angioplasty- out a wire in and blow up a balloon and put a stent in sometimes
ALOT LESS invasive
At what level does aorta bifurcate
L4- same as umbilical therefore have to always have to palpate above umbilicus
What is A fib
Chaotic and irregular atrial rythm
How does tourniquet test work for varciose veins
Hold patients leg above level of bed and “milk” blood out of the veins
Place tourniquet over saphofemoral junction(2/3cm lateral and inferior to pubic tubercle)
Get patient to stand up and view if varicose veins fill or not
If veins dont fill then veins collapse so problem is at level of SFJ
If do fill then must move down leg to find level of problem
Overall management guidance for arrythmias
Conservational- treat immediate cause like less caffeine or pill in pocket
Medication- rythm and rate control or medical cardioversion
Interventional- DC cardioversion, pacemaker, ablation
5 major criteria for rheumatic fever
Carditis Arthritis Erythema marginatum Sub cut nodules Chorea
Rare presentation of mitral stenosis
Hoarse voice
Dysphagia
All from enlarged LA putting pressure on left recurrent laryngeal nerve
What are indicated in immobility
Clotting factors
What to use if adenosine contraindicated in SVT
Verapamil
What causes venous ulcers
Venous HTN leads to capillary leakage
What is kussmauls sign
Increased jugular distension on inspiration
Treatment paroxysmal A fib
Pill in pocket of sotalol or flecainide
Associated findings with arterial ulcers
Consistent with chronic ischaemia- hair loss, pale, pulseless and extended cap refill
What artery is normally affected when get mitral regurg
RCA
Risk factors for clot forming in situ
Cancer
Coagulopathy
Pregnancy
Dose of aspirin for coronary artery ischaemia evidence
75mg
Define SVT
A regular narrow complex tachycardia with no p waves and a sv origin
What is epistaxis
Nose bleed spontaneously
What are risk factors for WPWS
Ebsteins anomaly
Cardiomyopathy
Septal defects
Valve defects
What is major RF for acute limb ischaemia
AF
Pathway to ACS
Risk factors Coronary artery inflammation Atherosclerosis Plaque rupture Atherothrombosis ACS
Complications of IE
Heart block TIA AKI HF Vertebral osteomyelitis
What presents with ST elevation, unraised troponin and chest pain in am or in night
Variant angina
Management of AF BP stable 3 main aims of treatment
Rate
Rhythm
Stroke risk
Why does left sides STEMI show up on lead l
Direction of its travel is to left
when to consider marfans
unusually tall with very long limbs
What changes can be seen in NSTEMI
T wave inversion
ST depression
Why are complexes narrow in SVT
It starts at level below atria so start at same time
Ebsteins anomaly on ECG
Tall and broad p waves
Prolonged PR intervals
Right bundle branch patterns
Tachyarrythmias
What must be taken into account when prescribing LMWH
Weight of patient
Renal function
What is the name of first part of second heart sound
Aortic
Management of Stable angina
Beta blockers
GTN
Rf modification
Most common cause angina
Atherosclerosis
Management path of SVT
If haemodynamically unstable then DC
If stable do vagal manoeuvres and then course of adenosine
Longer term management of HF
Beta blocker
ACE inhibitor
RF management
Common risk factors for A flutter
Heart failure very common
surgical or post-ablation scarring of atria, increasing age, valvular dysfunction, chronic ventricular failure, atrial septal defects, atrial dilation, recent cardiac or thoracic procedures, hyperthyroidism, COPD, asthma, or pneumonia.
problem with viral serology test
takes 2 weeks for test to come back so useless in acute diagnoses
How does congestive heart failure appear on CXR
Cardiomegaley
Pleural effusion- can’t see costophrenic angle
Kerley B lines
Which drugs commonly affect heart valves
Appetite suppressants
Differentiate between unstable and stable angina
stable only feels pain on exertion whereas unstable can be at rest and sporadic
What causes low output HF by category
Excessive preload- fluid overload from IV fluid xs, mitral regurg
Pump failure- diastolic and systolic causes
Chronic excessive afterload- aortic stenosis and HTN
What to do if STEMI Sx started less than 12 hours ago
PCI- if going to be 2 hours until PCI due to site of hospital then give thrombolysis
Treatment for complete heart block
Pacemaker
How does treatment vary between AF and a flutter
DC cardioversion preffered over medication. Recurrence rates common so radio frequency ablation
What is buergers angle
The angle at which the leg is positive for burgers
What can make a MI very hard to diagnose
ST segments are interpretable in BBBs
Typical presentation of rheumatic fever
History of recent throat infection
Fever and joint pain
Apical heart murmur
Ring like rash on abdomen and thighs
What causes third heart sound
HF- ventricular filling
Results of investigations for mitral regurg
CXR- pulnomary oedema, large LA and LV
ECG- pulnomale mitrale, LVH
What are indications for DC cardioversion
Any arrythmia most commonly A fib or A flutter
What can cause bradycardia after an MI
Heart block- side dependant on side of artery damaged
Most cases normally resolve within a few days
Long term management of STEMI
Bisoprolol
ACE inhibitor
Atorvastatin
What happens to BNP in HF
Goes up
What drugs must be avoided after a MI
NSAIDS as CVS side effects
Rarer types of angina
Decubitus angina
Prinzmetal angina
Chest syndrome x
What can make a MI very hard to diagnose
ST segments are uninterpretable in BBBs
Treatment for suspected aortic dissections
Have to control pain and maintain BP around a stable level with anti-hypertensives
Investigations for infective endocarditis
Echo
Three sets of blood cultures
What causes radiofemoral delay
Aortic coarctation
Aortic dissection
What does treatment for AF depdend on
If Sx started within or after 48hrs
T2 second degree HB ECG
All p waves aren’t followed by a QRS so is disparity. Could be in a 2:1 or 3:1 ratio
Tests to be carried out for arrythmias
U and Es FBC Glucose TSH ECG potential tape Echo Provocation ECG Stress test
Common abdo finding IE
Splenomegaly
What arrythmia is associated with death in WPWS
A flutter or fib leading to V fib
What is drug used to convert fast af to slow af
Digoxin
What is used to monitor LMWH dose
APTT
What is done in valsava manoeuvre
Manouevres that strain against a close glottis
What are 5 main causes of pleuritic pain
Pneumothorax Pericarditis PE Pneumonia Pleuracy
Acute causes of aortic regurg
Trauma
Infective endocarditis
Type A aortic dissection
What is difference between WPW pattern and syndrome
Pattern asymptomatic and without arrythmias
Typical presentation of aortic coarctation
Congenital young person
Atherosclerotic elderly RFx
Radiofemoral delay
Bruits over intercostal spaces
Investigations for DVT
Doppler US
Venometry
D-dimer
What murmur associated with aortic dissection
Early diastolic
What is given when adenosine contraindicated in asthmatics for SVT
Flecainide
What is asystole
When no cardiac electrical activity
What tends to precipitate arterial ulcers
Trauma to that area
Clinical symptoms of v tach
Light headedness
Chest pain
Palpitations
SOB
Why do patients stay in hospital after angioplasty
Strong chance of going into V fib as very reactive fibres
Problem of warfarin
Have to have INR checked regularly as warfarin has narrow therapeutic window
What do you see quinckes sign in
Aortic regurg
What is cardiac arrest
sudden state of circulatory failure due to a loss of cardiac systolic function
What are indications for an ICD
Arrythmias Conditon that could predispose you to issue in future- cardiomyopathy and long QT syndrome Structural heart conditions Previous cardiac arrest V tach and v fib in particular
What is pain like in aortic dissection
Sudden shearing pain that radiates to back
Characteristics of neuropathic ulcers
Punched out with deep sinus
Variable depth- can involve down to bone
What does ST depression suggest
NSTEMI and ischaemia long term
Cardinal symptoms of mitral stenosis
SOB
Fatigue
What are 6 Ps for limb ischemia
Pallor Pain Parasthesia Pulseless Paralysis Perishingly cold
Antibodies made in rheum fever
Anti-streptolysin
What can rheumatic fever be caused by
Type A strep throat infection
Scarlet fever
What is catheter ablation
Process used to destroy or scar area of heart giving you the problems
What part of virchows triad are anti-platelets aimed at
Vessel wall damage as leads to platelet activation
What HS is associated with HF
3rd- ventricular filling
What to do if STEMI Sx started more than 12 hours ago
Angiography followed by PCI if needed
Where are arterial ulcers normally on leg
Distal- on dorsum of toes or feet
What is target BP for people
Over 80 aim for below 145/85
Under 80 aim for below 135/85
What tests do you need to do after stable angina history
Exercise test and monitor ECG
What happens to pulse pressure as get older
Widens
How best to visualise if an aortic aneursym is leaking
CT aorta
Main investigations post MI
ECG
CXR
Enzymes
Third degree heart block physiologically
Atria contracting completely independant of ventricles
Pills that can lead to coagulopathy
Warfarin
OCP
If recurrent PEs without RFx what would be thing to check
Thrombophilic screen
What does QRS look like in heart blocks
Narrow in bilateral blocks
Tests for varicose veins
Tourniquet/Tredelenburg test
Doppler
What is word normally used to describe hyperkalaemia on ECG
Tented
Management of HCM
CCB and B blockers which reduce load on LV and then amiodarone to reduce chance of arrythmias
ICD
Surgery when aortic outflow becomes impaired
What part of virchows triad are anticoagulants aimed at
Stasis as leads to activation of coagulation factors
Presentation of mitral regurg
SOB
Fatigue
Palpitations
How does hypokalaemia appear on ECG
U wave
What exclusively normally causes mitral stenosis
Rheumatic fever
3 types of limb ischaemia
Intermittent claudication- stable angina
Critical limb ischaemia-unstable angina
Acute limb ischaemia- STEMI
What are 5 wave forms of JVP
ACXVY
What else would present with ST elevation
Ventricular aneurysms
How best to listen to aortic regurg murmur
In expiration sat forward
Difference in heart muscle diastolic vs systolic HF
Weak heart muscle in systolic from dilatation whereas in diastolic heart muscle stiff so doesnt fill
Investigations for heart failure bedside, bloods, imaging
Bedside- ECG
Bloods- ABG, troponin, BNP
Imaging- CXR, Echo
Management options if adenosine doesnt work on SVT
IV beta blocker
IV digoxin
IV amiodarone
DC cardiovert
What could be cause of red swollen leg after an operation
DVT
Post operative leg oedema
Typical presentation of aortic stenosis
Chest pain, syncope and exertional dyspnoea
Very commonly seen in heart failure
Other symptoms include dizziness and dyspnoea at rest
What test is used to visualise where blockage in coronary artery is
Angiogram
Causes of cardiac murmurs
Senile calcification Rheumatic fever ever Cardiomyopathy IHD Infective endocarditis Physiological
How would leaking abdominal aorta present on examination
Tender
Palpable
Pulsatile
Expansile AA
Lower limb purpura
What does pain relieved by GTN suggest
Unstable angina
How to take palpitations history
Nature- fast/slow? regular/irregular? What precipitates it Duration Any accompanying symptoms Drug history Medical history of cardiac problems Does it happen during exercise?
Causes of aortic stenosis
SEEN IN OLD AGE due to senile calcification and fibrosis
Bicuspid aortic valve
Rheumatic fever
What does shortened PR interval show
WPWS
Urgent reatment for any septal defect
Intra aortic balloon pump
Appropriate investigations for mitral stenosis
ECG
CXR
Echo
What is stable angina
Partly blocked coronary artery that when HR increases iscahemia becomes significant. Lactate accumulates as aerobic exercise impossible due to lavk of oxygen leading to ST depression
Complications of DC cardioversion
Clot dislodgement
burns
bradycardia
can develop further arrythmias
How is pleuritic pain normally described
sharp
What would shallow t wave inversion in pericarditis suggest
Myopericarditis
How does AAA appear on AXR
Curved and calcified
Most definitive test for HF
Echo
What causes tachypnoea post MI
Pain
What is acronym for treating MI
MONA BASH
What are main symptoms of rheumatic fever
Joint pain
Fever
Malaise
What if is no ST elevation
Is troponin elevated?
Yes is NSTEMI
No is UAP
Immediate generic management of ACS
Morphine
O2 if required
GTN spray
Dual Antiplatelet therapy
Lifestyle suggestions post MI
Reduce fat intake Increase intake of whole grains, nuts and veg Graded exercise programme Stop smoking Alcohol in regulation Avoid NSAIDS
How can pneumonia cause AF
In middle lobe irritates atrium
What could be seen on ECG limb ischaemia
AF
Signs of ichaemia
What is ebsteins anomaly
Ebstein anomaly is a rare heart defect in which the tricuspid valve — the valve between the upper right chamber (right atrium) and the lower right chamber (right ventricle) of the heart — isn’t formed properly. As a result, blood leaks back through the valve and into the right atrium. Very common for accessory pathways to form around the TV
Signs examination of mitral regurg
AF
PSM
Displaced hyperdynamic apex
If patient has previous MI what must consider when looking at their obs
Might be on Beta blockers so will mask signs of shock
How would investigations appear for aortic regurg
ECG
CXR
ECG- LVH
CXR- pulnomary oedema, cardiomegaly, dilated ascending aorta
Echo
How do you exclude a pericardial effusion
Echo
For rheumatic fever does infection have to have affected pharynx
Yes- always type a beta haemolytic strep infections
Dual antiplatelet therapy used in ACS management
Aspirin and Clopidogrel
What is management of SVT
Adenosine 6mg-> if fails another 6mg then if fails again -> 12mg
1st degree heart block ECG
Long PR interval
T1 second degree HB ECG
PR interval increasing until missed P wave then reverts to normal
Definition of AF
Irregulalrly irregular narrow complex tachycardia with no p waves
Immunological signs IE
Osler nodes
Positive RhF
Glomerulonephritis
Swollen fingers or toes
What does pulsatile liver suggest
Tricuspid regurg
What does ABPI do
Checks pressure difference between brachial and ankle to give index. Ankle/brachial systolic
How to diagnose a ventricular spetal defect
Check sats of blood in each chamber- if defect will be massive disparity between atria and ventricle
Pathogenesis of rheum fever
Antibodies produced against strep infection that then attacks proteins mimicked in body such as in heart, joints and brain
How to define SVT
Abnormally fast heart rate (100bpm
Symptoms of mitral regurg
Dyspnoea- pulnomary hypertension
Palpitations
Fatigue
Fever depending on cause
What is most common cause of aortic stenosis in under 60s
Bicuspid aortic valve
Major criteria for IE diagnosis
Positive echo finding
Positive blood culture
Investigations A fib
ECG
Bloods for normal arrythmia investigations
Echo
Managment of acute limb ischaemia
IV heparin immediately
Refer to vascular surgery where could emolectomy, bypass or amputation
Common valvular dysfunction post MI
Mitral regurg due to papillary muscle necrosis
Do you use vagal maoeuvres in AF
No only in SVT
What is aspirin dose post MI
300mg stat
What is done immediately post MI low BP with fluid in lungs
CPAP to force fluid back into vasculature and improve BP
DONT give fluids
Differentials for broad complex tachycardia
V fib
V tachycardia
Torsades de pointes tachycardia
Antidromic AVRT
What happens to valves in cardiomyopathy
As walls extend the valves get pulled apart meaning cant shut properly- get regurg disease
What causes A fib
HF PE Mitral valve disease Caffeine Alcohol Thyroid issues Electrolyte issues
What does p pulmonale suggest
Right atrial enlargement
Treatment options for acute limb ischaemia
Moving in severity IV heparin Emolectomy Intra arterial thrombolysis Amputation
What is name given to area where venous ulcers are found on leg
Gaiter area
Management of AF haemodynamically unstable
DC cardioversion
When do you hear a bruit
Anywhere with turbulent flow such as aneurysm or narrowing in vessel
Complications of Acs
Pump failure Rupture of Paillard muscle or septum Aneurysm Embolism Dressler syndrome PRAED
what is sign on examination of pericardial tamponade
raised jvp
What is ABPI
Ankle brachial pressure index
Causes of bradycardia
Hypothermia Hypothyroidism Aerobic training Legionnaires disease MI
What is the mitral stenosis murmur
Low rumbling diastolic
difference in history between pericarditis and PE
PE very acute onset
how can heart failure be excluded from a heart problem diagnosis
CXR
When best to hear mitral stenosis murmur
On expiration with patient rolled over to left
Presentations of arrythmias
Palpitations Syncope Chest pain Hypotension Can be asymptomatic and finding is incidental
What drugs cant be given if patient hypotensive
Nitrates
What does pericardial rub sound like
Scratching
Appropriate investigations for aortic regurg
ECG
CXR
Echo
Problem with beta blockers for angina patients
Reduce exercise tolerance
What is pulse pressure
Difference between systolic and diastolic pressure
What to think in broad complex QRS
VT
BBB
What is dressler syndrome
Chronic pericarditis
What electrolyte disorder is associated with long QT changes
Hypocalcaemia
Causes of AF
Idiopathic Pneumonia PE Alcohol IHD Valvular disease Hyperthyroidism
Characteristics of arterial ulcers
Irregular edge
Poor granulation
Dry
Punched out with sharp demarcation
When can feel apex thrill what is this most likely
Mitral stenosis
Complications of VSD
Pulmonary HTN
Endocarditis
HF
Shunt reversal
Non cardiac causes of arrythmias
Caffeine Smoking Pneumonia Alcohol Electrolyte imbalances (K,Ca,Mg) Hypoxia and hypercapnia Thyroid
What is barlow syndrome
Most common murmur
A mitral valve prolapase where doesnt close properly
Important thing check as cause of hypotension in severely ill patients
Renal function
Differences between antidromic and orthodromic accessory pathways on ECG
Orthodromic appears with delta wave and is narrow complex
Antidromic conceals the accessory pathway and appears wihtout delta wave but has broad complex
What is focal atrial tachycardia often caused by
Digoxin toxicity
What layer is affected in aortic dissection
Tunica intima- this shears and blood falls goes into layers
Complications of aortic dissection
Rupture into mediastinum Aneurysm Cardiac tamponade Aortic regurg Blockage of branch of coronary artery or aortic arch
Gold standard investigation for aortic dissection
CT aorta showing false lumen
What can cause pericarditis
URTI recently TB Lupus, RA etc Cancer diagnosis Uraemia Post MI
What are key defining features of pericarditis ECG
Widespread concave ST elevation
AvF often spared and has PR elevation + ST depression
How do pericarditis and MI differ on serial ECGs
Pericarditis often stays the same whereas MI will change dynamically
Complications of pericarditis
HF
Tamponade
Recurrent pericarditis
Restrictive pericarditis
What is pulsus alternans seen in
Pericardial effusion
HF
What investigation can help determine cause of pericarditis
Pericardiocentesis- high protein may suggest infective cause or cytology may show cancer as cause
What are biphasic T waves
Where initially T wave elevates and then is inversed
What is difference physiologically between NSTEMI and STEMI
STEMI affects whole myocardium whereas NSTEMI affects only subendocardium
Progression to ACS flow chart
Risk factors Coronary artery inflammation Atherosclerosis Plaque rupture Atherothrombosis ACS
What causes mitral regurg post MIs
Papillary muscle necrosis
What causes pulmonary oedema
Mitral valve conditions
Dysrrythmias
Renal failure
Acute MI
What is the NYHA HF classification used for
Chronic HF
What do wires over sternum suggest on CXR
Previous sternotomy
Bloods ordered for HF
FBC Renal profile BNP Troponin ABG
Long term management of HF
ACEi or ARB
B blockers
Spironolactone
Cardiac resynchronisation therapy- dual chambered ICD
Causes of aortic dissection
Marfans Ehlers danlos HTN Previous cardiac surgery Vasculitis
What is difference in pain between Type A and B dissection
Type A to retrosternal
Type B to interscapular
O/E aortic dissection
HTN Aortic regurg BP difference in arms HF Tampondade Neuro sx- limb weakness, horners syndrome, SVC syndrome Asymmetrical pulses
Bloods ordered for aortic dissection
FBC-leukocytosis
Cross match
D-dimer
Troponin
Aortic dissection indications for surgery
Type A
Rupture
How do systolic murmurs sx tend to differ from diastolic ones
Systolic tend to present with exertional dyspnoea whereas diastolic tends to present with fatigue palpitations as well as HF signs
What congenital syndrome can cause aortic stenosis
Williams- due to high levels of calcification
What presents with outgoing personality, mild learning difficulties, large forehead and a short nose
Williams syndrome
O/E aortic stenosis
ESM Slow rising pulse Left ventricular heave Narrow pulse presssure Silent S2 in severe AS
Causes of aortic stenosis
Calcification with age
LV dilation
Rupture of chordae tendinane and papillary muscle post MI
O/E mitral regurg
Irregularly irregular as AF common
LV heave
PSM
What is pulsus tardus and parvus felt in
Aortic stenosis
Causes of tricuspid regurg
Infective endocarditis
Carcinoid syndrome
RV dilation
Ebstein anomaly
O/E tricuspid regurg
Raised JVP
PSM
Pulsating hepatomegaly
Parasternal heave
O/E aortic regurg
Wide pulse pressure Displaced apex Corrigans Quinkes De musset Waterhammer pulse Early diastolic murmur
What is austin flint murmur caused by
Severe aortic regurg as blood even regurgitates into the LA
Where is austin flint murmur heard best
Apex- mid diastolic
Where is aortic regurg murmur heard best
Left sternal edge 3rd/4th ICS
What is parasternal heave indicative of
Tricuspid regurg
Mitral stenosis
O/E mitral stenosis
Malar flush Tapping apex Low rumbling murmur mid diastolic- doesnt radiate Opening snap AF common Parasternal heave
What presents with chest pain when lying down
Decubitus angina
Other than troponin and CKMB what other cardiac enzymes can get elevated plus how long they take to be elevated
AST- 24 hrs
LDH- 48 hrs
How to class HF
Pump failure
Increased demands
How to classify causes of LHF
Valvular
Myocardium
Systemic
Valvular causes of HF
Mitral regurg
Aortic stenosis
Aortic regurg
Myocardial causes of HF
IHD
Cardiomyopathy
Myopericarditis
Arrythmias
Systemic causes of HF
Amyloidosis
HTN
Drugs- cocaine, chemo
Increased demands causes of HF
Anaemia
Hyperthyroidism
Pregnancy
Signs on examination of HF
Arryhtmia could be cause Murmur could be cause 3rd/4th HS Displaced apex Pulsus alternans Increase BP and HR Fine end inspiratory crackles Cardiac asthma
What is high output HF
When demands of body overwhelm the heart
Diagnositc method for HF
TTE coupled with doppler colour
What is cut off for reduced ejection fraction HF
Less than 40
Why is echo so useful in HF
Visualise the heart and any potential causes
Can work out EF
To diagnose preserved ejection fraction HF what must EF be
Over 50
What diagnositic criteria is used to diagnose HF clinically
Framingham
2 major with 1 minor
1 major with 2 minor
Long term management of HF principles
Treat the cause
Lifestyle management
Drugs- ABD
Way to remember drugs used in chronic HF
ABD devilliers
ACEi
Beta blockers
Diuretics- spironolactone, loop
What drugs are considered in HF as further management
Digoxin
Hydralazine
nitrates like ivabradine
What further drugs are considered in HF patients who are black
Hydralazine
Nitrates like ivabradine
What is last considered option for chronic HF
Cardiac resynchronisation therapy
Complications of HF
Death
Resp failure
Kidney failure
Acute exacerbations
Generally how does cardiomyopathy present
SOB on exertion
Fatigue
Fainting
Generally how would investigate cardiomyopathy
ECG
Bloods- BNP, tropinin etc
Echo
Cardiac catheterisation
O/E cardiomyopathy
HF signs
Key finding on examination of dilated cardiomyopathy
Displaced apex
What causes dilated cardiomyopathy
Alcohol
Idiopathic
Post viral- from myocarditis
What is main problem of dilated cardiomyopathy
Leads to poor elecetrical conduction and arrythmias
Only in HOCM does prevent by obstruction
What causes hypertrophic cardiomyopathy 50% of time
Familial
What is inheritance of HOCM
A Dominant
Typical presentation of hypertrophic cardiomyopathy
Can just be death SOBOE Angina Syncope Arrythmias
What is jerky carotid pulse seen in
HCM
Examination findings HCM
S4
ESM
Double apex beat with heave
Jerky carotid pulse
Investigations for HCM
ECG- Left axis deviation, Q waves, LVH
Echo- LVH
Causes of restrictive cardiomyopathy
Sarcoidosis
Haemochromatosis
Amyloidosis
Familial
Presentation of restrictive cardiomopathy
Asymptomatic or HF signs
O/E restrictive cardiomyopathy
S3 Ascites Hepatomegaly Oedema Kussmals sign
What can be seen on CXR of myocarditis
Pericardial calcification
How can echo differentiate constrictive pericarditis from restrictive cardiomyopathy
Pericarditis has pericardial thickening whereas restrictive cardiomyopathy will be normal heart muscle
How can you cure chronic pericarditis
Remove pericardium
What is resultant cardiomyopathy myocarditis can lead to
Dilated
Presentation of myocarditis
Pleuritic chest pain worse on lying down
SOB
Palpitations
Flu like prodrome
Most common cause of myocarditis
Post cocksackie B virus
Causes of myocarditis
Post cocksackie B virus
Cocaine
Metals
Radiation
How can CK and troponin differentiate myocarditis from pericarditis
Myocarditis theyre much more elevated
ECG changes seen in myocarditis
Random ST elevation and T wave changes
Test ordered for myocarditis
ECG
CK and troponin
Endomyocardial biopsy
Diagnostic test for myocarditis
Endomyocardial biopsy
If has angina as PC what are some causes
Hypertrophic cardiomyopathy
Aortic stenosis
