Cardio + resp Flashcards
Non-murmur signs in aortic stenosis
Narrow pulse pressure
Slow rising pulse
Thrill
Non-murmur signs in aortic regurgitation
Wide pulse pressure
Collapsing pulse
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
Non-murmur signs in mitral stenosis
Malar flush
Dyspnoea
Haemoptysis
Causes of different murmurs
Aortic stenosis: rheumatic fever, bicuspid valve, calcification
Aortic regurgitation: rheumatic fever, bicuspid valve, connective tissue disorder
Mitral regurgitation: rheumatic fever, calcification, connective tissue disorder
Mitral stenosis: rheumatic fever
Different cardiothoracic incicions
Midline sternotomy
Clamshell incision (for widespread traumatic chest injury)
Sub-clavicular incision
Indication for midline sternotomy
Open valve surgery
Coronary artery bypass grafting
Cardiac transplant
Different types of valve replacements procedures and valves
Procedures:
Transcatheter aortic/pulmonary valve implantation (usually biological)
Surgical aortic valve replacement
Valves:
Metallic - younger patients (last longer, tolerate anticoagulation therapy)
Biological - older patients (usually porcine/bovine, or homograft more durable but less widely available)
Drugs you need to be on after valve replacement
Only needed in metallic heart valve, or biological if there is atrial fibrillation
LMWH for bridging
Warfarin
Not recommended to use DOACs regardless of AF
Murmur investigations
Bedside: obs for pulse pressure, ECG for ventricular strain
Bloods: BNP, FBC, CRP and blood cultures for infective endocarditis, risk factors e.g. lipids, HbA1c
Imaging: TTE
Murmur management
MDT for regular follow-up
Conservative e.g. cardiovascular lifestyle
QRISK to determine whether statins, etc. are needed
Valve replacement
Regurgitations: reduce afterload with ACEi, BB, diuretics
What is a QRISK score?
QRISK3 (the most recent version of QRISK) is a prediction algorithm for cardiovascular disease that uses traditional risk factors
A QRISK over 10 (10% risk of CVD event over the next ten years) indicates that primary prevention with lipid lowering therapy (such as statins) should be considered
Indications for valve replacement
Asymptomatic and valve gradient >40mmHg or valve area <1cm2
Symptomatic
Balanced with patients history, overall health, and risk/benefits
Take into account the cause e.g. infective endocartditis
Heart failure signs
Left signs:
- dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea
Right signs:
- raised JVP
- peripheral oedema
- hepatomegaly, ascites
Heart failure causes
Myocardial (coronary artery disease, HTN)
Valvular
Pericardial (constrictive)
Arrhythmias
Non-cardiac: high output (sepsis), volume overload (CKD, nephrotic syndrome)
New York Heart Association classification for heart failure
1 - no limitation
2 - dypnoea on activity
3 - marked limitation on activity
4 - dyspnoea at rest
Ejection fraction classification for heart failure
HFpEF: >= 50% (LV unable to relax)
HFrEF: <40% (LV unable to contract properly)
Heart failure investigations
Bedside - ECG for LVH
Bloods - BNP: 400-2000 (TTE within 6 weeks), >2000 (TTE within 2 weeks)
CXR - alveolar oedema, Kerley B lines, cardiomegaly, upper lobe diversion, pleural effusion
Heart failure management
Conservative
1. ACE inhibitor, ARB, or beta-blocker
2. Spironolactone, SGLT-2 inhibitor (e.g. dapagliflozin) or entresto (sacubitril/valsartan) if HFrEF
3. Hydralazine with nitrate
Influenza and pneumococcal vaccine
Types of pacemakers and indications
Single-chamber: lead in right atrium OR ventricle (heart block affecting one chamber)
Dual-chamber: lead in right atrium AND ventricle (heart block affecting both chambers)
Biventricular/cardiac resynchronisation: lead in right atrium and both ventricles
Leadless: small and inside right ventricle, used for bradycardic patients, can’t have traditional surgery or complications with leads
CHADSVASc vs ORBIT
CHADSVASc for anticoagulation determination
0 - no treatment
1 - consider anticoagulation in males
2 - offer anticoagluation
Congestive heart failure
Hypertension / treated
Age >= 75 (2)
Age 65-74 (1)
Diabetes
Previous stroke, TIA, thromboembolism
Vascular disease
Sex - female
ORBIT for bleeding risk, to consider whether anticoagulation is in the best interests of the patient, no formal rules, depends on individual patient factors (e.g. alcohol or drug abuse, how bad their bleeding history is)
Low haemoglobin (2)
Age > 74
Bleeding history e.g. GI bleed
Renal impairment
Antiplatelets
Which anticoagulation is recommended for reducing stroke risk in atrial fibrillation?
- DOAC e.g. apixaban
- Warfarin
NOT aspirin
Infective endocarditis signs
Clubbing
Splinter haemorrhages
Osler’s nodes (tender)
Janeway lesions (non-tender)
Roth spots (fundoscopy)
Splenomegaly
Infective endocarditis investigations
Bedside: obs, ECG
Bloods: infection including blood cultures, inflammation
Imaging: echo
Cover Duke’s criteria (2 major, 1 major + 3 minor, 5 minor)
Major = positive blood culture, echo findings or new regurgitation
Infective endocarditis management
Antibiotics
Initial blind - native: amoxicillin, sepsis or allergic: vancomycin + gentamicin, prosthetic: vancomycin + gentamicin + rifampicin
Treat according to culture after
Surgery
- severe incompetence
- aortic abscess (long PR interval)
- cardiac failure
- resistant to abx
CABG indication and procedure
Severe coronary artery disease, failed PCI, very high risk
Put on heart-lung bypass machine, healthy vessel taken from leg, chest or arm, and attach to heart to bypass blockage
Atrial fibrillation management
Haemodynamically stable < 48 hours
Rate control
1. BB (bisoprolol) or rl-CCB (verapamil)
2. Digoxin
OR
Rhythm control
1. Electrical cardioversion
2. Pharmacological cardioversion (flecainide, amiodarone)
Haemodynamically stable > 48 hours
Rate control
1. BB (bisoprolol) or rl-CCB (verapamil)
2. Digoxin
ORBIT score
Start anticoagulation for 3 weeks (DOAC - apixaban, or warfarin)
Electrical cardioversion
If you can’t wait: LMWH + echo to rule out left atrial thrombus
Haemodynamically unstable
Electrical cardioversion
DVLA for ACS, CABG, pacemaker and ICD insertion
ACS: 4 weeks off (or 1 week if angioplasty)
CABG: 4 weeks off
Pacemaker: 1 week off
ICD: 6 months if ventricular arrhytmia, 1 month if prophylactic
What is an ICD?
Implantable cardioverter-defibrillator
Treat tachyarrhytmias and life-threatening rhythms (pacemaker is for slow or irregular rhythms) e.g. VT and VF
Delivers shocks in addition to pacing the heart
Causes of clubbing
Cardiovascular
- infective endocarditis
- congenital cyanotic heart disease
- brachial arteriovenous fistula
Respiratory
- pulmonary fibrosis
- bronchiectasis
- bronchial carcinoma
- mesothelioma
- TB
Gastrointestinal
- IBD
- Coeliac disease
- Liver/bowel cancer
- Cirrhosis
Investigations for pulmonary fibrosis
Bedside: ECG for right ventricular strain, spirometry (FVC decreased, so FEV1/FVC increased)
Bloods: ABG, ANA, infection, inflammation
Imaging: CXR and HrCT
Management of pulmonary fibrosis
Acutely: supportive and high-dose corticosteroids
Long-term:
Pulmonary rehabilitation (exercise, breathing techniques, education, psychosocial support, nutritional counseling for overall health, stop smoking)
Antifibrotics: pirfenidone
Supplemental oxygen if hypoxic
Investigations of bronchiectasis
Bedside: sputum culture (pseudomonas aerigunosa most common)
Bloods: superimposed infection, inflammation
Imaging: CXR, HrCT
Causes of bronchiectasis
Post-infective e.g. TB, pneumonia
Cystic fibrosis
Obstruction e.g. lung cancer
Management of bronchiectasis
Exercise - airway clearance
Inhaled bronchodilator e.g. salbutamol
Mucoactive agent e.g. nebulised saline or mucolytic like acetylcysteine
Antibiotics for exacerbation
Investigations of COPD
Bedside - sputum culture, post-bronchodilator spirometry FEV1/FVC ratio <0.7
Bloods - FBC (secondary polycythaemia from hypoxia)
Imaging - CXR
Management of COPD
Exacerbation:
A-E
24% venturi mask
Nebulised salbutamol + ipratropium
IV hydrocortisone
IV abx
Long-term:
1. SABA or SAMA (ipratropium)
2. No asthmatic features: add LABA (salmeterol) and LAMA (tiotropium). Asthmatic features: LABA + ICS
Switch SAMA to SABA if taking.
3. LABA + (LAMA + ICS)
Additional management of CREST (that has pulmonary HTN/RHF)
For CREST
Exercise, stop smoking, physiotherapy
Immunosuppression: methotrexate
ACE inhibitor if renal involvement
More specific investigations of lung cancer
CXR
CT chest
Bronchoscopy
PET scanning
Management of lung cancer
Small-cell
- Surgery if small
- Most are metastasised: radio and chemo (or just palliative chemo)
Non-small cell
- Surgery if small
- radiotherapy
- poor response to chemo
Types of lung scars and their indications
Posterolateral thoracotomy
Anterolateral thoracotomy (goes under pec)
May be done for:
Lobectomy: malignancy, recurrent localised infection (CF, bronchiectasis)
Pneumonectomy
Single lung transplant (double is through clamshell)
Bullectomy in COPD (bulla space >1cm)
Causes of pulmonary fibrosis
Occupational
- Asbestosis
- Silicosis
Infection
- Aspergillosis
- TB
Drugs
- Methotrexate
- Amiodarone
Radiation fibrosis
Idiopathic
CXR/CT changes of pulmonary fibrosis
bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’)
Differentiation between asthma and COPD in investigations
Asthma has post-bronchodilator reversibility
COPD has post-bronchodilator FEV1/FVC <0.7
Peak flow results in different lung conditions
Asthma: usually 20-30% lower
Bronchiectasis: usually 20-30% lower
COPD: lower than asthma due to airway obstruction
Pulmonary fibrosis: lowest due to restrictive lung disease
Investigations for pleural effusion
PA x-ray
USS
CXR
CT for underlying disease
USS guided pleural aspiration
>30g/L = exudate
<30g/L = transudate
Management of pleural effusion
Treat underlying cause
Recurrent aspiration
Indwelling catheter
Opioids for dyspnoea
Signs of CO2 retention
Flap
Bounding pulse
Narcosis (drowsiness)
Signs of cor pulmonale
Lung disease -> right ventricular hypertrophy
Peripheral oedema
Raised JVP
Systolic parasternal heave
Upper and lower lobe causes of pulmonary fibrosis
Upper: COPD, silicosis, tuberculosis
Lower: idiopathic, systemic sclerosis, hypersensitivity
What FiO2 is 1L and other L
1L = 24%
2L = 28%
(increases by 4%)
15L = 80%
Which vessels are used for CABG?
Saphenous vein
Internal mammary artery (best)
Radial artery
Gastroepiploic artery
