Cardio: General Flashcards
JVP A wave
right Atrial contraction [presystolic]
JVP X descent:
right atrial relaxation; fall in atrial pressure during ventricular systole
- JVP C wave (not seen Clinically):
bulging of the triCuspid valve closer into the right atrium [beginning of systole]
JVP V wave:
max Venous return [late systole]; due to passive filling of blood into the atrium against a closed tricuspid valve
JVP Y descent:
Right ventricular filling [diastole]; opening of tricuspid valve
EmptYing of RA
Cardiac cycle what happens during:
Atrial contraction
-Valves/ sounds
-ECG
-JVP
Last 10% of blood is pushed into vent
Atrial contraction = SA node firing
ECG = P wave
JVP = A wave
(S4 – blood is push into stiffened vent )
Ends with MV closing
Cardiac cycle what happens during:
Isovolumetric Ventricular Contraction
(ventricular systole)
-Valves/ sounds
-ECG
-JVP
Ventricular depolarization (just before vent cont) = Start of QRS; AV (T&M) valves close = S1
Ventricles start to contract all valves are closed
C wave Jvp= Buldge of AV into atria=
Cardiac cycle what happens during:
Rapid ventricular ejection
(ventricular systole)
-Valves/ sounds
-ECG
-JVP
Aortic and pulmonary valves open- large amount of blood out of the vent;
ECG ST segment
JVP X wave = AV relax and
Cardiac cycle what happens during:
reduced ventricular ejection (diastasis)
(ventricular systole)
-Valves/ sounds
-ECG
-JVP
Ventricular Repolarization = t wave
Cardiac cycle what happens during:
Isovolumetric ventricular relaxation
(ventricular diastole)
-Valves/ sounds
-ECG
-JVP
End of T wave Start ventricular diastole,
Aortic and then pul valves close =ST2
= V wave JVP- passive filling of blood into the atrium against a closed tricuspid valve
Cardiac cycle what happens during:
** Rapid Ventricular Filling
(ventricular diastole)**
-Valves/ sounds
-ECG
-JVP
AV (M&T) valves open
= Y on JVP = 3rd hrt sound (Vent dilation/ overload )
Cardiac cycle what happens during:
reduced ventricular filling
(ventricular diastole)
-Valves/ sounds
-ECG
-JVP
Reduced ventricular filling, also called diastasis; Passive fill= 90% filling of the vent.
Name the 7 phases of the cardiac cycle
- Atrial contraction
- Isovolumetric ventricular contraction
(ventricular systole) - rapid ventricular ejection
(ventricular systole) - reduced ventricular ejection (diastasis) (ventricular systole)
- isovolumetric ventricular relaxation(ventricular diastole)
- rapid ventricular filling (ventricular diastole)
- reduced ventricular filling
(ventricular diastole)
JVP: Abnormally large A waves (3)
indicate increased resistance to right atrial emptying from
Pulmonary hypertension
Tricuspid stenosis
Pulmonary stenosis
nb. a wave = atrial contraction blood thru the open tricuspid
JVP: Absent A wave
AF
nb. a’ wave = atrial contraction blood thru the open tricuspid
JVP: Cannon A wave
Cannon a waves occur when the atria and ventricle contract simultaneously, producing a greatly elevated a wave.
Causes:
Complete heart block- Irregular waves
Ventricular tachycardias- regular waves
JVP in Constrictive pericarditis
Sharp x and y descent
Large v wave
Tamponade
JVP features:
Sharp x descent only
Large v wave
Elevated JVP with no waves present
Cause: Superior vena cava obstruction
JVP: Kussmaul’s sign what is it and what does it signify (3)
JVP should go down with inspiration as a result of the drop in intrathoracic pressure. Kussmaul’s sign is an abnormal finding that refers to the JVP paradoxically rising with inspiration.
Causes:
Tamponade
Constrictive pericarditis
Right heart failure
JVP giant v waves
in tricuspid regurgitation
Heart sounds:
S1
Mitral & tricuspid closures
Isovolumetric ventricular contraction
(ventricular systole)
Start of QRS
Heart sounds:
S2
Aortic and then pul valves close =ST2
isovolumetric ventricular relaxation(ventricular diastole)
Heart sounds:
S3 (3)
3rd hrt sound Vent
- Dilation/ overload
- normal if < 30 years old (may persist in women up to 50 years old)
- heard in: LVF(e.g. dilated cardiomyopathy),
- constrictive pericarditis (called a pericardial knock) and mitral regurgitation
rapid ventricular filling (ventricular diastole)
Heart sounds:
S4
Causes
S4 – blood is push into stiffened vent
- Severe aortic stenosis,
- HOCM,
- hypertension
Atrial contraction- the P wave on ECG
Heart sounds: Wide splitting of S2
Anything that delay RV emptying
pHTN
Pulmonary stenosis ,
PE
RBBB
(S2= A2+ P2 closing)
Heart sounds: Fixed splitting of S2
L to right shunts
ASD
(S2= A2+ P2 closing)
Heart sounds: Paradoxical splitting of S2
Delayed aortic valve closure
AS,
HTN,
Coartation
LBBB
(S2= A2+ P2 closing)
Heart sounds: Absent S2
Severe AS
Soft S1
MR, severe HF, LBBB, and 1st-degree heart block.
S4 is a marker of severity of which valvular disorder?
AS
variable intensity of S1
Complete hrt blk
What hrt sound occur w/ closure of mitral and tricuspid valves?
S1
Name the Vent systolic mummers
AS & PS
TR & MR
What hrt sound occur w/ closure of aortic and pulmonary valves?
S2
Name the Vent Diastolic mummers
AR& PR
TS & MS
Ejection systolic louder on expiration
o aortic stenosis
o HOCUM
Left side mummers
Ejection systolic louder on inspiration
o pulmonary stenosis
o atrial septal defect
* also: tetralogy of Fallot
(RIGHT sided mummers)
Standing increases mummers
MVP & HCM
Squatting will increases mummers
(decreases afterload )
VSD, AR, PR, MR & AS
RX mitral stenosis
Percutaneous balloon valvularplasty
2ond most common valve disease after aortic stenosis?
MR
What causes
Pansystolic murmur described as “blowing”
which radiats to axilla.
May cause quiet S1
In severe cases = widely split S2
MR (blows though systole)
Radiates to axilla
Late systolic murmur (longer if patient standing)
MVP (MPVs come late!)
Mitral valve prolapse
Associations
- Congenital heart disease: PDA, ASD
-
Collagen disorders : Marfan’s syndrome, osteogenesis imperfecta,
pseudoxanthoma elasticum, Ehlers-Danlos Syndrome
3.Gentic d’s: Turner’s syndrome, Fragile X, polycystic kidney disease
cardiomyopathy, WPW, long-QT syndrome
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
AR
Mummer ass. w/
-collapsing pulse
-wide pulse pressure
AR
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing) Is caused by
AR
Causes of AR
Rheumatic fever: most common cause
calcific valve disease
bicuspid aortic valve
connective tissue diseases: RA / SLE
spondylarthropathies (e.g. ankylosing spondylitis)
hypertension
syphilis
Marfan’s, Ehler-Danlos syndrome
Indications for Surgery in AR
- Symptomatic patients with severe AR
- Asymptomatic patients with severe AR who have LV systolic dysfunction
Features of severe aortic stenosis
Pulse 2
Sound 3
narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
LVH/LVF
Narrow and slow soft 2 added 4
Indications for Management of Aortic stenosis
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
aortic valve replacement (AVR)
which intervention is best for
low/medium operative risk patients
Pt w/ high operative risk
balloon valvuloplasty
low/medium operative risk patients: surgical AVR
pts with a high operative risk: transcatheter AVR (TAVR) is used for
balloon valvuloplasty
may be used in children with no aortic valve calcification
in adults limited to patients with critical aortic stenosis who are not fit for valve replacement
most common valves which need replacing are
the aortic and mitral valve.
Biological (bioprosthetic) valves disadvantages
Who normally gets these
deterioration and calcification over time.
pts > 65 years for aortic valves
Pts > 70 years for mitral valves receive a bioprosthetic valve
Long-term anticoagulation for Biological (bioprosthetic) valves
not usually needed in the long term
- Warfarin may be given for the first 3 months
- Low-dose aspirin is given long-term.
Major disadvantage of Mechanical valves
Increased risk of thrombosis = long-term anticoagulation is needed.
Warfarin is preferred
aspirin is only normally given in addition if there is an additional indication,
Mechanical valves warfarin targets
Aortic
Mitral
Target INR
aortic: 3.0
mitral: 3.5
Causes Pulsus paradoxus
(2)
(>10 mmHg) fall in sBP during inspiration → faint or absent pulse in inspiration
severe asthma,
cardiac tamponade
Pulsus alternans
regular alternation of the force of the arterial pulse
* severe LVF
Slow-rising/plateau pulse
- aortic stenosis
Collapsing Pulse
- Aortic Regurgitation
- PDA
- hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy
Pulsus alternans
regular alternation of the force of the arterial pulse
* severe LVF
‘Jerky’ pulse
- hypertrophic obstructive cardiomyopathy*
Endocarditis: Initial blind therapy- Native valve
- In pen allergy
amoxicillin +/-gentamicin
If penicillin allergic, MRSA or severe sepsis
vancomycin +/-gentamicin
Endocarditis rx: prosthetic valve Initial blind therapy-
vancomycin + rifampicin + gentamicin
Native valve endocarditis caused by staphylococci rx
& in pen allergy
Most common cause
Flucloxacillin
If penicillin allergic or MRSA
vancomycin + rifampicin
prosthetic valve endocarditis caused by staphylococci rx
& in pen allergy
Flucloxacillin + rifampicin + low-dose gentamicin
If penicillin allergic or MRSA
vancomycin + rifampicin + low-dose gentamicin
Endocarditis after prosthetic valve surgery most common cause
- Staphylococcus epidermidis commonly colonise indwelling lines & most common cause following prosthetic valve surgery
Streptococci Endocarditis caused by
Streptococcus bovis is ass. w/colorectal cancer.
Subtype Streptococcus gallolyticus
Streptococcus viridans - subtype Streptococcus mitis /oralis - linked w/ poor dental hygiene
Rx Streptococci Endocarditis fully-sensitive
Benzylpenicillin
If penicillin allergic
vancomycin + low-dose gentamicin
Endocarditis caused by less sensitive streptococci
Benzylpenicillin + low-dose gentamicin
If penicillin allergic
vancomycin + low-dose gentamicin
Endocarditis Indications for surgery (5)
- severe valvular incompetence
- aortic abscess (often indicated by a lengthening PR interval)
- Infections resistant to antibiotics/fungal infections
- cardiac failure refractory to standard medical treatment
- recurrent emboli after antibiotic therapy
What does the RCA supply
RA , most of RV,
Diaphragmatic part of the LV,
supplies the posterior 1/3 of the interventricular septum,
sinoatrial node &
AV node.
Leads II, III, AVF
What does the LCx typically supply
LA
most LV,
part of the RV,
the anterior 2/3 of the IVS, including the AV bundle, through perforating IV septal branches and the sinu-atrial node in some people.
I, v5, v6 avl; lbb
The Left anterior descending supplies?
What does this correspond to on ECG ?
Anteroseptal V1-V4
Anterior v1 v2
Septal V3 & V4
What vessel supplying is responsible for v1 v2
V3 & V4
LAD
What vessel supplies the
AV Bundle of HIS, RBB & anterior fascicle of the left bundle
LAD
The RCA supplies?
As represented on ECG
Inferior wall
II,III&AVF
The Left circumflex supplies ?
As represented on ECG
Lateral wall
V5, V6,
I
AVL
V1-V3 ST depression
Tall, broad R waves (>30ms)
Upright T waves
Dominant R wave (R/S ratio > 1) in V2
Represents
inferior or lateral infarction
Posterior MI
List the 3 components of Anginal pain
How is typical and Atypical angina defined
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- Precipitated by physical exertion
- Relieved by rest or GTN in about 5 minutes
Interpretation:
Pts with all 3 features = typical angina
pts w/ 2 of the above features = atypical angina
Pts with 1 or none=non-anginal chest pain
IX Stable PT with angina
1st line: CT coronary angiography
2nd line: Non-invasive functional imaging (looking for reversible myocardial ischaemia) (SPEC, Stress echo, MR perfusion)
3rd line: Invasive coronary angiography
Explain Drug rx for Angina
3 drugs all pts get
Monotherapy
then duel therapy
1.All pts receive aspirin + statin + sublingual glyceryl trinitrate
Monotherapy with β -blocker or a CCB
-rate-limiting CCB (verapamil or diltiazem)
Dual: β-blocker + long-acting dihydropyridine CCB (e.g. modified-release nifedipine)
Why don’t you prescribe β-blocker & rate-limiting CCB (verapamil or diltiazem)
Can cause complete heart block
If starting duel therapy for angina but cant have the addition of CCB/ β-blocker
What other drug should be considered (4)
Consider one of the following drugs: a
long-acting nitrate,
ivabradine,
nicorandil or ranolazine
Contra indications to β-blocker
Uncontrolled heart failure
Asthma
Sick sinus syndrome
Concurrent verapamil use: may precipitate severe bradycardia
β-blocker adverse effect
Adverse
* Bronchospasm
* Cold peripheries
* Fatigue
* Sleep disturbances, including nightmares
* Erectile dysfunction
SE Verapamil
Heart failure, constipation, hypotension, bradycardia, flushing
If a further drug is needed after duel tx in angina
what should they be lined up for?
is awaiting assessment for PCI or CABG
MAO Ivabradine
reducing HR.
It acts on the If (‘funny’) ion current which is highly expressed in the sinoatrial node, reducing cardiac pacemaker activity.
SE Ivabradine
- visual effects, particular luminous phenomena, are common
- headache
- bradycardia, heart block
4 Main indications for statin
- ALL pt w/ cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
- Anyone with a 10-year cardiovascular risk >= 10%
- DM2 should be assessed QRISK2 like other patients are
- DM 1 who were diagnosed >10 years ago OR >40 OR have established nephropathy
Should statin be monitored and when should they be discontinued ?
LFTs @ baseline, 3 months and 12 months.
Discontinued if serum transaminase conc x persist at 3 times the upper limit of the reference range
Contra indications to statins
Contra indications
Pregnancy and macrolides
DVLA LOC 2ndry to cardiovascular origin
6 Months
DVLA Cardiac catheter procedure (incl PCI)
1 week
DVLA MI
1 Month
DVLA prophylactic ICD
1 month
After ICD or 2ndary prevention
6 months
