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5thyr > Cardio > Flashcards

Cardio Flashcards

1
Q

What is the Management of orthostatic hypotension

A

Management of orthostatic hypotension
1. Education and lifestyle measures such as adequate hydration and salt intake

  1. Discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs
  2. if symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping
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2
Q

What drugs should you use with caution in aortic stenosis?

A

Calcium channel blockers (amlodopine and nifedipine) should be avoided as can provoke collapse)

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3
Q

What are the 2 systolic murmurs?

A

Mitral rergugitation

Aortic stenosis

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4
Q

What is the classic triad of aortic stenosis?

A

Aortic stenosis (most common valvular disorder)

  1. Angina
  2. Syncope (exercise induced)
  3. Breathlessness
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5
Q

What is the most common cause of aortic stenosis?

A

DEGENERATIVE!!!!!!! (normal calcification process)

  • this is made worse by congenital bi-cuspid valve (more wear and tear)
  • Rhuematic heart disease can also cause (but not as common)
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6
Q

Aortic stenosis
What is the Apex beat like?
What is the JVP like?

A

Aortic stenosis

  • Apex beat: forceful but not displaced (pressure overload not volume overload)
  • JVP: not elevated (not volume overload)
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7
Q

What is the pulse like in aortic stenosis?

A

Aortic stenosis

-Pulse: slow rising pulse. Low volume with low pulse pressure

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8
Q

What is the murmer like in aortic stenosis?

A

Aortic stenosis
-Ejetion systolic radiates to carotids
-Bbbbbrrr da (can hear 2nd heart sound after murmur)
(2nd heart sound may become quite if severe because aortic valve doesn’t close properly)

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9
Q

What is the treatment for aortic stenosis?

A

Aortic stenosis
-Treatment is valve replacement
(TAVI-Transcatheter aortic valve implantation if unfit for incisional surgery and cardiopulmonary bypass machine)

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10
Q

What conditions cause pressure overload of left ventricle?

A

Pressure overload of left ventricle
• Aortic stenosis
• Coarctation of the aorta
• Hypertrophic cardiomyopathy (with LV outflow tract obstruction: “subvalvar stenosis”)

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11
Q

What are some causes of mitral regurgitation? (think leaflet/papillary muscles/annular dilatation)

A 
Mitral regurgitation 
Leaflet: 
• congenital
• endocarditis
• degenerative

Papillary muscle and chordae:
• MV prolapse
• acute coronary syndrome
• Marfan’s

Annular dilatation:
• cardiomyopathy (valve no longer fits)
• ischaemic heart disease with heart failure

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12
Q

Mitral regurgitation

  • What is the Apex beat like?
  • What is the JVP like?
A

Mitral regurgitation

  • Apex beat is displaced (volume overload)
  • JVP is raised (volume overload)
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13
Q

Mitral regurgitation

What is the murmer like in mitral regurgitation?

A 
Mitral regurgitation 
-Pansystolic murmer radiating to axilla 
S1zzzzzzzS2
-quite S1
-can't hear a gap between end of murmer and S2
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14
Q

What is the treatment of mitral regurgitation?

A

Mitral regurgitation

  • Mild and moderate: medical treatment with ACE inhibitors, diuretics +/- anticoagulants
  • Severe: valve repair

(acute MR: SOB, cough, fatigue treat like pulmonary oedema)

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15
Q

What is the 4th heart sound?
Is it normal?
Why does it happen?
Apex beat?

A

4th heart sound

  • “LE lub dub”
  • ALWAYS ABNORMAL (HF/MI/cardiomyopathy/HTN)

-Why: Atrial contraction into a non-compliant or
hypertrophied ventricle
-powerful apex beat due to hypertrophy (not displaced)

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16
Q

What is the 3rd heart sound?
Is it normal?
Why does it happen?
Apex beat?

A

3rd heart sound (ventricular gallop)

  • “lub DE dub”
  • normal in children and young adults (can also be caused by HF/MI/cardiomyopathy/HTN/constrictive pericarditis/REGURGITATION!!)

-Why:
•A ventricular sound: blood rushing in during
rapid filling phase of early diastole
•Stiff or dilated ventricle suddenly reaches its
elastic limit and decelerates the incoming rush
of blood
-Apex beat displaced (volume overload)

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17
Q

What is rheumatic heart disease?

A

Rheumatic fever

  • Bacterial tonsillitis with group A beta haemolytic strep
  • 2 to 4 weeks later can develop acute rheumatic fever
  • then 10-20 years later develop rheumatic heart disease
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18
Q

What are the 2 most common valves affected in rheumatic heart disease? (what conditions does this cause?)

A

Rhematic heart disease

  1. Mitral valve (mitral stenosis)
  2. Aortic (aortic regurgitation)
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19
Q

What are the 2 diastolic murmurs and where do you hear them?

A

Mitral stenosis - at apex with bell

Aortic regurgitation - at tricuspid area with patient leaning forward and holding breath

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20
Q

How does mitral stenosis present?

A

Mitral stenosis

  • Malar flush
  • Atrial fibrillation (rheumatic heart disease causes AF)
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21
Q

Mitral stenosis

  • What is the Apex beat like?
  • What is the JVP like?
A

Mitral stenosis
• Tapping apex beat (AF patient tapping the beat out)
• Apex beat not displaced (no volume overload)
• JVP not raised until late

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22
Q

Mitral stenosis

-What is the murmur like?

A

Mitral stenosis

-Diastolic murmur with a load 1st heart sound ur to high atrial pressure “LUB dedeerrrrrrr”

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23
Q

What might you see on a chest Xray in mitral stenosis?

A

Mitral stenosis chest x ray

-Convex left atrium (lots of clots can form here)

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24
Q

For which valvular heart condition is warfarin really important?

A

Mitral stenosis: WARFARIN WARFARIN WARFARIN (they probs have AF because RHD is a cause of AF)

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25
Q

What is the treatment for Mitral stenosis?

A

Mitral stenosis
-Mild: medical treatment (eg anticoagulants, diuretics, rate control of atrial fibrillation)

  • Moderate: ? trans-septal valvuloplasty ? valve replacement
  • Severe (valve area reduced from normal 5cm2 to 1.5cm2 with>5mm gradient): valve replacement
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26
Q

What is the pulse like in aortic regurgitation?

A

Aortic regurgitation

  • collapsing pulse in arm WATERHAMMER (corrigans pulse) because high systolic and low diastolic
  • collapsing pulse in neck (corrigans sign)

wide pulse pressure

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27
Q

Aortic regurgitation

  • What is the apex beat like?
  • What is the JVP like?
A

Aortic regurgitation

  • Apex beat displaced (volume overload)
  • JVP is not raised (volume cant get through aorta to cause it)
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28
Q

What is the murmur like in aortic regurgitation?

A

Aortic regurgitation
-High pitched diastolic murmur following 2nd heart sound “lub taar”
(think of the dance)

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29
Q

Causes of aortic regurgitation?

A

Aortic regurgitation (REALMS)

  • Rhumatic heart disease
  • Endocarditis
  • Ankylosing Spondylitis
  • Luetic heart disease (syphilis)
  • Marfans
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30
Q

Which valvular problems do you get S3?

A

Aortic and Mitral regurgitation (because you get volume overload>also causes displaced apex beat)

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31
Q

What is De Musset’s sign?

A

Head-bobbing due to aortic regurgitation

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32
Q

What is the diagnostic investigation for heart murmurs?

A

Transophageal echo (TOE) diagnostic for murmurs

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33
Q

What are the most common organisms to cause infective endocarditis?

A

Strep Viridans - most common (usually sub-acute)
Staph aureus - most common in prosthetic valves and IVDU
Strep Bovis - must do colonoscopy because there may be a tumour

34
Q

How would infective endocarditis present (symptoms)?

A

With non-specific symptoms such as:

  • fatigue
  • low grade fever
  • night sweats
  • flu-like symptoms
  • polymyalgia
  • may present with stroke (emboli from endocarditis)
35
Q

What is the diagnostic criteria for infective endocarditis?

A

Duke’s criteria

36
Q

What are the signs of endocarditis

A

Endocarditis (2 hands, 2 abdo, 1 heart)

  • Splinter haemorrhages
  • Clubbing
  • Change in murmurs
  • Splenomegaly
  • Microscopic heamaturia

**also Roth’s spots (retinal haemorrhages)/Osler’s nodes /Janeway lesions

37
Q

Investigations for infective endocarditis? (bedside, bloods, imaging)

A

Endocarditis
Bedside
-Urinalysis – may find microscopic haematuria (+blood)
-Baseline and serial ECG (look for heart block)

Bloods

  • Blood cultures: 3 serial blood cultures in 24hrs (from different sites at different times)
  • Blood film: normochromic, normocytic anaemia (↓Hb)
  • Bloods: ↓Hb, ↑Neut, ↑ESR, ↑CRP, U+E, Mg, LFTs

Imaging

  • TOE!!!! (tranosophageal echo)
  • CT: look for emboli (brain, spleen)
  • CXR: cardiomegaly/pulmonary odema
38
Q

Treatment of endocarditis?

A

Endocarditis

MEDICAL
-IV Abx broad (4-6 weeks), usually through central or midlines (BUFALO if sepsis)

SURGICAL
-Surgery – Many need valve replacement (refer to surgeons early to gain advice)

39
Q

Complications of endocarditis

A

Endocarditis complications

  • Stroke (from septic emboli)
  • Congestive heart failure
40
Q

What empirical antibiotics should be started for patient with infective endocarditis?

A

Infective endocarditis
-Blind therapy (normal valve) = Amoxicillin ± Gentamicin

Blind therapy (prosthetic valve) = Vancomycin, Rifampacin + Gentamicin

41
Q

What is varicose veins? (which vein is typically involved)

Who is at risk?

A

Varicose veins
-leakage @ venous valve causes retrograde flow → deep veins can tolerate pressure, superficial veins cannot and become dilated and tortuous → typically SAPHENOUS vein

Risk factors

  • pregnancy (hormones ↑pliability of walls + valves)
  • obstruction to venous outflow (e.g. DVT or extravascular tumours)
  • obesity
  • age > 65yo
42
Q

Symptoms of varicose veins?

Signs of chronic venous insufficiency?

A

Varicose veins symptoms

  • itching
  • heavy feeling of legs
  • ↓Exercise tolerance
  • Restless leg + Night cramps
  • Oedema (legs)
  • Burning sensation or paraesthesia
  • Exacerbated by prolonged standing

Chronic venous insufficiency

  • ulcers
  • lipodermatosclerosis (skin hardens, indurates, inflam)
  • pigmentation
  • telangiectasia
  • eczema
43
Q

What is Trendelenbergs test for varicose veins?

A

Trendelenburg test

  • assess location of valvular competency
  • Pt. lie flat, leg elevated (allows veins to empty), apply tourniquet over the saphenofemoral junction (SFJ)
  • Ask patient to stand> if veins have filled again this indicates the incompetent valve is BELOW the SFJ
44
Q

What is Perthe’s test for varicose veins?

A

Perthe’s test

  • assess deep venous patency
  • Apply tornequet to a varicose leg, then stand repeatedly on tip toe activating calf muscles, normally this empties varicosities, but in DEEP vein obstruction they would paradoxically become CONGESTED
45
Q

What is the diagnostic investigation for varicose veins?

A

Duplex USS (combo of doppler and normal US) is diagnostic for varicose veins

46
Q

What is the management of varicose veins?

A

Varicose veins
Specialist referral to vascular – if bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on QoL

  1. Education – avoid prolonged standing and elevate legs, support stockings, lose weight, regular walks (calf muscles aid venous return)
  2. Endovascular treatments (less pain and earlier return to activity than surgery)
    - Radiofrequency ablation – a catheter inserted into vein, HEAT, destroys endothelium and closes vein
    - Endovenous LASER ablation
    - Injection sclerotherapy – liquid or foam injected in multiple sights over weeks
  3. Can have surgery (trendelenburg procedure)
47
Q

Symptoms of chronic limb ischemia? (due to atherosclerosis)

A

Chronic limb ischemia
-Cramping pain on walking (intermittent claudication)
•Commonly calf or foot, also buttocks, thigh
•Relieved by rest/hanging legs over bed
•Worse going up hill/incline

-Skin changes
•Hair loss + colour change

48
Q

Claudication pain in buttocks/thigh w/ absent femoral pulse + MALE IMPOTENCE

A

Leriche’s syndrome

-due to saddle aorto-iliac obstruction

49
Q

What is critical limb ischamia?

What are the features?

A

Critical limb ischaemia (advance form of chronic limb ischemia)

  1. ISCHAEMIC REST PAIN (for 2 weeks) – partially relieved by HANGING LEGS
  2. ISCHAEMIC LESIONS
  3. ABPI <0.5

Also, may be pale and cold, with weak/absent pulses

50
Q

How do you measure an ABPI?

How do you calculate an ABPI?

A

ABPI (ankle-brachial blood pressure index)
-pt. resting and supine, record systolic in both arms and posterior tibial, dorsalis pedis and peroneal.a (if possible)

Calculation
ABPI = highest ankle pressure / highest arm pressure

51
Q

What do the ABPI results indicate?

what is normal/critical/acute?

A

ABPI results

> 1.2 indicates calcified stiff arteries = advanced age or PAD

Normal= 1 to 1.2 (less than this is likely PAD)

Critical PAD requires urgent referral= < 0.5

ACUTE ISCHAEMIC LIMB = < 0.1

Doppler probe – document nature of sound
Triphasic (norm); Biphasic (abn); Monophasic (PAD)

52
Q

What is the treatment for chronic limb ischemia?

A

Chronic limb ischaemia
Conservative
-Supervised exercise programme + smoking cessation
-Analgesia for pain (follow pain ladder)
-Treat co-morbidities (HTN/DM/obesity) 80mg statin
-Antiplatelet (Clopidogrel) to reduce CVD risk
-Naftidrofuryl oxalate (vasodilator) if no surgery

If conservative fails: Revascularsation

  1. Percutaneous tranluminal ANGIOPLASTY (balloon inflated)
    - only good when one arterial area effected
  2. Surgical reconstruction with BYPASS
    - If extensive disease but good distal collaterals
  3. Amputation
53
Q

Causes of acute limb ischemia?

A

Acute limb ischaemia

  • thrombosis/emboli
  • graft/angioplasty occlusion
  • trauma
54
Q

How does acute limb ischemia present?

A

Acute limb ischaemia

  • 6Ps of acute ischemia
  • in patients with known PAD this may present as deterioration of symptoms and dusky skin (due to collaterals-due not misdiagnose as cellulitis)
55
Q

What is the management of acute limb ischemia?

A

ACUTE LIMB ISCAHEMIA

  • Emergency! Treat within 4-6hrs to save limb!
  • Do an urgent arteriography if in doubt

SAVE THE LIMB
1st line
-Surgical Embolectomy (fogarty balloon) – if embolic
-Can do catheter directed thrombolysis with alteplase (weigh up risks)

2nd line
-open thromboembolectomy

Either either procedure anticoagulate with
IV heparin afterwards

56
Q

1st line imaging for peripheral arterial disease?

A

1st line imaging is colour duplex US (do before revascularation)

57
Q

What is repercussion injury?

A

Reperfusion injury

  • may cause more damage than initial ischaemia
  • Neutrophils migrate to reperfused tissue → inflammation
  • ↑capillary permeability →Limb oedema→ compartment syndrome
  • Leakage from damaged cells → acidosis, ↑K+ (arrhythmia), myoglobinaemia (acute tubular necrosis → AKI)
58
Q

Arterial vs venous ulcers?

appearance/location/additional features

A

Arterial

  • Punched out
  • Toes/dorsal foot/lateral malleolus
  • Thin shiny skin
  • Reduced hair growth
  • Pulses reduced/ CRT increased
  • Painful (relieved by lowering legs)

Venous

  • Irregular/shallow
  • Medial aspects of legs
  • Hemosiderin staining/itchy
59
Q

What is Superficial thrombophlebitis?

A

Superficial thrombophlebitis/Superficial vein thrombosis

  • superficial vein (often long saphenous of leg) becomes inflamed and forms a clot within (virchows triad)
  • basically an SVT (not deep)
60
Q

Managment of Superficial thrombophlebitis

A

Superficial thrombophlebitis/Superficial vein thrombosis
-NSAIDS
-warm towel
-elevate legs
-continue to use leg
-Continue treatment until pain settles (usually within 1–2 weeks, although the thrombosed vein may be palpable and tender for several weeks to months)
-Investigate for malignancy (CT abdo/pelvis)
-Can refer to vascular
• Venous duplex scanning
• LMWH

61
Q

What is pericardial effusion?

What are the causes?

A

Pericardial effusion
-An accumulation of fluid in serous pericardium (normally 10ml-50ml)

Causes:

  • Pericarditis
  • myocardial rupture (heamopericardium-trauma, post MI)
  • aortic dissection
  • malignancy
62
Q

Symptoms of pericardial effusion?

A 
Pericardial effusion
-dyspnoea
-chest pain 
-signs of local compression: 
  •hiccups (phrenic nerve)
  •nausea(diagphram) 
  •compressed left lobe-bronchial breathing 
-muffled heart sounds 
CAN PROGRESS TO TAMPONADE
63
Q

What would pericardial effusion look like on chest x ray?

A

Pericardial effusion would show enlarged globular heart if effusion >300ml

64
Q

What is the managment of pericardial effusion?

A

Pericardial effusion

  • treat cause
  • Pericardiocentesis can be diagnostic (suspected bacterial pericarditis) or theraputic (tamponade)
65
Q

What is cardiac tamponade?

A

Pericardial effusion → increased pericardial pressure →reduced ventricular filling →reduced CO

66
Q

Signs of cardiac tamponade?

A 
Cardiac tamponade
BECKS TRIAD 
1. ↓ BP 
2. ↑ JVP
3. Muffles heart sounds
  • ↑pulse (compensatory
  • pulsus paradox (reduction of sys BP >10 in inspiration)
  • Kussmauls sign (rise in JVP in inspiration)
67
Q

Management of cardiac tamponade?

A

Cardiac tamponade

  • seek urgent help
  • pericariocentesis
68
Q

What is the most common type of cardiomyopathy?

Name some causes.

A

Dilated cardiomyopathy is the most common (caused by alcohol/ HTN/viral/autoimmune/post partum/congenital

69
Q

What is the pathophysiology of dilated cardiomyopathy?

A
  • floppy heart

- problems with pumping (systole)

70
Q

Which cardiomyopathy causes sudden cardiac death in young people?

A

-Hypertrophic myopathy (problem with filling/diastole)

71
Q

What is restrictive cardiomyopathy?
What heart sound?
What would cause this?

A

-STIFF WALLS leads to problems with filling (diastole)
-Non compliant ventrical would cause S3
-Caused by infiltrative diseases
•amyloidosis
•sarcoidosis
•fibrosis (post-radiotherapy)
•heamatomatosis

72
Q

What is the effect of hypertrophic cardiomyopathy on the valves?

what murmur would you hear?

what increases/decreases this murmur?

A

-Hypertrophy leads to problem with filling/diastole
-This type can cause mitral valve obstruction (which causes further obstruction)
-Causes left ventricular outlet obstruction
•aortic stenosis type murmer (ejection systolic)
•crescendo-descresendo
•INCREASES with valsalva manoeuvre!
•DECREASES with squatting/hand grip

73
Q

What can happen during excercise in hypertrophic cardiomyopathy?

A

Excercise can cause: (demand>supply)

  • Synocpe
  • Angina
  • Dyspnoea
74
Q

What added sounds do you hear in hypertrophic cardiomyopathy?

How does it sound? is this normal?

A

-S4 (hypertrophy>obstruction>PRESSURE OVERLOAD)

4th heart sound=le lub dub and is ALWAYS ABNORMAL

75
Q

Symptoms and signs of dilated cardiomyopathy?

A

Dilated cardiomyopathy>classic HF signs

  • Displaced apex beat (volume overload)
  • S3 heart sound (happens with flabby/stiff ventricles)
  • SOB/fatigue/↑JVP/↑HR/mitral or tricuspid regurge
76
Q

What is the inheritance for hypertrophic cardiomyopathy?

A

Hypertrophic cardiomyopathy is autosomal dominant- B myosin (can just be idiopathic)

77
Q

How can you manage Raynauds syndrome (once you’ve ruled out important causes)

A

Conservative

  • stop smoking
  • warm hands

Medical
-Nifidipine an help (CCB- allows vessels to relax)

78
Q

What is the management of acute limb ischemia (viable, non threatened limb)?

A
  1. Anticoagulation IV heparin
  2. Angiography (need to localise site of occlusion)
  3. Revascularsation procedure within 6-24 hours
79
Q

2 types of mesenteric ishemia?

A

Non gangrenous (85%)

Gangrenous (15%)

80
Q

How does non gangrenous mesenteric ischemia present?

A
  1. Hyperactive phase
    - diarrhea
    - widespread pain out of proportion
    - worse after eating
    - melena
  2. Paralytic phase
    - bloating
    - absent bowel sounds (psuedo obstruction)
    - more duffse pain
81
Q

How does gangrenous mesenteric ischemia present?

A
  • haemodynamically unstable

- bloody diarrhea

82
Q

Treatment for mesenteric ischemia?

A

Haem unstable

  • open surgical embolectomy/ bypass
  • resection of necrotic tissue

Haem stable
-balloon angioplasty and stenting

5thyr (18 decks)

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