Cardio station Flashcards

Question

Mechanical vs bioprosthetic valves

Answer 1

Mechanical - More durable - lasts life - Lifelong WARFARIN only (NOACs get thrombosis) bio valve - lasts 10-15 years - Short duration anticoag post op Endocarditis no difference between

Answer 2

What do you mean? What happened Before, - Need to get the activity preceding - Prev epsodes - any fainting During - Any witnesses - Rigid? - Tongue biting After - Recovery Chest pain / haemoptysis Drug history -Any recent changes - Hypertensives - Drugs for arrhythmia PMH - Parkinsons - autonomic / postural - Structural heart disease eg AS Social history - Roofers - HGV / drive for work Family history - Sudden death / cardiomyopathy - Anyone with collapses / devices in chest

Answer 3

Syncope - sudden onset Cardiogenic - no prodrome Quick recovery post

Answer 4

No common in syncope - Usually fairly random and short lived - Usually flaccid rather than rigid Incontinence happens with all syncope Tongue biting - particularly side and back of tongue - likely seizure - Represents clonus of jaw

Answer 5

LOC without prodrome Occurring on exertion History of strucutal heart disease / family sudden death

Answer 6

Pulse Lying standing bp Fingerprick glucose 12 lead ECG - structural / LVH / ectopy / QT interval / heart block / ion channel opathy Bloods HB - anaemia WCC / CRP - infection renal / liver - starting medications Electrolytes / TFTs Possible 24hr tape Consider ECHO but not in first instance

Answer 7

Symptom rhythm correlation

Answer 8

Patient education - Avoid precipitants / triggers Drink plenty of fluid - Bolus water drinking High sodium diet Consider compression garments

Answer 9

<140/90 in clinic <135/85 at home

Answer 10

How long Secondary causes Brain - Pit tumour - cushings, acromegaly Neck - OSA, Hyperthyroid Kidney - PKD, RAS, RCC Endo - Conns, phaeo End organ damage - Kidney - frothy urine, kidney problems - Brain - headaches, blurred vision, TIA / strokes, nose bleed - Heart - chest pain, fluid overload, SOBOE Social - Liquorish - aldosterone effect - Alcohol - Ilicit drugs - cocaine - Smoking Meds - Steroids for chronic conditions - COCP - Are they taking antihypertensives PMH - Surgery when young - coarctation - Peripheral vascular disease - Asthma / COPD / IBS - steroids -> cushings - CKD FamHx - Family history - High cholesterol - Fam Hx RRT / CVA ?ADPCKD ## Footnote - Renal artery stenosis - tried ACEi - Renal Ca - weight change - Thyroid hyper - OSA - daytime drowsiness - Phaeo - hot flushes, palps, chest pain, anxiety - Cushings - steroids - Carcinoid - flushing / diarrhoea - Acromegaly - changes in appearance / hands - Conns

Answer 11

Target organ damage **Kidneys** - Renal function - end organ damage and K+ for conns - Renal dip for proteinuria + Albumin creatinine ratio - Preg test - If worried about renal artery stenosis need to do a CT **Heart** - ECG - LVH - Consider Echo for LV mass - CXR / BNP if any evidence of failure **Brain** - Imaging if headaches **Bloods** TFTs HBa1c Lipid profile Consider - Aldolsterone renin ratio or dexamethasone supression test, pituitary profile QRISK score Ambulatory BP monitoring ## Footnote Q RISK calculates a person's risk of developing a heart attack or stroke over the next 10 years

Answer 12

Check BP Hands Radial-radial delay Radial femoral delay Perform fundoscopy Look at back of neck for buffalo hump Carotid / femoral bruis Thyroid palpate Abdo Any striae - cuhings Polycystic kidneys Renal bruis Urine Dip

Answer 13

AV nipping flame haemorrhages

Answer 14

Renal artery stenosis - would expect a doubling in creatinine

Answer 15

Aldosterone renin ratio Need to stop antihypertensives that affect RASS - Basically only one that doesnt is doxasosin

Answer 16

Urinary / blood catecholamines -Paracetamol on urine

Answer 17

Low dose dexamethasone suppression test

Answer 18

sleep study looking at saturations

Answer 19

Renal vein sampling for aldosterone CT scan

Answer 20

Split into Hypertensive urgency - sustained hypertension without end organ damage - Aim to reduce diastolic pressure to <110 - Reduce MAP by no more than 25% Hypertensive emergency - with end organ damage - Aim to reduce diastolic to <115 -Use IV labetalol / GTN in a HDU environment

Answer 21

Phentolamine - alpha blocker ## Footnote phaeo phento

Answer 22

IV labetalol + GTN

Answer 23

Education Reminder of times to do it eg after teeth brush Dossett box Autonomy of thier own care - eg BP machine and see the difference

Answer 24

Lifestyle - Salt - especially bread - Weight loss - Excercise - Alcohol and smoking ACEi /ARB or CCB if >55 / Black Both Thiazide

Answer 25

Compliance issues Add in spironolactone B blockers/ Alpha blockers if tachy

Answer 26

No - one is non obstructive

Answer 27

Autosomal dominant - Most commonly (total 75%) MYH7 gene - beta myosin heavy chain (MYosin Heavy) MYBPC gene - Cardiac myosin binding protein C

Answer 28

Young Hands -nil - Pulse - AF most common arrhythmia / ectopics Arms -Nil Neck - Large a waves in JVP - Chest - Scars for myectomy / ICD (check sub cut in left axilla) - Palpation left axilla, Heave, apex Auscultate - Often outflow murmur - Mitral murmur -Get patient do do Valsalva -> does it extenuate murmur Heart failure - Lung bases - Pedal oedema

Answer 29

HCM Cardiomyopathy / channelopathy Congenital heart disease

Answer 30

Long QT WPW Brugada HCM

Answer 31

forceful atrial contraction against non compliant RV - due to septal hypertrophy

Answer 32

Systolic anterior motion of the mitral valve -> Mitral regurg ## Footnote occurs when the anterior leaflet of the mitral valve moves toward the left ventricular outflow tract (LVOT) during systole which causes a LVOTO

Answer 33

Bicuspid aorta / aortic stenosis VSD Mitral valve disease

Answer 34

12 lead ECG - rhythm / AF, large P waves if atrial enlargement - narrow / broad QRS esp if fibrosis - LVH - often with deep T waves in lateral leads Bloods - Consider genetic tests [MYH7 gene - beta myosin heavy chain (MYosin Heavy) MYBPC gene - Cardiac myosin binding protein C] - Sometimes chronic low grade trop - BNP if failure CXR - Cardiomegaly Echo - LVH typically septum and asymmetric - Systolic anterior motion of the mitral valve - L atrial dilatation - Measure gradient and consider exercise echo CMRI

Answer 35

- Apical segment of HCM often not seen on echo - Can more accurately assess gradients - Can see scar - ectopic / ventricular arrhythmias focus

Answer 36

Cardio referral Advise to notify DVLA especially if syncope / Ventricular arrhythmias / ICD Conservative - Clinical genetics + screening 1st degree relatives - Cardiac imagining specialists - Specialist nurses - Aim to avoid dehydration - Light exercise ok. Avoid weight lifting as can worsen outflow tract gradients Medical - Beta blockers / CCB - reduce outflow tract gradients. - Be very careful using diuretics - especially if outflow tract obstruction Surgical - Primary prevention ICDs - Septal myectomy

Answer 37

Sudden death risk calculator

Answer 38

disapriamide - sodium channel blocker Then either surgical or - Mavacamten - Brand new - cardiac myosin inhibitor

Answer 39

Either / both Mitral regurg Aortic regurg

Answer 40

5th intercostal space Mid clavicular line

Answer 41

Haematocrit >48% women and >49% in men Must be persistently in that range

Answer 42

Myeloid stem cells - can become RBCs, platelets, and neutrophils, basophils, monocytes etc [all white cells bar lymphocytes] - In polycythemia would expect changes in neuts and platelets - Lymphocytes should not be affected

Answer 43

Apparent - Due to eg dehydration True Primary = primary haem disorder polycythaemia ruba vera Secondary (something making marrow produce more) Appropriate - Chronic lung disease - Cyanotic disease - OSA Inappropriate - Exogenous epo -testosterone -PKD -RCC

Answer 44

Why was the blood test done? - Dehydration / alcohol / D&V Hyper-viscosity symptoms - Arterial / venous thrombosis - Sometimes bleeding - Head fog / headaches [think about waldenstroms if so] PRV - Sweats drenching - Weight loss 10% / 6months - Occationally fever - Puritis after hot shower Symptoms of splenomegaly - Early satiety - LUQ pain Secondary causes - Chronic lung issues - Check for SOBOE - Snoring Daytime solomence- OSA -Known diagnosis of tumours PMH - Lung / heart disease DH - Any diuretics - Testosterone SH - Smoking - Alcohol FH -PKD or renal disease

Answer 45

Myeloproliferative disorders - CML - Essential thrombocythaemia - Myelofibrosis Antiphospholipid syndrome Polycythaemia Paroyxysmal nocturnal haemaglobinuria

Answer 46

JAK 2 - Also picks up 50% of essential thrombocythaemia

Answer 47

Bedside - Spo2 - Examine lung disease / organomegaly - Evidence of thrombus Bloods - Repeat FBC - Epo level and JAK 2 CXR - Undiagnosed chronic lung disease US abdo - Renal tumours / PKD - Splenomegaly -Polysonography / sleep studies

Answer 48

Low in PRV High in secondary causes

Answer 49

Referral to Haem Conservative - Stop smoking - CV control - Follow up as risk of developing **AML** Medical -Venesection Reduce haematocrit to 0.45 [If secondary depends on history of thrombosis and up to haem] - Aspirin or clopi [Secondary don't use] - Treatment of thrombosis

Answer 50

Hydroxycarbamide -> non selectivley reduces marrow production -> can reduce all blood counts

Answer 51

MR may have AF and displaced apex

Answer 52

AS - crescendo decresecendo MR - crescendo / pansystolic

Answer 53

MR loudest expiration TR - loudest inspiration

Answer 54

Young - almost all are closed now Very loud pansystolic most in inspiration

Answer 55

Primary - Congential - Degenerative- Mitral prolapse, age related - Rheumatic heart disease - Connective tissue disease Secondary - ischaemic heart disease - heart failure - Post endocarditis - Ruptured cordae post MI - Ilfiltrative Functional - LV dilation

Answer 56

Bloods FBC U&E BNP ECG Chest XR Echo Diagnosis and quantification Mechanism Also any other valves / haemodynamic issues such as LVD / atrial dilation

Answer 57

Mild mod Approx risk 5% of progression over 5 years Need regular clinic review Severe - anyone should be considered for intervention [If severe and symptoms need intervention Asymptomatic + AF / atrial dilation -> likely intervention Asymptomatic and otherwise normal echo]

Answer 58

Decisions made with surgeon, cardiologist and interventionist Repair Replace Mitraclip - those who open heart surgery would not be option - through groin

Answer 59

Clinical - AF - thursting displaced apex beat (means LV dilation) - palpable thrill Echo - measure MR jet - evidence of LV dilation / impairment

Answer 60

Syncope Features heart failure Previous cardiac history eg MI Scarring Family history unexplained death DH Recent abx which prolong QT Recreational drugs Secondary Phaeo - Tremor weight loss htn sweating flusing OSA - snoring weight / tiredness Thyrotoxicosis

Answer 61

Hands Tremor Pulse regular BP eg phaeo Face anaemia Jvp / lung bases failure Thyroid Murmurs eg HCM Valsava breath hold murmur ICD scar look in axilla Abdo flank mass

Answer 62

Bloods + extended Electrolytes TFTs Consider BNP CXR ECG Tape 24 vs 72 vs loop looking for rhythm symptom correlation Echo - rule out structural heart disease Rule in murmurs - Ideally done prior to fleccanide Occasionally CMRI

Answer 63

Hcm - STE and t wave inversion Brugada - Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave. QT interval ARVC - arrythmogenic right ventricular cardiomyopathy (Brugada)

Answer 64

Autosomal dominant genetic disorder of myocardium in which there is fatty infiltration of the right ventricular free wall, predisposing to paroxysmal ventricular arrhythmias - second most common cause of sudden cardiac death T wave inversion in right precordial leads V1-3, in absence of RBBB (85% of patients) Epsilon wave (most specific finding, seen in 50% of patients) Localised QRS widening in V1-3 (> 110ms)

Answer 65

a - Atrial contraction x - relaXation of atria c- triCuspid Closure v - Venous filling of atria y - emptYing of atria

Answer 66

ABCCCDD Alcohol Beri beri Coxackie B virus Cocaine Chagas disease Doxorubicin, Daunorubicin

Answer 67

Waterhammer pulse Quicke’s sign: visible capillary pulsations in the fingernails [caPINKY QUINKY] De Musset’s sign: nodding of the head with each heartbeat [Mullet head banging] Becker’s sign: visible pulsations of retinal arteries and pupils Muller’s sign: systolic pulsations of the uvula [Muller Yoghurt] Corrigan’s pulse: visible carotid pulsations [corrigans carotid] Rosenbach’s sign: systolic pulsations of the liver Gerhard’s sign: systolic pulsations of the spleen Traube’s sign: pistol shot femorals Duroziez’s sign: ejection systolic and diastolic murmurs heard with the stethoscope when the bell is used to compress the femoral arteries Hill’s sign: popliteal > brachial systolic pressure by > 60mmHg

Answer 68

Marfanoid body

Answer 69

?Marfans Hands - IE Feel both pulses Collapsing pulse **Get BP** JVP / lung bases Look in mouth at uvula - mullers sign High arched palate Parasternal heave + thrill Auscultate - Early diastolic murmur heard best over the LLSE with the patient leaned forward and in expiration - **Length** of murmur correlates with severity (short is bad, volume of murmur is not) - High-pitched, decrescendo murmur - Ejection flow murmur over the aortic area (does not equate to co-existent aortic stenosis) from increased flow across the aortic valve Legs - oedema I would like a full set of observations especially BP and temperature. fundoscopy to assess for roth spots, Urine dip looking for blood If time - Palpate liver and spleen - Rosenbach’s sign: systolic pulsations of the liver Gerhard’s sign: systolic pulsations of the spleen - Traube’s sign: pistol shot femorals - Duroziez’s sign: ejection systolic and diastolic murmurs heard with the stethoscope when the bell is used to compress the femoral arteries

Answer 70

Austin-Flint murmur - Functional mitral stenosis caused by regurgitant jet striking mitral valve leaflets - Marker of severe AR - Distinguished from MS in that there is no opening snap, S1 is not loud PR / MS / TS very hard to hear

Answer 71

Systolic - just after pulse Diastolic - just before pulse

Answer 72

Acute severe - Will have florid pulmonary oedema - Acute aortic dissection - Infective endocaritis - Fever, janeway, oslers - Prosthetic valve failure eg trauma to chest Chronic - D Bad CRRAMPSS - Dilated arotic root - Bicuspid valve - Congentital - Rheumatic heart disease - Rheumatoid arthritis: - Anklylosing spondylisis: - Marfan’s syndrome: high, arched palate, long limbs - Pseudoxanthoma elasticum: neck skin - Syphilitic aortitis: Argyll-Robertson pupil (reacts to accommodation but not to light) - Systemic lupus erythematosus: rash, oral ulcers, alopecia - Hypertension / Calcific AV - Osteogenesis imperfecta: blue sclerae, hearing aids

Answer 73

Small, red spots with white or pale centers that appear on the retina of the eye. They are caused by bleeding, or hemorrhages, and are usually round, oval, or flame-shaped. Possibly in IE / Diabetes / hypertension / myeloma / leukaemia / HTN...

Answer 74

AR Pseudoxanthoma elasticum

Answer 75

Bedside - Full set of obs especially BP and tempurature - Urine dip for blood - Fundoscopy for roth spots - ECG - Evidence of LVH / strain eg TWI / LAD Bloods - Blood cultures - Inflammatory markers - NT ProBNP CXR Evidence of pulm pedema Echo - Vegitations / aortic root / look at central jet of AR / valve morphology

Answer 76

Cardiac ct

Answer 77

Acute severe AR - Referral to ICU for IV vasodilators + inotrope - >Surgical valve replacement Chronic Patient education - especially symptoms to look out for Medical - ACEi may provide symptomatic improvement - If Marfanoid / Aortic root dilation - BB to reduce shear stress over valve Surgical - If chronic AR + evidence of LVD or LVSD. OR if symptomatic - If aortic root >55mm

Answer 78

Transvalvular - though middle of valve Paravalvular - around valve, often a sign of dehiscnece

Answer 79

Long + Loss of second heart sound

Answer 80

Dukes 2 Major or 1 major and 3 minor Major - Typical blug in 2x BCs - Echo findings Minor - Pyrexia - suspicious echo - embolic pneumonia - prostehtic valve - vasculitic crp/esr rise - atypical organism in BCs

Answer 81

p mitrale - broad / bifid AF Right heart strain

Answer 82

Strep pyogenes B haemolytic strep Duckett-jones diagnostic criteria [Throat swab rapid antigen detection test antistreptolysin O titre +2 major criteria] Rest, high dose aspirin and penicillin -> long term penicillin prophylaxis

Answer 83

Wide splitting of S2 Loudest on expiration

Answer 84

Raised JVP with large v waves thrill left sternal edge Pansystolic murmur loudest on inspiration Reversed split left secodn heart sound Pulsitile liver / ascities Peripheral oedema

Answer 85

Either conditions causing RV failure - functional - most common eg RV dilation eg post infarct - Pulm HTN - Rupture of papilary muscles Conditions affecting Valve - infective endocarditis - rheumatic fever - Congenitcal - ebsteins anomoly - Marfans - Libman sacks - carcinoid

Answer 86

ECG - p-pulmonale (peaked p), RVH CXR - Double right hear boarder (large RA) Echo - TR, RV /RA dilation

Answer 87

Raised JVP with giant A waves L parasternal heave ESM loudest on inspiration Widely split second heart sound (delay in RV emptying) RV failure - oedema / ascities ...

Answer 88

Loss of second heart sound

Answer 89

P Pulminale RVH RBBB CXR - Oligaemic lung fields, Large RA / RV Echo - Severity, RV function

Answer 90

Congenital - Congenital PS - Tetralogy of fallot - PS, RVH, VSD, Overriding aorta - Noonans - think turners but in men Aquired - Rheumatic heart disease - Endocarditis - Carcinoid

Answer 91

Valvulotomy - if evidence of RV failure / raised gradient >70mmHg Percutaneous pulm valve inplantation Surgical repair / replace

Answer 92

Flow murmur in AVR - Systolic - A diasolic AR murmur would indicate non funcitoning valve MVR - Diastolic flow murmur normal - MR would indicate non functioning valve

Answer 93

Thromboembolus - 1% per year despite warfarin Bleeding secondary to anticoagulation Haemolysis - much more significant with old ball-in-cage valves and may be low grade with new Eg St Jude Endocarditis AF - especially MVR Valve failure - especially if tissue (can get a valve-in-valve) - May be calcification / dehiscence

Answer 94

Primary prevention - MI > 4weeks ago +Severe LVSD + non-sustained VT in EP study / broad QRS - Familal condition with high risk sudden caridac death - LQTS, Brugada, HCM, Complex congenitcal heart disease Secondary prevention - Arrest due to VT / VF - VT with haemodynamic compromise CRT pacemakers consider if - LVEF <35% NYHA >1 and on optimal medical therapy - QRS >150ms

Answer 95

Raised JVP Prominent y descent (tricuspid opening) Kussmals sign - increase in JVP on inspiration Pulsus paradoxus - drop of >10mmHg on inspiration Auscultation - pericardial knock Ascities Peripheral oedema

Answer 96

TB - Cervical lymphadenopathy Trauma / surgery Tumour Therapy (Radio) connective Tissue disease - Rheum / SLE | TTTT

Answer 97

CXR - calcification +/- TB Echo - high signal from pericardium CT - thickened pericardium Cath - equalisaition of heart pressures

Answer 98

Thick fibrous capsule insulates heart from intrathroacic pressure changes with respiration -> **ventricular interdependence** - Filling one ventricle reduces size and filling of the other

Answer 99

Fixed splitting second heart sounds - may have pulm ESM and diastolic tricuspid flow murmur Downs syndrome

Answer 100

primum - AVSD (Downs) - RBBB + LAD (wide bifid P) Secundum - more common - RBBB + RAD (Peaked p)

Answer 101

Irregular, tachycardic pulse – atrial tachyarrhythmias Pronator drift – paradoxical emboli Cyanosis, pulmonary hypertension, cor pulmonale – Eisenmenger’s syndrome

Answer 102

Symptomatic breathlessness Paradoxical embolism RV dilation Significant shunt Contraindication - Severe pulm HTN / Eisenmenger

Answer 103

Pansystolic - no audible S2 - Tetralogy of fallot - turners - downs - PDA - Coarctation

Answer 104

Blalock - taussig shunt - anastamose subclavian artery to pulm artery - > Absent radial pulse

Answer 105

Continuous radiating to back loud A2 - Hypertension Right +/- L arm. lower in legs - Weak femoral pulses

Answer 106

VSD Turners bicuspid aortic valve 50-80%

Answer 107

ECG - LVH, RBBB CXR - rib notching, double aortic knuckle (due to post stenotic dilation)

Answer 108

Perc EVAR endovascular aortic repair Surgical - patch aortoplasty Follow up with angiograms (including cerebral for anneurysms.) Long term antihypertensive management

Answer 109

Aorta -> pulm artery connection with L->R shunt Rubella Collapsing pulse thrusting apex loud continuous murmur Eisenmengers Endocarditis Perc / surgical closure

Answer 110

Soft p2 - no evidence of pulm HTN Apex not displaced, no overload, no Left parasternal heave suggesting RHF

Answer 111

ASD PDA MR TR Pulm stenosis Tetralogy of fallot

Answer 112

Can be differentiated into L->R and R->L shunts L->R - Associated with increased pulm blood flow - Usually acyanotic - May slowly lead to increased pulm, vascular resistance with pulm HTN and reversal of shunt called **eisinmengers syndrome** - Eg **VSD, ASD, AVSD, PDA** R->L - Deoxygenated blood into aorta - Tetralogy of fallot, Pulmonary atresia, transposition of great arteries, ebsteins abnormality, hypoplastic left heart syndrome

Answer 113

ASD - usually just mid/ eject systolic and usually much softer - Often has fixed splitting of the second heart sound [Unlikely to get in paces] PDA - continous murmur

Answer 114

Post MI / trauma

Answer 115

Previous endocarditis Eisinmengers syndrome <6months since patch repair

Answer 116

Confirm diagnosis via echocardiography with assessment of shunting and pumonary pressures. Small VSDs often managed with observation any symptomatic/ endocarditis/large are repaired - Patch - Percutanous device closure

Answer 117

Pulm vasodilators eg Sildenafil Prophylactic Abx Monitoring for hyperviscosity / secondary polycythaemia Consider referral for heart-lung transplant

Answer 118

Full history Bedside - ECG - Observations esp pyrexia - If acute consider inflam markers Echocardiogram - Severity of MR and cause If consideration of surgery - Would perform angiography toassess need for CABG at same time

Answer 119

Clinical - Signs and symptoms of LVF - Evidence of AF Echo - Usualy on colour flow doppler

Answer 120

Pansystolic murmur which radiates to axilla May get 3rd heart sound due to rapid LV filling

Answer 121

- Evidence of LVSD / LV dilation - Symptomatic

Answer 122

Rheumatic heart disease

Answer 123

AS - Degenerative calcific - Bicuspid - Rheumatic fever and endocarditis AR - Rheumatic heart disease - Endocarditis - Long standing HTN - Connective tissue disease - Eg Ank Spond, Marfans, Osteogenesis inperfecta MR - Most common Functional caused by LV dilation - Rheumatic heart disease - degeneration - Papilllary muscle rupture post MI - Connective tissue eg Marfans / ehlers danlos MS - Almost always rheumatic heart disease (99%) - Calcific valve disease / endocarditis

Answer 124

Usually occult blood loss secondary to anticoag Haemolysis - would have raised Bili Sub acute endocarditis -> anaemia of chronic disease

Answer 125

MVR -> lower velocities so clots can stick

Answer 126

Examination of the heart - Detailed echo evaluation - Angiogram - assess for CAD (simultaneous CABG) - Carotid dopplers if AVR Can the lungs handle it? -Pulmonary function tests esp if smoker - Anaesthetic assessment eg with CPET testing **Referral for MDT** to discuss options eg Open vs perc / medical

Answer 127

MDT in hospital Cardiology ID / Micro Cardiothoracic surgery - Highly likely to require surgery - Acute heart failure will require diruesis and W/H any heart failure meds - High dose IV antibiotics ideally post 3x blood cultures

Answer 128

1. subtle narrowing of arteries 2. presence of AV nipping 3. Infarction (cotton wool spots), and flame haemorrhages 4. Swelling of optic disk - pappiloedema

Answer 129

Idiopathic essential (90%) Renal - Eg Renal artery stenosis or PKD Endocrine - Eg Cushing / conns Anatomical - coarctation Pre/Eclampsia

Answer 130

Lifestyle modifications Esp Smoking cessation, Low salt, exercise, diabetic controll, reduced alcohol. Check medication compliance Baseline ECG looing for LVH Check bloods especially FBC, TFTs and renal function prior to medication Meds ACE/CCB -> Thiazide + mineralocorticoid receptor antagonis

Answer 131

Betaxolol Acebutelol Esmolol Atenolol Metoprolol ## Footnote Mnemonic: Betablockers Acting Exclusively At Myocardium

Answer 132

- JVP represents RA pressure - Can be seen between insertion points of sternocleidomastoid - JVP falls with inspiration and rises with expriation. Carotid does not - JVP can be increased with hepatojugular reflex - Not usually palpable

Answer 133

AR PDA AV fistula

Answer 134

Non tender macular - Janeway lesions Tender palpable - Olsers nodes Spinter haemorrhages Roth spots Sternotomy scar Murmurs Cardiac failure

Answer 135

**Native valve - Strep viridans - staph aureus / Gram negative eg enterococcus** - Rare HAECK- Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species **Prosthetic** - **Staph aureus or staph epidermis** most common

Answer 136

Any bacteraemia Eg Infection of any sort Injury to skin Dental work

Answer 137

Anyone can get it More likely in any valve abnormality / prothetic heart valves

Answer 138

Damaged valve -> exposed endothelium -> Thombus and bacteria attach

Answer 139

Heart failure - valve incompetence Abscess in arotic root -> rhythm disturbance Infective elboli Eg brain, kidneys, bowel etc

Answer 140

-Large vegitations -Severe AR / MR -Heart failure -Fungi **Prosthetic** -Evidence of dehiscnece -Valve obstruction -Abscess Relapsing infection

Answer 141

Fungal Libman-Sacks endocarditis (also known as murantic or verrucous endocarditis) - nonbacterial endocarditis which involves the presence of sterile vegetations on the cardiac valves. - Seen in SLE Malignancy Eg pancreatic adenocarcinoma

Answer 142

Cardio - IHD - HTN - Mitral valve disease - cardiac surgery - congenital heart disease - pericarditis - cardiomyopathy Resp - Infections - Lung ca - COPD - PE - Connective tissue disease Abdo - Alcoholic liver disease - Any infection Other - Hyperthyroid

Answer 143

Strokes Heart failure

Answer 144

Bedside A-E ECG to confirm Bloods Inflam markers, renal function / Thyroid function, extended elctrolytes CXR any heart failure Echo - assess lv and and structural disease

Answer 145

Marker of RA pressure with a normal rise and fall. Starts with A wave of atrial filling and ending with Y descent of atrial emptying **Specific findiings** - Raised - congested - Prominent V waves and rasied - RV failure and tricuspid regurg - Cannon A waves - Atrial contraction onto closed tricuspid in heart block - Loss of A wave in AF as ineffective atrial contraction

Answer 146

JVP raises in inspiration - Should drop Associated with severe heart failure of any cause Suggests inability of RV to accept increasing volume of blood during inspired venous return

Answer 147

Squatting Expiration -> as increases cardiact output and flow

Answer 148

group A strep

Answer 149

Ben pen aspririn Steroids

Answer 150

Ducket jones criteria

Answer 151

Heart failure management AF management Balloon valvulotomy Surgical replacement

Answer 152

AF Heart failure Left atrial englargement -> dysphagia Endocarditis

Answer 153

Systolic murmur with click as the posterior leaflet of the valve prolapses into Left atrium during systole -> systolic click

Answer 154

Click - Congentital - connective tissue eg marfans / elhers danlos - Osteogenesis imperfecta - pseudoxanthoma elasticum - HCM - PKD - Rheumatic heart disease Differentials - Atrial myxoma - Bicuspid aortic stenosis - Endocarditis

Answer 155

SLG2 inhibitors MRA eg spironolactone / eplenerone

Answer 156

Right sided failure Valvular lesions HFPEF

Answer 157

Loudest on inspiration Large v waves on JVP Pulsitile liver There is a history of IVDU and pyrexia

Answer 158

S3 - rapid ventriuclar filling - MR / TR / VSDs - LV failure s4 - tubulent blood flow into stiff ventricle - Aortic stenosis, HTN, HCM, LVH

Answer 159

Take a full history in particular asking about rheumatic fever history and recreational drug use Bedside ECG - RVH / arrythmias, Urine dip, fundoscopy, BP Bloods Blood culutes x 3 if suspicious of endocarditis FBC and CRP for infection U&Es as may need diuretics Coag profile Imaging CXR - resp cause of TR eg pulm htn / cardiomegaly Echo - endocarditis and heart falves / function

Answer 160

Optomising cause eg connective tissue disease / lung function / endocarditis Diruesis for symptoms Surgical may need valve replacement

Answer 161

congenital defect in tricuspid valve position which causes tricuspid regug Leads to atrialisation of a portion of the RV leading to an enlarged RA and a small RV

Answer 162

Inadequate BP response on treadmill LV dysfunction

Answer 163

Gradient over 4m/s Valve area < 1cm

Answer 164

Likely requires cardiac MRI R and L heart catheters Constrictive - Infective pericarditis - post op eg cabg - TB - Radiation Restricitve - Cardiac fibrosis - Sarcoid - Haemochromatosis - Malignancy - Radiation Treatment is different - Constrictive -> surgical (removal of pericardium) - Restricitive -> treat cause eg iron overload / DMARDs ## Footnote “RESTRICT vs. CONSTRICT” RECENT INFLAMMATION (Restrictive = Infiltrative) CHRONIC SCAR (Constrictive = Scarring) Or: “R.E.S.T.R.I.C.T.” (Restrictive Cardiomyopathy) * Radiation fibrosis * Endomyocardial fibrosis * Sarcoidosis * Thickened myocardium (but non-dilated) * Restricted ventricular filling * Infiltrative disorders (Amyloidosis, Hemochromatosis) * Chest X-ray normal (no pericardial calcification) * Troponin usually normal “C.O.N.S.T.R.I.C.T.” (Constrictive Pericarditis) * Calcified pericardium (seen on CXR/CT) * Overall pericardial thickening * Normal myocardium (not infiltrated) * Square root sign on ventricular pressure tracing * Tuberculosis (common cause worldwide) * Reciprocal ventricular interdependence (septal bounce) * Impaired diastolic filling * Cardiac output drops with inspiration (Kussmaul’s sign) * Treatment is pericardiectomy These mnemonics emphasize the myocardial infiltrative nature of restrictive cardiomyopathy versus the pericardial scarring and constriction seen in constrictive pericarditis.