cardio SBAs Flashcards
Most definitive investigation for prosthetic valve endocarditis
Transoesophageal echocardiography
Marfan’s syndrome (autosomal dominant) CVS criteria
Aortic dissection
Aortic dilatation
Mitral valve calcification
Mitral valve prolapse (with or WITHOUT regurg)
Atrial myxoma on auscultation
Loud S3
Will present with non-specific symptoms of fever, SOB, syncope. Blood tests = raised ESR and TOE diagnoses.
62 year old man with enlarging pulsatile mass in left groin. 3 days previously he had had a coronary angiogram.
False aneurysm, most are due to iatrogenic trauma
Metabolic syndrome includes
insulin resistance IGT central obesity dyslipidaemia hypertension
Risk of developing T2DM is 5x higher in those with metabolic syndrome.
50 yr old man presents with typical history of exertional angina with ischaemic changes on resting ECG. Coronary angiography shows 70% stenosis of LAD, no lesions elsewhere. What should treatment be?
Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG. Most single vessel disease can be adequately managed with PCI.
Young male with hypertension and LVH likely diagnosis and presentations?
Coarctation of aorta
High BP
RF delay
Mid-systolic murmur in aortic area that radiates to back
Diagnosis of phaeochromocytoma
Urine metanephrines (metadrenalines) Sensitive and specific
[Rx = a-blockers then b-blockers]
Constrictive pericarditis (chronic) signs + symptoms
Pleuritic chest pain
Quieter S1 and S2 sounds due to pericardium wall thickened
Increased JVP on inspiration (Kussmaul’s sign)
Pulsus paradoxus (low systolic BP >10mmHg on inspiration)
Hepatomegaly
Ascites, oedema, AF
Widespread saddle-shaped ST segments
Cannon ‘a’ waves on JVP
Complete heart block
Single chamber ventricular pacing
Ventricular arrythmias (e.g. sustained VT - broad QRS)
Ventricular ectopics
Non-sustained VT is defined by
> 5 consecutive heartbeats within 30secs
Torsades de pointes
irregular QRS complexes and prolonged QT interval
a type of polymorphic VT. Can develop into cardiac arrest. Rx: IV magnesium sulfate and ventricular pacing
Variant (Prinzmetal’s) angina
random ST elevation (can be at rest)
HOCM is associated with risk of sudden death. Treatment includes
- b-blockers
2. CCBs
Pregnant hypertensive patients Rx
- methyldopa (a2-receptor agonists)
2. b-blockers
Symptoms of left ventricular failure
Exertional dyspnoea Palpitations/AF Atypical chest pain Displaced apex beat Bibasal crackles (pulmonary congestion)
Mitral regurg (backwars flow form LV to atrium in systole) common causes…
Rh heart diease
Infective endocarditis
Mitral valve prolapse (post-MI)
Types of cardiomyopathy
- restrictive
- dilated
- hypertrophic
Cardiac tamponade is caused by pericarditis. Tachycardia and pulus paradoxus are signs, along with Beck’s triad of…
- Increased JVP
- Decreased BP
- Muffled heart sounds
Aortic dissection investigations and treatment
CXR - widening of aorta
CT/MRI scans - diagnostic. If confirmed, BP reduction and dampening of aortic systolic wave by b-blockers and consider urgent surgery
A 12 year old boy presents with polyarthritis and abdominal pain. He had a sore throat about a week ago. Examination reveals an early blowing diastolic murmur at the L sternal edge. There are bilateral involuntary jerky movements worse when the patient is asked to make a movement. What is the likely diagnosis?
Rheumatoid fever.
Caused by an AI process post-strep (group A) infection.
5 major manifestations of acute rheumatic fever are carditis, polyarthritis, chorea, erythema marginatum and subcutaneous nodules.
Other signs can also be seen e.g. spooning sign and pronator sign.
A 16 year old boy presents with 5 month history of chest pain on exertion and two episodes of collapse in the last month. There is also progressive SOB on exertion and now he cannot walk up the stairs without stopping. Examination reveals a loud systolic murmur. What is the likely diagnosis?
Aortic stenosis
It can present with chest pain, dyspnoea and syncope
The pulse pressure is narrow and there may be an associated slow-rising and plateau pulse.
This is a congenital cause (HOCM causes pan-systolic murmur)
A 13 year old girl presents with increasing SOB, particularly when lying down at night to try to sleep. She has also noticed some ankle swelling. Examination reveals a raised JVP, tachycardia and an S3 gallop rhythm on cardiac auscultation. What is the likely cause?
CCF (congestive cardiac failure)
SOB with orthopnoea due to the sudden increase in pre-load, indicates LV failure.
A 70-year-old diabetic male presents with severe pain in his L foot. The pain is at rest and is alleviated by hanging his leg off the foot of the bed at night. O/E: advanced gangrene with superimposed infection of the left foot with absent dorsalis pedis and posterior tibial pulses. What is the likely diagnosis?
There is advanced gangrene here - complication of necrosis. It can be due to ischaemia, trauma or infection. With severe limb sepsis, amputation is needed.
Diabetes (high glucose, impaired immunity, peripheral neuropathy and arterial disease) is a RF here for infectious and ischaemic gangrene. Absent pulses and symptoms = critical limb ischaemia, with diabetic chronic peripheral arterial disease.
Necrotising faciitis may cause infectious gangrene. Common causative organism is
Streptococcus pyogenes
Causative organism of gas gangrene
Clostridium perfringens
A 65-year-old female presents with sudden-onset pain in her L calf. She is taking digoxin and verapamil for her ‘funny’ heart beat. O/E, the left leg is pale, cold and painful. What is the likely diagnosis?
The patient’s arrhythmia led to an embolus that has resulted in acute limb ischaemia.
There is a sudden decrease in limb perfusion with threatened tissue viability. An emergency vascular assessment needs to be done with duplex USS.
Rx = anticoagulation, thrombolysis, ±embolectomy
Ankle brachial pressure index (ABPI) results less than or equal to 0.9 are diagnostic for…
Peripheral vascular disease
n.b. test may not be accurate if patient has non-compressible arteries (diabetic patients and obese)
5 Ps of limb ischaemia
pale perishingly cold paralysis paraesthesia pulseless
A 55-year-old obese smoker presents with pain in his legs on walking 800 metres, which is immediately relieved by rest. His ankle-brachial pressure index (ABPI) is 0.9. What is the likely diagnosis?
This is peripheral vascular disease with classic symptoms of intermittent claudication. ABPI should be performed in symptomatic patients. This patient has only presented with claudication which is not severely lifestyle limiting so treatment is not always required. Monitor development of ischaemic symptoms or CVS complaints.
A 65-year-old man collapsed in his home. He had excruciating pain in his lower back. O/E: the patient is pale and cold with shut-down peripheries. There is a palpable epigastric mass. What is the likely diagnosis?
This is a history of a ruptured AAA. This patient has blood loss and is in haemorrhagic shock.
As this AAA has ruptured = urgent surgical repair, with standard resuscitation: ABCDE
A 45-year-old T1DM lady is brought in unconscious. She has been ill and neglected to take insulin. The right leg is wrapped up in bandages. When these are removed, there is evidence of gangrene (tissue is dry, black and cold) . There is fixed mottling of the skin up to the mid-shin level. What is the diagnosis?
Atherosclerosis is associated with DM and causes dry gangrene due to chronic impairment of blood flow. Evidence of non-viability and irreversibility of affected limb: major tissue loss, sensory loss with rest pain, inaudible arterial Doppler signals and muscle weakness. Fixed mottling does not blanch on pressure and is associated with a limb which is beyond salvage.
A 40-year old gentleman with a history of diabetes mellitus and CHD presents with pain in his buttocks after walking only 100m. He has had difficulty to maintain an erection. O/E: femoral pulses are absent.
Leriche’s syndrome - involves abdominal aorta +/ both iliac arteries
Triad: buttock claudication, impotence, reduced/absent femoral pulses.
An ambulance crew is dispatched to attend a 999 call made by passers-by. A 71-year-old diabetic lady at a bus stop collapsed, could not get up and was complaining of back pain. After basic investigations, she was taken to hospital. Subsequent CT showed no abnormalities. What is the diagnosis?
Atypical MI which is more common in diabetics and the elderly, due to autonomic neuropathy. These are ‘silent’ MI and should be excluded in all causes of collapse. An ECG is indicated here after the clear CT scan.
A 62-year-old diabetic lady presents with recurrent ulceration of the gaiter area of the left leg. The ulcer is well circumscribed, irregular in shape and of partial thickness. There is a brown discolouration and ‘eczema’ over both calves. What type of ulcer is this?
Venous ulcers - usually from deep venous insufficiency and follows trauma.
They are on medial gaitre region with oedema, brown skin discolouration due to haemosiderin deposition, lipodermatosclerosis and an inflammatory response - eczema-like thickening and hardening of the skin. The skin is drawn tightly around the ankle. Shape is irregular with granulation tissue base (sloughy) and sloping edges.
Punched out lesions
Arterial ulcers
A 60-year-old obese man presents with a ulceration on the sole of the right foot, beneath the metatarsal heads. The ulcer is deep and penetrating, however the skin around it appears well perfused. There is no pain and ankle reflexes are absent bilaterally. What is the diagnosis?
This is diabetic neuropathy (microvascular complication of DM due to peripheral nerve dysfunction).
Complications: painless neuropathic ulcer at weight loading sites, to the Charcot foot. Treat neuropathic pain with gabapentin, pregabalin, duloxetine
Types of aortic dissection (Stanford classification)
Type A - ascending aorta
Type B - descending aorta
What order are valves affected in infective endocarditis
Mitral
Aortic
Tricuspid
Pulmonary
Roth spots
Petechiae on retina
Occurs in infective endocarditis
Infective endocarditis medical Rx before surgery (valve replacement)
Clinical suspicion + Strep - benzylpenicillin + gentamicin
Staph + HACEK - flucloxacillin/vancomycin + gentamicin
Enterococci - ampicillin + gentamicin
Culture - vancomycin + gentamicin
Absent ‘a’ waves on JVP waveform
Atrial fibrillation
Dysfunctional atrial systole (contraction)
Large ‘a’ waves on JVP waveform (n.b. this is not cannon ‘a’ waves)
Pulmonary hypertension/stenosis
Large ‘v’ waves in JVP waveform
normally v wave = atrial (venous) filling when tricuspid valve is closed.
Tricuspid regurgitation
Pansysytolic murmur heard best at lower L sternal edge during inspiration, in a patient with pulsatile hepatomegaly suggests…
Infective endocarditis with tricuspid regurgitation
Common in IVDU
Giant systolic ‘v’ waves seen in JVP
Elevated JVP with absent pulsation is caused by…
SVC obstruction
bronchial carcinoma is a cause of this. other symptoms: early morning headache, facial congestion, oedema with upper limb involvement.
Jerky pulse suggests
HOCM
Mitral regurg
Mixed aortic valve disease
Pulsus paradoxus occurs in
Constrictive pericarditis
Cardiac tamponade
Loss of sensation in acute limb ischaemia signifies…
limb is not viable
Causes of heart block
MI/ischaemic heart disease - commonest Infection - Rh fever, IE Drugs - digoxin, b-blockers, CCBs Infiltration - sarcoid, amyloid, tumours Degeneration
Target blood pressures in:
HTN patient
HTN diabetic without proteinuria
HTN diabetic with proteinuria
HTN - <140/90
HTN diabetic w/o proteinuria - <130/80
HTN diabetic w/ proteinuria - <125/75
Severe HTN (diastolic BP >140mmHg) Rx
Atenolol or nifedipine
In patients who cannot undergo exercise ECG can do pharmacological stress testing. This uses drugs such as
Dipyridamole
Adenosine
Dobutamine
These induce tachycardia
Tests to confirm group A strep presence (i.e. cause of rheumatic fever)
Bloods - FBC (WCC), high ESR/CRP, high anti-streptolysin O titre
Throat swab - GAS cultures, rapid strep Ag test
ECG - carditis
Echocardiogram
Causes of tricuspid regurg
Congenital: Ebstein anomaly, cleft valve in ostium primum defect
Functional: RV dilation, valve prolapse
Rheumatic heart disease
Infective endocarditis
Other: carcinoid syndrome, trauma, cirrhosis
Infective endocarditis common causative organisms
Streptococcus
Staphylococcus
Enterococcus
Other: HACEK - haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
Strep bovis in IE is associated with
GI malignancy
colonoscopy is important
Define:
Janeway lesions
Osler’s nodes
Janeway lesions - painless palmar macules, blanch on pressure.
Osler’s nodes - tender nodules on finger/toe pads.
Patients with multiple recurrent pulmonary embolism may have symptoms associated with
Pulmonary hypertension
R heart failure
Carvallo sign
Pansystolic murmur louder on inspiration
i.e. in tricuspid regurg
CXR shows double shadow right heart broder, prominent left atrial appendage and left main bronchus elevation. What is the likely diagnosis?
Mitral stenosis
advanced with these signs of elevation of L main bronchus, double R heart border, carina widening, prominent L atrial appendage. mitral valve may also be calcified and pulmonary oedema.
