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PACES > Cardio > Flashcards

Cardio Flashcards

1
Q

Cardiac Causes of Clubbing

A
  • Atrial Myxoma
  • Bacterial Infective Endocarditis
  • Congenital Cyanotic Heart Disease
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2
Q

Causes of collapsing pulse

A
  • AR
  • Thyrotoxicosis
  • Pregnancy
  • Anaemia
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3
Q

Causes of absent radial pulse

A
  • Dead
  • Trauma
  • Thrombosis or embolism
  • Coarctation of the aorta
  • Takayasu’s Arteritis
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4
Q

Causes of impalpable apex beat

A
  • COPD
  • Obesity
  • Pericardial effusion
  • Dextrocardia
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5
Q

What are the features of Pulmonary HTN

A
  •  ↑JVP
  •  Left parasternal heave
  •  Loud P2 + PSM of TR
  •  Pulsatile hepatomegaly
  •  Ascites and peripheral oedema
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6
Q

What are the four heart sounds

A
  •  S1: mitral valve closure
  •  S2: aortic valve closure
  •  S3: rapid ventricular filling of dilated left ventricle
  •  S4: atrial contraction against stiff ventricle
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7
Q

What investigations would you want to do at the end of a cardio examination?

A
  • ECG
  • Blood
    • FBC: anaemia exacerbates cardiac symptoms
    • U+E: renovascular disease
    • NT-proBNP: heart failure
    • Fasting lipids and glucose: cardiac risk
    • Trops
  • Imaging
    • CXR
    • Echo
    • Cardiac catheterisation
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8
Q

Features of Aortic Stenosis

A
  • Crescendo decrescendo ESM
  • Right 2nd ICS
  • Radiates to carotids
  • Sitting forward in end-expiration
  • May be an ejection click in bicuspid valve disease

Features of severe disease:

  • Low-volume pulse
  • Slow-rising (anacrotic)
  • Narrow pulse pressure (<30mmHg)
  • Aortic thrill
  • Heaving apex
  • Reversed splitting of S2
  • Soft aortic component of S2
  • 4th HS
  • Pulmonary HTN
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9
Q

Ddx of AS

A
  • Aortic sclerosis: no radiation, normal pulse character
  • MR
  • HOCM:
    • valsalva ↑s murmur
    • squatting ↓s murmur
  • Right-sided: PS
  • Supra-valvular aortic stenosis (William’s syndrome)
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10
Q

Causes of AS

A

Common:

  • Age-related senile calcification
  • Bicuspid aortic valve and other congenital causes
  • Rheumatic heart disease

Rare:

  • Infective endocarditis
  • Hyperuricaemia
  • Alkaptonuria
  • Paget’s disease
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11
Q

Rx of AS

A
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12
Q

Clinical signs of severe MR

A
  • LVF
  • AF
  • Soft first HS
  • 3rd and 4th HS
  • Displaced apex beat
  • Precordial thrill
  • Mid-diastolic flow murmur
  • Widely split second HS
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13
Q

Murmur in MR

A

 Blowing PSM

 Apex

 Left lateral position in end-expiration

 Radiates to the axilla

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14
Q

DDx for MR

A

 Right-sided: TR

 AS

 VSD

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15
Q

Causes of MR

A

Chronic:

  • Functional: LV dilatation (e.g. 2O to HTN or idiopathic)
  • Annular calcification → contraction
  • Rheumatic heart disease
  • Mitral valve prolapse
  • Connective tissue disorders: Marfan’s, Ehler’s danlos, osteogenesis imperfecta
  • Cardiomyopathies
  • SLE (Libman-Sachs endocarditis)
  • Papillary muscle dysfunction (ischaemia)

Acute

  • Rupture of chordae tendinae
  • Infective endocarditis
  • Trauma
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16
Q

What might you see on ECG and CXR for a patient with MR?

A

ECG

  • AF
  • P mitrale (LA hypertrophy)

CXR:

  • LA (double right heart border) and LV hypertrophy
  • Splaying of the carina (LA dilatation)
  • Left atrial appendage
  • Mitral valve calcification
  • Pulmonary oedema
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17
Q

Echo features for severe MR

A

 Jet width >0.6cm

 Systolic pulmonary flow reversal

 Regurgitant volume >60ml

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18
Q

Specific Mx of MR

A

 AF: rate control and anticoagulation

 Emboli: anticoagulant

 ↓ afterload

 ACEi or β-B (esp. carvedilol)

 Diuretics

 Valve replacement

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19
Q

Murmur in AR

A

 High-pitched early diastolic murmur
 LLSE (3rd left IC parasternal)
 Sitting forward in end-expiration

Additional Murmurs:

 Ejection systolic flow murmur

 Austin-Flint murmur (rumbling MDM @ apex secondary to regurgitant jet fluttering the anterior mitral valve)

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20
Q

Signs of AR

A

Eponymous Signs

Quincke’s: capillary pulsation in nail beds

Corrigan’s: visible vigorous carotid pulsation

De Musset’s: head nodding

Traube’s: pistol-shot sound over femorals

Duroziez’s

 Systolic murmur over the femoral artery ̄c proximal compression.

 Diastolic murmur ̄c distal compression

Mueller’s: systolic pulsations of the uvula

Rosenbach’s: systolic pulsations of the liver

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21
Q

Causes of AR

A

Chronic

  • Bicuspid aortic valve
  • HTN
  • Rheumatic heart disease
  • Autoimmune: Ank spond, RA, SLE
  • Connective tissue: Marfan’s, Ehler’s Danlos
  • Aortitis: Takayasu, syphilis, Reiter’s syndrome
  • Perimembranous VSD

Acute

  • IE
  • Type A Aortic dissection
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22
Q

Indications of valve replacement for AR

A

 Symptomatic: NYHA >2

 LV dysfunction

 Pulse pressure >100mmHg
 ECG changes: T inversion in lateral leads

 LV enlargement on CXR or EF <50%

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23
Q

Mitral Stenosis Murmur

A

 Opening snap

 Rumbling MDM

 Apex - tapping apex

 Left lateral position in end-expiration

 With the Bell

 Radiates to the axilla

 Loud first HS

 Pre-systolic accentuation if pt. in sinus rhythm

 Atrial contraction

 Graham Steell murmur (EDM secondary to PR)

24
Q

ECG Features of Mitral Stenosis

A

 P-mitrale

 AF

25
Q

Criteria for Rheumatic Fever

A

Revised Duckket Jones Criteria

 2 major criteria, or
 1 major + 2 minor

Major Criteria

 Pancarditis

 Arthritis

 Subcut nodules

 Erythema marginatum

 Sydenham’s chorea

Minor criteria

 Fever

 Raised ↑ESR or ↑CRP

 Arthralgia

 Prolonged PR interval

 Prev rheumatic fever

26
Q

Rx of Rheumatic Fever

A

 Bed rest until CRP normal for 2wks

 Benpen 0.6-1.2mg IM for 10 days

 Analgesia for carditis/arthritis: aspirin / NSAIDs

 Add oral pred if: CCF, cardiomegaly, 3rd degree block

 Chorea: Haldol or diazepam

 Secondary prophylaxis (Pen V 250mg/ 12h PO for 5-10 years)

27
Q

Most likely valves to be affected by Rheumatic Heart Disease

A

 Mitral (70%)

 Aortic (40%)

 Tricuspid (10%)

 Pulmonary (2%)

28
Q

Common acute IE organisms

A
  • S. aureus
  • S. epidermidis
29
Q

Most common organisms for Bacterial Endocarditis

A

 S aureus now

 S. viridans (previously)

 S. epidermidis (Valvular in the first two months)

 S. bovis (do colonoscopy for colonic neoplasm)

30
Q

Clinical features of subacute endocarditis

A

Hands

 Clubbing

 Splinters

 Janeway lesions

 Oslers nodes

Other

  • Fever
  • Roth spots
  • Splenomegaly
  • Haematuria
31
Q

Criteria for diagnosing Endocarditis

A
32
Q

Rx of endocarditis

A

Depends on the organism and type of valve:

  • Strep viridans or bovis = Benpen + gent (+/- vancomycin)
  • Staph = flucloxacillin
  • Staph on mechanical valve = Flucloxacillin + rifampicin + low-dose gentamicin
33
Q

What are the different types of heart valves for replacement?

A

Xenograft:

  • Porcine

Homograft:

  • Cadaveric
  • Ross procedure → using pulmonary valve

Mechanical:

  • Ball and cage: e.g. Starr-Edwards
  • Tilting disc: e.g. Bjork-Shiley
  • Bileaflet: e.g. St. Jude
34
Q

Which patients would you consider a biological valve in?

A

 Older patients

 Women of child-bearing age

 Bleeding risk: e.g. peptic ulcer, frequent falls

35
Q

Complications of a valve prosthesis

A

FIBAT

  • Failure
  • Infective endocarditis
  • Bleeding: minor – 7%/yr, major – 3%/yr
  • Anaemia: warfarin and haemolysis
  • Thromboembolism: 1-2% per annum despite warfarin
36
Q

The differentials for a Irregularly Irregular Pulse. How would you distinguish them from each other?

A

 AF
 Multiple ventricular ectopics

Clinical Distinction

  • Exercise pt.
    •  AF: pulse stays irregularly irregular
    •  VE: ↑ HR → regular pulse
      • ↓ diastole time closes window for ectopics
37
Q

What is the CHA2-DS2-VAS Score?

A

 Determines necessity of anticoagulation in AF

 Dabigatran may be cost-effective alternative to warfarin

38
Q

ECG of a patient with a pacemaker

A
  • Pacing spikes
    • May be absent if pt. producing adequate intrinsic rhythm
  • Evidence of ischaemia
39
Q

What are some indications for pacing?

A
  •  Complete AV block
  •  Mobitz Type 2
  •  Symptomatic bradycardia: e.g. sick sinus syndrome
  •  Drug-resistant tachyarrhythmias
  •  Biventricular pacing in chronic heart failure
40
Q

What are some common complications of a pacemaker?

A
  • Insertion
    • Bleeding
    • Arrhythmia
  • Post Insertion
    • Erosion
    • Lead migration
    • Pocket infection
    • Malfunction
41
Q

Causes of LHF

A
  •  IHD
  •  Idiopathic dilated cardiomyopathy
  •  Systemic HTN
  •  Mitral and aortic valve disease
42
Q

Signs of LHF

A
  • Cold peripheries ± cyanosis
  • Often in AF
  • Cardiomegaly ̄c displaced apex
  • S3 + tachycardia = gallop rhythm
  • Wheeze (cardiac asthma)
  • Bibasal creps
43
Q

Causes of RHF

A
  • LVF
  • Cor pulmonale
  • Tricuspid and pulmonary valve disease
44
Q

Signs of RHF

A

 ↑JVP + jugular venous distension

 Tender smooth hepatomegaly (may be pulsatile)

 Pitting oedema

 Ascites

45
Q

Causes of a displaced apex beat

A
  • idiopathic
  • cardiomyopathy
  • congestive cardiac failure
  • aortic regurgitation
  • mitral regurgitation
  • ventricular septal defect
46
Q

Features of TR

A
  • Loudest in the tricupsid region
  • Louder on inspiration
  • Pansystolic murmur
  • Raised JVP
  • Palpable liver
47
Q

Presenting

A

O/E of the hands: pulse … , I would like the BP

O/E of the head and neck … the JVP was not raised and there were no signs of carotid bruits

O/E of the chest … both heart sounds were audible with no additional sounds, the apex was not displaced

In addition … the lung bases were clear and there was no peripheral or sacral oedema

48
Q

What is a Graham Steele Murmur?

A

Soft, blowing, decrescendo early diastolic murmur of pulmonary incompetence caused by pulmonary hypertension

49
Q

How do you classify severity of AS?

A
  • Valve area <1cm squared
  • Transaortic pressure gradient >40mmHg
  • Dyspnoea has worst prognosis
50
Q

Complications of AS?

A
  • LVF
  • Sudden death
  • Pulmonary HTN
  • Arrhythmia
  • Heart block
  • Infective endocarditis
  • Systemic embolic complications
  • Haemolytic anaemia
  • Heyde’s syndrome (iron deficiency anaemia)
51
Q

What might you see on ECG of a patient with AS?

A
  • LVH
  • LV strain
  • P mitrale (left atrial hypertrophy)
  • LAD
  • LBBB/1st degree heart block
52
Q

Causes of mitral stenosis?

A
  • Rheumatic fever (most common)
  • Congenital mitral stenosis
  • Rheumatoid arthritis
  • SLE
  • Carcinoid syndrome
53
Q

Features of severe mitral stenosis?

A
  • Early opening snap
  • Increasing length of murmur
  • Pulmonary HTN
  • Graham Steele murmur
  • Low pulse pressure
54
Q

Differential dx for malar flush?

A
  • Mitral stenosis
  • Hypothyroidism
  • Carcinoid
  • SLE
  • Systemic sclerosis
  • Polycythaemia
55
Q

How to differentiate between MR and TR clinically?

A
  • Location of murmur
  • Pulse may be jerky in MR
  • Systolic ‘v’ waves in JVP for TR
  • Pulsatile hepatomegaly for TR
  • Thrill is apical in MR and parasternal in TR
56
Q

Complications of MI?

A
  • Death
  • Arrhythmia
  • Rupture (free ventricular wall/ ventricular septum/ papillary muscles)
  • Tamponade
  • Heart failure (acute or chronic)
  • Valve disease
  • Aneurysm of ventricle
  • Dressler’s syndrome
  • thromboEmbolism (mural thrombus)
  • Recurrence/ mitral Regurgitation
57
Q

Indications for PCI

A

 Poor response to medical Rx

 Refractory angina but not suitable for CABG

PACES (13 decks)

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