Cardio Brief Flashcards
Describe the significance of an opening snap on auscultation in a patient with mitral valve disease.
An opening snap indicates a non-calcified mitral valve.
What is the most common finding on cardiac examination in a patient with mitral valve disease?
Atrial fibrillation.
Do ejection systolic murmurs in aortic stenosis radiate to the carotid arteries?
Yes, ejection systolic murmurs in aortic stenosis radiate to the carotid arteries.
What is a characteristic auscultatory finding in atrial septal defect (ASD)?
Wide fixed splitting of S2.
What is the characteristic murmur in ventricular septal defect (VSD)?
Pan-systolic murmur radiating to the whole myocardium.
Describe the murmur heard in patent ductus arteriosus (PDA).
Continuous machinery murmur.
Do patients with coarctation of the aorta (COA) typically have delayed femoral pulsations?
Yes, patients with COA may have delayed femoral pulsations.
Pt with well developed UL& underdeveloped LL. Exam shows delayed femoral pulsation…
COA murmur…
at whole precordium radiating to back
What is the most common congenital heart disease causing cyanosis?
Tetralogy of Fallot (TOF).
What is the first step in managing cyanotic spells in TOF?
Placing the patient in a squatting position.
Describe the presentation of transposition of the great vessels (TGVs) in terms of cyanosis.
Cyanosis present since birth (1st day of life).
1st step in management… PG infusion (to maintain patency of PDA)
Heart failure symptoms few days after birth…
hypo-plastic left heart $
Fixed splitted S2……
ASD
What is the most important drug for aortic regurgitation (AR)?
Angiotensin-converting enzyme inhibitors (ACEI).
What is the most common association with atrial septal defect (ASD) in terms of conduction abnormalities?
Right bundle branch block (RBBB).
What is the most common complication of tetralogy of Fallot (TOF)?
Cyanotic spells.
Most common cyanotic heart disease….
TOF
3 day child with symptoms of HF and shock…
hypoplastic ventricle
Describe the murmur heard in coarctation of the aorta.
Murmur heard at the whole precordium radiating to the back.
Systolic murmur over aortic area with syncope…
Cyanosis since birth……
Cyanosis relieved by squatting….
Systolic murmur radiating to the back….coarctation of aorta
Continuous machinery murmur…..
Mid-diastolic rumbling murmur…………….
Decrescendo early diastolic murmur……..
Systolic murmur over apex radiate to axilla…
Systolic murmur over apex radiate to carotid…
Systolic murmur over aortic area with syncope…AS
Cyanosis since birth……TOG
Cyanosis relieved by squatting….TOF
Systolic murmur radiating to the back….coarctation of aorta
Continuous machinery murmur…..PDA
Mid-diastolic rumbling murmur……………. MS
Decrescendo early diastolic murmur…….. AR
Systolic murmur over apex radiate to axilla…MR
Systolic murmur over apex radiate to carotid…AS
What is the characteristic sound of the murmur in patent ductus arteriosus (PDA)?
Continuous machinery-like murmur.
What type of murmur is typically heard in mitral stenosis (MS) during mid-diastole?
Mid-diastolic rumbling murmur.
What type of murmur is typically heard in aortic regurgitation (AR) during early diastole?
Decrescendo early diastolic murmur.
Describe the radiation of a systolic murmur heard over the apex in mitral regurgitation (MR).
Radiates to the axilla.
Describe the radiation of a systolic murmur heard over the apex in aortic stenosis (AS).
Radiates to the carotid arteries.
What is the most common drug addiction associated with causing congenital heart disease?
Cocaine.
What is the most common substance associated with causing congenital heart disease?
Alcohol.
What is the most common congenital heart disease associated with Down syndrome?
Endocardial cushion defect.
What is the most common congenital heart disease associated with diabetes mellitus?
Ventricular septal defect (VSD).
Describe the clinical presentation of a patient with marked differences between upper body and lower body blood pressure, including delayed femoral pulses.
This presentation is indicative of coarctation of the aorta (COA).
What is the most common complication associated with mitral stenosis (MS)?
Atrial fibrillation (AF).
What is the first step in managing transposition of the great vessels (TGVs)?
Prostaglandin infusion.
Do patients with pericarditis typically experience chest pain that improves with sitting and leaning forward?
Yes, patients with pericarditis often have chest pain that improves with sitting and leaning forward.
What is the most common cause of myocarditis?
Viral infections, particularly coxsackie virus.
Pericarditis.
TTT…………………. NSAIDs
TTT…………………. NSAIDs
Describe the treatment of uremic pericarditis.
Dialysis
What is the best investigation for constrictive pericarditis involving a calcified pericardium?
CT scan
calcified pericardium)
What is the main treatment for constrictive pericarditis
Pericardiectomy
What are the clinical signs of a patient with pericardial effusion and tamponade? What is the next step in management?investigation
Distant heart sounds, elevated JVP, hypotension. Next step: chest x-ray
How is pericardial effusion typically managed?
Pericardiocentesis
Describe the presentation of a patient with rheumatic fever who is an immigrant from Iraq or Aboriginal.
Erythema marginatum, elevated ASO titer, prolonged PR interval on ECG
What is the next step in management for a patient with rheumatic fever presenting with rash, migratory arthritis, and a history of upper respiratory tract infection?
Oral penicillin
What are the most important ECG findings in rheumatic fever?
Prolonged PR interval
List the organisms commonly causing Infective Endocarditis based on different scenarios.
Strep viridians (most common overall and after dental procedures), Staphylococcus (in drug addicts and after cardiac catheterization),
Strep fecalis (after gastrointestinal or genitourinary procedures),
Strep bovis (associated with colon cancer)
What is the recommended next step if a patient with Infective Endocarditis has blood cultures growing Strep bovis?
Colonoscopy
Which heart valve is most commonly affected in drug addicts with Infective Endocarditis?
Tricuspid valve
What is the most common valve lesion in drug addicts with Infective Endocarditis?
Tricuspid regurgitation
What is the first most important investigation for Infective Endocarditis?
Trans-esophageal Echo (to detect vegetation)
What is the second most important investigation for Infective Endocarditis?
Blood culture (to identify the causative organism)
Describe the prophylaxis criteria for Infective Endocarditis.
Significant cardiac defect (e.g., prosthetic valve, previous IE) and dental procedures. Prophylaxis involves taking Amoxicillin 1 hour before and half an hour after the procedure
Prophylaxis against IE… 2 conditions
MUST be met;
- Significant cardiac defect (prosthetic valve, previous IE)
- Dental procedure
Prophylaxis against IE…
Amoxicillin 1h before & ½ an hour after procedure
What are the most common causes of dilated cardiomyopathy?
Alcohol (most common) and viral infections (especially coxsackie virus)
Describe the typical presentation of a young patient with hypertrophic obstructive cardiomyopathy (HOCM).
Syncope, arrhythmias, or sudden death during exercise with a family history of sudden death during exercise at a young age
What is the genetic inheritance pattern of hypertrophic obstructive cardiomyopathy (HOCM)?
Autosomal dominant
What exacerbates the symptoms of HOCM?
Exercise, dehydration, valsalva maneuver, or standing
What is the most common cause of death in patients with HOCM?
Obstruction
What is the second most common cause of death in patients with HOCM?
Arrhythmias
What are the most common types of arrhythmias seen in patients with HOCM?
Ventricular tachycardia and ventricular fibrillation
What is the preferred investigation for diagnosing hypertrophic obstructive cardiomyopathy (HOCM)?
Echo
Describe the treatment of choice for Hypertrophic Obstructive Cardomyopathy (HOCM)
1st line: Beta-blockers, 2nd line: Calcium channel blockers
What is the treatment for arrhythmias in HOCM?
Implantable defibrillator
Define the 1st most common risk factor for Ischemic Heart Disease (IHD)
Hypertension
What is the 2nd most common risk factor for Ischemic Heart Disease (IHD)?
Smoking
How does a young smoker with recurrent attacks of typical chest pain present?
Variant angina
1st MC RF of IHD……………………………….……..
2nd MC RF of IHD……………………………………..
Highest risk of MI in pt with IHD……………….
1st MC RF of IHD……………………………….…….. HTN
2nd MC RF of IHD…………………………………….. Smoking
Highest risk of MI in pt with IHD………………. Angina (not HTN)
What is the treatment for variant angina?
Stop smoking, nitrates during attack
What is the next step if a patient with a history of typical chest pain has a normal ECG?
Exercise ECG
What do nitrates do in the treatment of Ischemic Heart Disease (IHD)?
Relieve chest pain
Pt with DM, HTN, hyperlipidemia lose consciousness, lab shows serum glucose of <40
which medication is responsible…
bb
Do beta-blockers mask or cause signs of hypoglycemia?
Mask the signs of hypoglycemia but do not cause it
Describe the important findings in an ECG during Myocardial Infarction (MI)
ST segment elevation
What does ST elevation in leads II, III, and aVF indicate in MI?
Inferior wall infarction
How soon does Myoglobin appear as a cardiac enzyme in MI?
The earliest to appear
Which enzyme is the most accurate in diagnosing MI?
Troponin
What is the best enzyme to detect re-infarction?
CK-MB
What is the definitive treatment of Myocardial Infarction (MI)?
Angioplasty
What is the best treatment in case of late presentation of MI?
Heparin
Medication decrease mortality…for heart
BB, ACE-Is& statin
What is the best investigation/treatment for myocardial aneurysm?
Echo/Surgery
After MI, when is it safe to consider an operation?
No operation for 6 months
What should be done in emergent surgery for a patient with a history of angioplasty and stent in the last 6 months?
Don’t stop clopidogrel (high risk of thrombosis)
What should be done in elective endoscopy for a patient with a history of angioplasty and stent in the last 6 months?
Don’t stop clopidogrel (high risk of thrombosis)
Describe the management of a female on oral contraceptive pills who develops hypertension
1st: stop OCP, 2nd: re-evaluate
What should be done if a patient has a blood pressure reading above 140/90 for the first time?
Ask the patient to come back in 1-2 weeks
What is the best investigation for hypertension?
Ambulatory monitoring
What is the best investigation for paroxysmal arrhythmia?
Holter monitor
What are the important investigations for arrhythmia?
Thyroid function tests, complete blood count, and electrolytes
What is the first lifestyle modification in the treatment of hypertension?
Weight loss
What is the second lifestyle modification in the treatment of hypertension?
Low sodium diet
What is the best initial drug for hypertension?
Thiazides
What is the first-line drug for a patient with diabetes mellitus and proteinuria ?
ACE Inhibitors
Describe the treatment for hypertension in a patient with unilateral renal artery stenosis.
ACE inhibitors
What is the recommended treatment for hypertension in a patient with bilateral renal artery stenosis?
Angioplasty and stent
What medication is indicated for hypertension in a patient with osteoporosis?
Thiazides
How should hypertension in a patient with hyperthyroidism be managed?
Beta blockers
What is the recommended treatment for hypertension in a patient with benign prostatic hyperplasia (BPH)?
Alpha blockers
Describe the treatment approach for hypertension in a patient with heart failure.
ACE inhibitors
-
Lifestyle Modifications:
- Low-sodium diet
- Regular physical activity
- Weight management
- Limiting alcohol intake and smoking cessation
-
Medications:
- ACE Inhibitors/ARBs: First-line for blood pressure control and heart failure management.
- Beta-Blockers: Used to manage heart failure symptoms and control hypertension.
- Diuretics: Particularly loop diuretics, to manage fluid overload.
- Aldosterone Antagonists: For additional blood pressure control and heart failure management.
- Hydralazine and Nitrates: For patients intolerant to ACE inhibitors/ARBs.
-
Monitoring and Follow-up:
- Regular blood pressure monitoring
- Periodic assessment of kidney function and electrolytes
- Adjustment of medication based on patient response
For more detailed guidelines, refer to the RACGP guidelines.
What are the recommended medications for hypertension during pregnancy?
Alpha methyldopa and labetalol
What is the initial treatment for hypertensive emergency?
Hospitalization and first-line: Labetalol / Second-line: Sodium nitroprusside
-
Initial Assessment:
- History and Physical Examination: Assess for symptoms of end-organ damage such as chest pain, shortness of breath, headache, visual changes, and neurological deficits.
- Blood Pressure Measurement: Confirm elevated BP (systolic BP ≥180 mmHg and/or diastolic BP ≥120 mmHg).
-
Immediate Management:
- Admission to Intensive Care Unit (ICU): For continuous monitoring and management.
-
Intravenous Antihypertensive Therapy:
- First-Line Agents: Start with IV labetalol or sodium nitroprusside.
- Alternative Agents: Nicardipine, esmolol, or hydralazine may be used based on the clinical scenario and patient’s condition.
-
Monitoring and Adjustment:
- Continuous BP Monitoring: Monitor BP closely, aiming for a controlled reduction.
- Adjust Medications: Titrate IV medications to achieve a gradual BP reduction. The initial goal is to reduce mean arterial pressure (MAP) by no more than 25% within the first hour, then to 160/100-110 mmHg over the next 2-6 hours.
-
Identify and Treat Underlying Causes:
- Investigations: Perform relevant investigations such as blood tests, ECG, chest X-ray, CT scan, or MRI as needed to identify any underlying causes or complications.
- Specific Treatments: Address underlying causes like renal artery stenosis, pheochromocytoma, or aortic dissection if identified.
-
Transition to Oral Medications:
- Once BP is stabilized and target BP is achieved, transition from IV to oral antihypertensive medications.
- Follow-Up: Arrange for close follow-up to monitor BP and adjust treatment as needed.
For more detailed guidelines, refer to the RACGP Hypertension Management Guidelines.
Describe the most common risk factor for digitalis toxicity.
Hypokalemia
What are the typical presentations of digitalis toxicity?
Vomiting, abdominal pain, colored vision, arrhythmia on ECG
What is the most important ECG finding in digitalis toxicity?
Down-sloping ST segment with sagging appearance
How should a patient on digoxin with arrhythmia be managed?
Stop digoxin and administer potassium
What is the most common cause of left-sided heart failure (LHF)?
Myocardial infarction (MI)
What is the most common cause of right-sided heart failure (RHF)?
Left-sided heart failure (LHF)
Describe the most important sign of left-sided heart failure (LHF).
Bilateral basal lung crepitations
Describe the most important sign of right-sided heart failure (RHF).
Systemic congestion
What is the preferred imaging modality for evaluating heart failure?
Echocardiography
What does a positive hepatojugular reflux indicate in the context of heart failure?
Hepatomegaly due to congestive heart failure
+ve in hepatomegally DT congestive HF
What does a negative hepatojugular reflux indicate in the context of liver pathology?
Absence of congestive heart failure
… -ve in hepatomegally DT liver pathology
Describe the essential medications for heart failure management.
ACE inhibitors, beta blockers, aldosterone antagonists
What is the most dangerous type of lipids?
LDL
What is the key feature on examination to suggest familial hypercholesterolemia?
Tendon xanthomas (not xanthelasma)
What is the first-line treatment for hyperlipidemia?
Statin
What is the mechanism of action of statins?
HMG-CoA reductase inhibition
Pt on statin, BB, ACE-I, aspirin develop myopathy… Cause:
Statin
How should statin-induced myopathy be managed in a patient on statin, beta blocker, ACE inhibitor, and aspirin?
Inv of choice in suspected statin- induced myopathy
Check CK levels
What are the important side effects of statins?
Myopathy (check CK levels) and hepatitis (check AST, ALT levels)
What are the dangerous combinations involving statins?
Statin and gemfibrozil leading to severe rhabdomyolysis
What are the dangerous combinations involving nitrates and sildenafil?
Severe hypotension
What are the dangerous combinations involving allopurinol and azathioprine?
Severe toxicity
Describe the presentation of a patient with severe chest pain radiating to the back.
Aortic dissection
What is the most common risk factor for aortic dissection?
Hypertension
What is typically seen on X-ray in a patient with aortic dissection?
Wide mediastinum
What is the imaging modality of choice for a stable patient with aortic dissection?
CT angiography
What is the preferred imaging modality for an unstable patient with aortic dissection?
Transesophageal echocardiography
What is the initial step in the treatment of aortic dissection?
Lowering blood pressure (beta blockers are the best initial choice)
What is the most common medication causing orthostatic hypotension?
Diuretics
What is the first-line treatment for orthostatic hypotension?
IV fluids
What is the seond-line treatment for orthostatic hypotension?
Stop the offending drug
Inv of choice…orthostatic hypotension?
Upright tilt table test
Pt with BPH loses conscious while micturating…
Situational syncope
What is the next step when a patient presents with sudden tearing chest pain referred to the back and hypertension?
Next step is to perform a chest X-ray to check for a wide mediastinum, which could indicate aortic dissection.
Describe the recommended lipid profile targets for a patient on statin therapy.
Total Cholesterol should be less than 4 mmol/l, LDL less than 2 mmol/l, HDL more than 1 mmol/l, and TG less than 2 mmol/l.
Define situational syncope and provide an example.
Situational syncope is when a patient loses consciousness in a specific situation, such as a person with benign prostatic hyperplasia fainting while urinating.
What is the drug of choice and its dosage for managing lipid profiles?
Statin at the maximum tolerated dose is the drug of choice for lipid management.
How should a patient with diabetes type 2 and any cardiovascular risk factor be managed in terms of statin therapy?
Add statin therapy regardless of the lipid profile.
Do patients with hypertrophic obstructive cardiomyopathy (HOCM) and aortic stenosis (AS) share any similarities in terms of syncope presentation?
Both HOCM and AS patients may experience sudden syncope, especially during exercise, and are at risk of sudden death.
Describe the differences in murmur characteristics between HOCM and AS.
HOCM presents with a systolic murmur over the sternal border without radiation, while AS has a systolic murmur over the aortic area that may radiate to the carotid.
HOCM….. murmur
HOCM murmur….noooo or radiation
AS….murmur
Chest pain…..more where
HOCM…..systolic murmur over sternal border
HOCM murmur….noooo radiation
AS….systolic murmur over aortic area radiate to carotid
Chest pain…..more with Aortic stenosis
What is the best assessment for determining obesity-related cardiovascular disease risk?
The waist-hip ratio is the best assessment for evaluating the impact of obesity on cardiovascular disease risk.
What is the recommended approach for a patient with hypertension, diabetes, and a history of smoking?
The next best step is to conduct a cardiovascular risk assessment for the patient.
Do patients with vasovagal syncope typically experience a quick or delayed recovery after an episode?
Patients with vasovagal syncope usually have a quick recovery after the episode.
vasovagal
Gradual
delayed
Prolonged standing - emotional stress - painful stimuli.
arrythmia
sudden
Quick
Exercise
MI and surgery:
Stent and urgent operation:
MI and surgery:
No operation before 6 months
Stent and urgent operation:
Do not stop clopidogrel…..risk of thrombosis
Sudden tearing chest pain referred to the back and HTN………
Next step………
aortic dissection
CXR……..wide mediastinum
