cardio Flashcards
ECG territories + coronary artery supply
II, III, AvF: inferior, R coronary artery
V1-V4: anterior, LAD
I, V5-V6, AvL: lateral, L circumflex
aortic stenosis causes
- mostly calcification from increasing age
- congenital bicuspid aortic valve (20%)
other:
rheumatic fever
infective endocarditis
CKD (hyperphosphataemia)
aortic stenosis signs on exam
ejection systolic murmur radiation to carotids loudest at R upper sternal edge at end expiration soft S2 narrow pulse pressure heaving apex beat
indications for aortic valve replacement
symptomatic dilated LV BP drop on exercise LVEF < 50% valvular gradient > 40mmHg
aortic stenosis treatment options
conservative (RF optimisation, serial echo)
open aortic valve replacement
TAVI (transcatheter aortic valve implantation)
balloon aortic valvuloplasty
systolic murmur differentials
- aortic / pulmonary stenosis
- mitral / tricuspid regurgitation
- VSD
- HOCM
5, mitral valve prolapse
heart failure CXR findings
A: alveolar oedema (bat wings) B: kerley B lines C: cardiomegaly D: dilated upper lobe vessels E: pleural effusion
L heart failure signs
gallop rhythm (presence of S3) displaced apex beat (LV dilatation) pleural effusion bibasal creps (end-inspiratory) ± wheeze L sided murmurs (aortic / mitral)
R heart failure signs
raised JVP tender hepatomegaly (pulsatile w tricuspid regurg) peripheral pitting oedema ascites facial engorgement R sided murmurs (tricuspid / pulmonary)
immediate management acute cardiac failure
- ABCDE
- sit pt upright
- 15L high flow oxygen 60-100%
- diuretics: furosemide (also venodilates initially)
- GTN → venodilation → ↓preload
- diamorphine → venodilation
pharmacological Tx chronic cardiac failure
symptomatic: furosemide
prognostic:
1. ACE inhibitor + β-blocker (LVEF < 55%)
2. + ARB / spironolactone (LVEF < 35%)
3. entresto (delay 36hrs after stopping ACEi/ARB)
4. digoxin
cardiac resynchronisation therapy
beta blocker contraindications
severe heart failure
asthma / COPD
bradycardia
heart failure contraindicated drugs
• Pro-anti-arrhythmics w potentially negative inotropic effects e.g. flecainide
• CCBs e.g. verapamil, diltiazem (only amlodipine is advisable)
• Tricyclic antidepressants
• Lithium
• NSAIDs and COX-2 inhibitors
• Corticosteroids
• Drugs prolonging QT interval and potentially precipitating ventricular arrhythmias e.g.
erythromycin, terfenadine
• β-blockers contraindicated in severe heart failure
cardiac failure complications
- Pleural effusion
- Acute renal failure/chronic renal insufficiency
- Anaemia
- Sudden cardiac death
- Cardiogenic shock
- Pulmonary HTN
what is cor pulmonale
R heart failure caused by chronic pulmonary HTN
pulmonary hypertension signs on examination
raised JVP (prominent “a” wave)
L parasternal heave (R ventricular hypertrophy)
loud pulmonary component of S2
causes tricuspid regurgitation
- R ventricular pressure overload (pulmonary HTN, L sided heart failure)
- Pacemaker
- Infective endocarditis
- Rheumatic heart disease
- Connective tissue disease e.g. Marfan’s
- Ebstein’s anomaly (malpositioned tricuspid valve)
signs tricuspid regurg
pansystolic murmur
loudest at left lower sternal edge on inspiration
irregular pulse (atrial flutter / fibrillation)
large “v” waves of JVP
pulsatile hepatomegaly
complications tricuspid regurg
atrial arrhythmias: flutter / fibrillation
liver disease
myocardial infarction
atrial fibrillation causes
infection thyrotoxicosis ischaemic heart disease rheumatic heart disease alcohol pulmonary embolism
atrial fibrillation ECG findings
irregularly irreguarly rhythm
loss of P waves
fibrillatory waves
atrial fibrillation management
rate control: beta-blockers / CCBs
rhythm control if onset < 48hrs: DC cardioversion / flecainide / amiodarone
anticoagulation: LMWH + IV heparin
if > 48hrs: anticoagulate for 3-4 wks with warfarin + heparin then DC / chemical cardioversion
atrial fibrillation Sx + signs
palpitations dizziness / syncope irregularly irregular rhythm hypotension tachycardia
scoring systems for AF complications (2)
CHADSVASc: risk of stroke → >2 = anticoagulate
HAS-BLED: risk of haemorrhage → >2 = do not anticoagulate
1st degree heart block ECG changes
prolonged PR interval (>5 small squares/0.2s)
Mobitz type 1 ECG changes
progressive prolongation of PR interval until dropped QRS
Mobitz type 2 ECG changes
constant PR interval, occasional dropped QRS
type 3 heart block ECG changes
complete dissociation between P waves + QRS complexes
management chronic stable angina
conservative: exercise, smoking cessation, improved diet
medical:
anti-anginals:
1. beta-blocker
2. CCBs
3. beta-blocker + CCB (but not verapamil - risk of complete heart block)
4. long-acting nitrate, nicorandil (K-channel activator), ranolazine, ivabradine
+ statin + aspirin
GTN spray: pt should call ambulance if no relief 5min after 2nd dose
surgical: PCI (angioplasty) / CABG
stanford classification
for aortic dissection
A: ascending aorta (requires surg)
B: descending aorta (after L subclavian) (non-operative management)
varicose veins RFs
obesity DVT pregnancy COCP prolonged standing
signs of venous insufficiency
varicose veins
lipodermatosclerosis
corona phlebetatica
venous ulcers
varicose vein management
cons: weight loss, reduce standing, raise legs, compression stockings
minimally invasive: endothermal ablation (radiofrequency / laser), USS-guided sclerotherapy
surgical: ligation + stripping (under GA)
mitral regurgitation causes
acute: papillary muscle rupture due to MI / endocarditis
chronic:
functional: heart failure → LV dilatation → separation of valve leaflets
congenital: connective tissue disease e.g. EDS, Marfan’s
acquired:
infective endocarditis
IHD
assoc w atrial fibrillation
venous ulcer presentation
painless wet ulcer irregular sloped edges haemosiderin deposition oedema gaiter region (around medial malleolus) lipodermatosclerosis
arterial ulcer presentation
painful dry ulcer
well-demarcated
between toes / lateral aspect of foot / ankle
reduced / absent pulses
hypertensive retinopathy grades
- silver-wiring (tortuous vessels with shiny thick walls)
- grade 1 + AV-nipping (narrowing of arteries crossing veins)
- grade 2 + flame haemorrhages + soft exudates
- grade 3 + papilloedema
signs on examination infective endocarditis
Osler's nodes: painful Janeway lesions: painless, thenar eminence splinter haemorrhages Roth spots (fundoscopy) new murmur
most common causative organisms infective endocarditis
strep viridans (subacute)
staph aureus → IVDU (acute, RH valves, no chronic signs)
staph epidermidis → prosthetic valves
diagnostic criteria for infective endocarditis
Duke criteria
major: persistently +ve cultures w typical organisms
+ve echo
new regurgitation
mitral regurgitation signs
pansystolic murmur loudest over apex on expiration radiates to axilla soft S1 chronic → LV dilatation → displaced apex beat
mitral regurgitation management
cons: monitor w serial echo
medical:
for functional MR: ACEi, beta-blockers, diuretics
treat AF if present (rate, rhythm, anticoagulation)
surgical: annuloplasty / valve replacement
indications for valve replacement in mitral regurg
acute severe MR
symptomatic
LV dysfunction: LVEF < 50% / LV dilatation
complications: new onset AF / pulmonary HTN
mod / severe MR already undergoing CABG
definition critical limb ischaemia
> 2 wks of:
- pain at rest
- tissue loss: arterials ulcers, gangrene
- ankle pressure < 40mmHg
signs chronic peripheral vascular disease
reduced pulses dry shiny cracked hairless skin brittle nails auscultation → bruit Buerger's angle < 20
management chronic peripheral vascular disease
cons: exercise, smoking cessation, improve diet
med: treat CV RFs (HTN, dyslipidaemia, diabetes)
surg: angioplasty, endarterectomy, bypass
complications acute limb ischaemia
rhabdomyolysis → AKI
ischaemia → lactic acidosis, hyperkalaemia (→ cardiac arrest)
management acute limb ischaemia
bolus IV heparin
urgent referral vascular surg:
surgical revascularisation: embolectomy / thrombolysis / angioplasty (for larger thrombus)
non-salvageable limb (paraesthesia, paralysis) → amputation
presentation acute limb ischaemia
Pain Pulseless Perishing cold Pale Paralysis Paraesthesia (final 2 indicate non-salvageable limb → amputation required)
classification for severity of heart failure
NYHA classification 1. asymptomatic 2. mildly symptomatic on activity 3. moderately symptomatic w activity confortable at rest 3. severely symptomatic unable to carry out physical activity Sx at rest
pharmacological management HTN
< 55yrs / T2DM: ACEi > 55yrs / Afro-Caribbean: CCB 2. ACEi + CCB / ACEi + thiazide diuretic 3. ACEi + CCB + thiazide 4. K < 4.5: low-dose spironolactone K > 4.5: alpha / beta-blocker 5. specialist review
causes postural hypotension
hypovolaemia
autonomic disturbance: diabetes, Parkinson’s
drugs: antihypertensive, L-dopa, diuretics, antidepressants
alcohol
signs on exam aortic regurgitation
early diastolic murmur loudest over aortic area on expiration
wide pulse pressure
collapsing pulse
extras:
austin flint murmur: rumbling mid-diastolic murmur (turbulent blood hits mitral valve leaflets)
quincke’s sign: capillary pulsation in nail bed
de musset’s sign: head nods in time w pulse
corrigan’s sign: visibly pulsating carotids
causes aortic regurgitation
congenital: bicuspid, connective tissue disease (Marfan’s), aortitis (ank spond, vasculitis)
acquired: endocarditis, type A aortic dissection
management aortic regurgitation
cons: serial echo, CV risk optimisation
med: CV risk optimisation
vasodilators: ACEi / ARBs / CCBs (reduce TPR + afterload)
beta-blockers reduce aortic root dilatation in marfan’s
diuretics for Sx relief
surg: AVR
CXR findings aortic regurgitation
cardiomegaly
widened mediastinum (aortic dilatation)
signs of L heart failure (pulmonary oedema, effusion)
signs on exam mitral stenosis
mid-diastolic murmur loudest on expiration over mitral region loud S1, opening snap tapping apex beat malar flush AF (irregularly irregular pulse)
causes of mitral stenosis
most common: rheumatic fever
prosthetic valve malfunction
inflammatory conditions: SLE, RA
complications of mitral stenosis
atrial fibrillation
pulmonary HTN → R heart failure (cor pulmonale)
management mitral stenosis
cons: serial echo + patient follow-up
med: optimise CV RFs
treat AF / heart failure
diuretics for Sx relief
surg: percutaneous transvenous mitral commisurotomy (PTMC)
2nd line mitral valve replacement
diagnostic criteria rheumatic fever
evidence of GAS + 2 major / 1 major + 2 minor
GAS: +ve throat culture, rapid Ag test +ve, high strep Ab titre
major: carditis, arthritis, sydenham’s chorea, erythema marginatum, subcutaneous nodules
minor: fever, raised ESR, leukocytosis, arthritis, prolonged PR on ECG, prev rheumatic fever
management rheumatic fever
cons: bed rest, immobilisation of arthritic joints
med: aspirin + corticosteroids
ABx: benpen IV STAT then PO pen V for 10 days
treat chorea w diazepam / haloperidol
surg: may require valve replacement
management infective endocarditis
treat w empirical IV ABx based on clinical suspicion:
acute → fluclox / vanc + gent
subacute → benpen + gent
surgery: removal of infected tissue, valve repair / replacement if decompensated heart failure, abscess, fungal endocarditis, repeated emboli
mechanical vs bioprosthetic valves
mechanical: require lifelong anticoag
last longer ~20years
types of mechanical valve
starr-edward's: ball & cage (high risk of clots - no longer used) tilting disc (bjork-shiley) st jude's: bileaflet (two tilting discs)
pacemaker indications
symptomatic bradycardia
tachyarrhythmias: SVT, VT
heart block: complete, Mobitz type II, AV block after anterior MI
biventricular pacing (CRT)
types of pacemaker
single chamber: RV
dual chamber: RV + RA
biventricular (CRT): RV + RA + LV
pacemaker complications
pneumothorax
infection
lead dislodgement
tricuspid regurg
types of ICD
single chamber: RV (ICD)
dual chamber: RV (ICD) + RA, for concurrent arrhythmia (AF)
CRT(D): RV (ICD) + RA + LV, for heart failure (cardiac desynchrony)
indications for ICD
primary prevention:
previous MI +
a. LVEF < 35% + non-sustained VT + positive electrophysiological study
b. LVEF < 30% + broad QRS (>120ms)
familial conditions w risk of sudden cardiac death: HOCM, long QT
secondary prevention following:
VT / VF causing cardiac arrest
haemodynamically unstable VT
VT w LVEF < 35%
signs on exam aortic coarctation
radio-femoral delay, weak femoral pulse
BP in UL > LL
ejection systolic murmur
signs of Turner’s: short stature, neck webbing, wide-spaced nipples
types of dextrocardia
- dextrocardia of embryonic arrest: heart placed further R in thorax than usual
- dextrocardia situs invertus: heart position mirrored from usual
(situs invertus totalis = all visceral organs)
assoc w Kartagener’s syndrome: primary ciliary dyskinesia
management unstable angina
acute: MONA beta-blocker + statin anticoagulation: heparin consider coronary angiogram ongoing: dual antiplatelet therapy (aspirin + clopi OD) statin + ezetimibe treat CV RFs
management STEMI
acute: MONA
heparin + PCI (ideally within 90min)
thrombolysis if PCI not acessible (IV alteplase)
failure of PCI (continued chest pain / haemodynamic instability) → CABG
management NSTEMI
acute: MONA
admit for at least 24-48hrs
fondaparinux / LMWH if undergoing angio
GRACE risk score
high → glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) + coronary angio within 96hrs of admission
low risk → close monitoring, consider angio
MONA (incl doses)
diamorphine (5-10mg IV)+ metaclopramide (10mg IV)
oxygen if sats < 90
nitrates (sublingual)
dual antiplatelet therapy (oral): aspirin 300mg + clopidogrel 300mg / ticagrelor (reduced risk of stent thrombosis)
post MI management
cons: exercise, diet
med: long-term dual antiplatelet (aspirin + clopi / ticagrelor)
statin for all pts
echo to assess damage to myocardium:
LVEF < 40% → beta-blocker
LVEF < 40% + HTN, DM, HF → ACEi
LVEF < 35% + HF / DM → spironolactone
differentials for midline sternotomy
CABG
open valve replacement
less common: heart / lung transplant, atrial myxoma excision
indications for CABG
multivessel disease single vessel disease + failed PCI left main artery disease pt unsuitable for long-term dual antiplatelet Tx
graft site options for CABG
- internal mamillary / internal thoracic artery
- long / short saphenous veins
- radial artery
indications for heart transplant
dilated / ischaemic cardiomyopathy (most common)
congenital heart disease
NYHA class III / IV
LVEF < 30%
causes of raised JVP
R heart failure tricuspid regurg pericardial effusion SVC obstruction complete heart block constrictive pericarditis
management ventricular tachycardia
stable → amiodarone
unstable → call crash team, electrocardioversion
consider ICD if recurrent
causes of ventricular tachycardia
ACS
cardiomyopathy
electrolyte imbalance
long QT
definition torsades de points + management
polymorphic ventricular tachycardia assoc w long QT
IV magnesium sulphate
signs on exam aortic dissection
collapsing pulse aortic regurg (mid-diastolic murmur) BP differential between L / R (>20mmHg) hypotension wide pulse pressure
investigations aortic dissection
bedside: BP, ECG
bloods: FBC, U+Es, LFTs, D-dimer +ve, X-match 10 units
imaging: initial CXR → widened mediastinum
CT angio → visualisation of dissection + intimal flap
TOE → intimal flap
management aortic dissection
ABCDE type A: urgent vascular surgical referral + control BP (100-120mmHg systolic) type B: control BP IV labetalol, nitroprusside opioid analgesia
complications aortic dissection
aneurysm dilatation + rupture
occlusion of branch vessels (coronary → MI)
cardiac tamponade
aortic regurgitation
cardiovascular causes of clubbing
endocarditis
cyanotic heart disease
aneurysms
atrial myxoma
types of AF
paroxysmal = self-terminated at least once persistent = > 48hrs permanent = cannot be terminated w drugs / DC
management wolff-parkinson white
cardiovert if haemodynamically unstable
IV adenosine
treat assoc arrhythmias
radiofrequency ablation of bundle of Kent (definitive)
wolff-parkinson white associated conditions
HOCM mitral valve prolapse thyrotoxicosis Ebstein's anomaly secundum ASd
management supraventricular tachycardia
IV adenosine uncovers underlying pathology
beta-blocker, CCB, amiodarone
DC cardioversion if haemodynamically unstable
management atrial flutter
if diagnostic uncertainty: IV adenosine / carotid sinus massage
rate control: beta-blocker, CCB, amiodarone
rhythm control: DC cardioversion
anticoagulation (CHADSVASc / HAS-BLED)
catheter ablation
management atrial flutter
if diagnostic uncertainty: IV adenosine / carotid sinus massage
rate control: beta-blocker, CCB, amiodarone
rhythm control: DC cardioversion
anticoagulation (CHADSVASc / HAS-BLED)
catheter ablation
causes of hypertension
primary / essential: most common secondary: renal disease: renal artery stenosis, PKD endo: conn's, cushing's, phaeo pregnancy drugs: steroids, OCP aortic coarctation
management of abdominal aortic aneurysm
cons / med: CV RF modification
surg: for > 5.5cm OR enlarged by >1cm / year OR rupture
EVAR (endovascular AAA repair): stenting for older pts / unable to tolerate open surg
complications: endoleak, need for further procedures
open repair: younger pts, longer recovery
abdominal aortic aneurysm screening
for all men > 65 years: one-off abdo USS
>5.5cm OR enlarging by >1cm / year → elective repair
4.4 - 5.5cm → 3mthly USS
3 - 4.4cm → annual USS
< 3cm → discharge
true vs false aneurysm
true: all layers of vascular wall + > 50% of normal diameter
false: collection of blood around vessel wall that communicates w vessel lumen
dissecting: tear in tunica intima creates false lumen
indications for amputation
peripheral vascular disease: gangrene, acute limb ischaemia
trauma
malignancy
severe pain
complications of amputation
infection, bleeding, site / phantom limb pain, disability, decreased mobility (difficulty fitting prostethesis if poor stump shape)
dry vs wet gangrene
wet: tissue necrosis + infection offensive odour, swelling, discharge dry: tissue necrosis due to chronic impairment of blood flow (PVD) dry, pulseless both: skin colour changes to black
causes acute pericarditis
idiopathic
viral (most common): coxsackie, mumps
bacterial: TB, strep
post-MI: early (12-96hrs) / late (Dressler’s syn; 2-10wks)
connective tissue tissue: RA, systemic sclerosis
investigations acute pericarditis
bedside: ECG
bloods: FBC, CRP, cultures, BNP, troponin
imaging: CXR, TTE (definitive)
management acute pericarditis
cons: exercise restriction
med: IV ABx, NSAIDs + PPI, corticosteroids + colchicine
surg: pericardial aspiration / pericardiectomy
follow-up echo to assess for myocardial involvement
complications acute pericarditis
pericardial effusion
cardiac tamponade
constrictive pericarditis
types of cardiomyopathy
dilated: inefficient pumping of blood
HOCM: autosomal dominant
restrictive: rigid walls → poor filling (caused by infiltration: sarcoid, haemochromotosis, amyloid)
presentation HOCM
syncope, chest pain, SOBOE, palpitations
ejection systolic murmur
jerky carotid pulse
pulsus bisferiens (double tapping apex beat / carotid pulse)
management venous ulcers
cons: CV RF modification, compression bandaging (if ABPI > 0.8) bed rest + leg elevation med: analgesia topical antiseptics e.g. manuka honey oral pentoxifylline (peripheral vasodilator) desloughing w larval therapy treat varicose veins surg: split-thickness skin grafts
causes of long QT
electrolyte abnormalities: low Mg, K, Ca antibiotics: macrolides, ciprofloxacin antiarrhythmics: amiodarone, sotalol lithium, SSRIs, TCAs antipsychotics: quetiapine, clozapine hypothermia
investigations for DVT
well score 2 or more: leg USS within 4 hrs D-dimer if -ve 1 or less: D-dimer leg USS if +ve if cannot perform leg USS within 4 hrs then give LMWH and USS within 24hrs
management heart block
1st degree / Mobitz type 1
conservative (ECG monitoring + review meds) if asymptomatic
consider pacemaker insertion if symptomatic
Mobitz type 2 / 3rd degree:
haemodynamically unstable: atropine + external pacing
stable: pacemaker insertion
complications mitral regurgitation
atrial fibrillation (→ stroke) pulmonary HTN (→ cor pulmonale)
complications aortic stenosis
L heart failure
arrhythmias
risk factors for heart block
increased age ACS drugs: AV node-blocking: b-blockers, CCBs, adenosine anti-arrhythmias: sotalol, amiodarone cardiomyopathy
interpretation of ABPI
> 0.9 = normal
0.5 - 0.9 = intermittent claudication
0.3 - 0.5 = rest pain
< 0.3 = critical limb ischaemia
management of tachyarrhythmias
ABCDE
sync DC shock if adverse features (shock, syncope, MI, HF)
VT: amiodarone 300mg
SVT: vagal manouevres, then adenosine 6mg
AF: rate (b-blocker / digoxin) + rhythm control (if < 48 hrs onset) (cardioversion / amiodarone / flecainide)
management of bradyarrhythmias
- IV atropine (500mcg)
- if no improvement consider one of:
Atropine up to 3mg Transcutaneous pacing
Isoprenaline / adrenaline infusion (titrated to response) - transcutaneous pacing
