Cardio Week 6 Flashcards
what is symptoms of valvular heart disease
chest pain, breathlessness, collapse/dizzy exertional symptoms
what kind of breathlessness are associated with valvular heart disease
orthopnoea (when lying flat) and paroxysmal noctural dyspnoea (patient wakes with sudden SOB)
what is apex beat in left ventricular dilation / hypertrophy
dilation - displaced and diffuse (volume overload)hypertrophy - heaving and displaced (pressure overload)
what is a murmur
audible turbulence of blood flow
what kinds of murmurs synchronise with pulse
systolic
what kinds of murmurs do not synchronise with pulse
diastolic
what is types of systolic murmurs
pan systolic - mitral regurgitationejection systolic - aortic stenosis
what is types of diastolic murmurs
early - aortic regurgitation mid - mitral stenosis
how should murmurs be described
systole or diastolewhat type or murmurwhere is it loudestwhere does it radiate towhat grade
what murmur radiates to carotids
aortic stenosis
what murmur radiates to axilla
mitral regurgitation
how to grade murmurs
I - very quiet II - quiet - easy to hearIII - loudIV - loud with thrillV - very loud with thrillVI - loud (audible without stethoscope)
right sided murmurs are louder with what?
inspiration
what is the characteristics of an innocent (functional) murmur
soft (less than 3/6 severity), position dependent, often early systolic (diastolic always pathological)
what is valve stenosis
valves do not open properly
what is valve regurgitation
valves do not close properly
what is investigations in murmur
non invasive - echoinvasive - cardiac catheterisation
causes of aortic stenosis
can be degenerative (age related), congenital (bicuspid valve) or rheumatic (previous rheumatic heart disease)
what is symptoms of aortic stenosis
breathlessness, chest pain (mimic angina but normal coronary arteries), dizziness, syncope
what is the treatment of aortic stenosis
valve replacement - preferrednew - TAVI (transcatheter aortic valve replacement - comorbidity, previous sternotomy) and BAV
what is features of mechanical valves
longevity, warfarin required, used in younger patients
what is features of bio-prosthetic valves
no warfarin, lasts 10 years, used in older patients
what is the causes of mitral regurgitation
leaflets (prolapse, rheumatic, myxomatous, endocarditis), chordae rupture (degenerative), papillary muscle rupture (ischaemic) or annular dilation
what is symptoms of mitral regurgitation
breathlessness, peripheral oedema, fatigue
what is signs of mitral regurgitation
displaced, tapping apexpansystolic murmer - axilla
what is the treatment of mitral regurgitation
diuretics and drugs for HF (ACE inhibitors)surgical - repair (prolapse) or replacement (degenerative)percutaneous - clips in infancy
what is main cause of mitral stenosis
rheumatic - congenital is rare
what is symptoms of mitral stenosis
breathlessness, fatigue, palpitations (AF)
what is signs of mitral stenosis
malar flush, tapping apex beat, mid diastolic rumbling, diastolic murmur localised to apex
what is the treatment of mitral stenosis
diuretics and treat AFsurgical - valve replacementballoon valvuloplasty
what is the causes of aortic regurgitation
leaflets (endocarditis, connective tissue diseases, rheumatic)annulus - marfans, aortic dissection
what is symptoms of aortic regurgitation
breathlessness
what is signs of aortic regurgitation
collapsing pulse, wide pulse pressure, displaced apex, early diastolic murmur left sternal edge
what is the the treatment of aortic regurgitation
medication - ACE inhibitors surgery - symptoms and LV dilation - valve replacement
what is the function of the placenta
fetal homeostasis, gas exchange, acid base balance, nutrient transport to fetus, waste product transport, hormone production, transport of IgG and PGE2
what are lungs like in foetus
fluid filled and unexpanded
what is liver like in foetus
little role in nutrition and waste management
what is the gut like in foetus
not in use
what is the foetal circulation
foetal heart pumps blood to placenta via umbilical arteriesblood from placenta returns to foetus via umbilical vein oxygenated, nutrient rich blood returns from placenta to right side of heart
what 3 shunts are specific to foetal life
ductus venosus, foramen ovule, ductus arteriosus
what is the role of the ductus venosus
connects umbilical vein to IVC - carries majority of placental blood straight into IVC by bypassing portal circulation
what is the role of foramen ovale
opening in atrial septum connecting RA and LAallows best oxygenated blood to enter LA then LVmembrane flat on LA side
what is the role of the ductus arteriosus
connects pulmonary bifurcation to descending aorta patency maintained by circulating PGE2 produced by placenta
what are adaptations which foetus undergoes after birth
PVR decreases (reaches normal by 2-3 months)SVR increases (cord cut)more cardiac output to lungsforamen ovale closes (LA pressure exceeds RA)duct constriction - anatomical closure 7-10 days & ends up as fibrous ligament
in which kind of babies does duct often fail to close
preterm treatment - wait and see, NSAIDs and surgery)
if a congenital heart disease cause duct dependent circulation what can be done
IV prostaglandin E2 can be used to keep duct open until alternative shunt established or definitive surgery carried out
what can happen if adaptation fails
persistent pulmonary hypertension more likely in sick babies - sepsis, hypoxic ischaemic insult, meconium aspiration syndrome, cold stress
what is features of persistent pulmonary hypertension
lung vascular resistance fails to fall, shunts remain, blue baby, large difference between pre and post ductal O2 saturation
what is treatment of persistent pulmonary hypertension
ventilation, oxygenation, drugs to make high systemic blood pressure, inhaled NO, ECLS (v severe cases)
how does congenital HD present
screening - antenatal, newborn checkwell baby with clinical signs eg murmur unwell baby - cyanosis, shock or cardiac failure
how does antenatal screening work
ultrasound at 18-22 weeks - 4 chamber view and outflow tract viewif disease - deliver in cardiac surgical centre or prostaglandin infusion if duct dependent lesion
how does newborn screening work
around 24 hours - femoral pulses, heart sounds, murmurseg small murmur VSD (no haemodynamic consequences and may close spontaneously)
which congenital HD signs presents soon after birth
cyanosis (deoxygenated blood either bypasses lungs and enters systemic or mixes with oxygenated and enters)eg transposition of great arteries
which congenital HD signs presents 1-2 days after birth
murmurs, abnormal pulses, cyanosis
what congenital HD signs presents 3-7 days after birth
sudden cardiac collapse, shock, cyanosis, sudden death
what congenital HD signs presents 4-6 weeks after birth
signs of cardiac failure (reduced feeling, failure to thrive, breathlessness, sweatiness, hepatomegaly, crepitations)
what congenital HD signs can present at 6-8 week GP check
incidental finding of murmurs at other clinical contacts
what is the differential diagnosis of these signs
cardiac babies - blue with no resp distress (pre-post duct differential)resp - increased WOB, XR changesPPHN - otherwise very unwell babies (large pre-post ductal differential)
what are examples of duct dependent conditions
duct dependent systemic circulation (hypopolastic left heart, critical aortic stenosis, interrupted aortic arch, critical coarctation of aorta)duct dependent pulmonary circulation (tricuspid atresia, pulmonary atresia)
how does cardiac failure present
usually seen with moderate to large left to right shunts - increased pulmonary flow, increase ventricular load
what is the long term management of major congenital HD
surgical management - repair vs pallitation developmental problems - hypoxia, bypass timeneed for further surgery - valves, stenosis or transplant emotional/social issues
what kind of surgery can take place
patent ductus arteriosus repair (catheter), VSD repair or HLHS (3 stage complex surgery - ends with RV supplying systemic circulation)
what are the two different kinds of inherited disease
channelopathies (mutations in genes that encode cardiac ion channels)cardiomyopathies (disease of heart muscle)
what are 7 different types of channelopathies
congenital long QT syndrome, brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), short QT syndrome, progressive familial conduction disease, familial AF (in young ppl!!), familial WPW
what is congenital long QT syndrome
QT interval >440 males, >450 femalesassociates arrhythmia - polymorphic VT (torsades de pointes), lone, AF, heart block
what is the symptoms of CLQTS
syncope, SCD (sudden cardiac death) in children in young adults
what is triggers of CLQTS
exercise, sleep, sudden noise, drugs, hypokalaemia
what is the management of CLQTS
avoid QT prolonging drugs, correction of electrolyte abnormalities, avoidance of triggers
what is brugada syndrome
risk of polymorphic VT, VFAF common ST elevation and RBBB in V1-V3
what is genes associated with brugada syndrome
SCN5A and CACN1Ac
what is triggers in brugada syndrome
sleep or rest, fever, alcohol, large meals
what drugs should be avoided in brugada syndrome
anti-arrhythmic drugs, psychotropics, analgesics, anaesthetics
what are the three different types of cardiomyopathies
hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (AVRC) and dilated cardiomyopathy
what is hypertrophic cardiomyopathy
mutation in sarcomeric genes 1% CV mortality
how can hypertrophic cardiomyopathy present
sudden death, heart failure, angina, atrial fibrillation, or can be asymptomatic
what is arrhythmogenic right ventricular cardiomyopathy (ARVC)
fibro-fatty replacement of cardiomyocytes autosomal dominant mutation in genes for desmosomal proteins; recessive in nondesomosomal genes
what is dilated cardiomyopathy
sacromere and desmosomal genes, lamin A/C and desmin if connection disease, dystrophin if X linkedmales>females
how is channelopathies and cardiomyopathies managed
diagnostic - clinical and genetic testingrisk management - lifestyle, pharmacological, non-pharmacoloicalfamily screening
how may bacteraemic occur
patient specific reasons (poor dental hygiene, IV drug use, soft tissue infections) or associated with procedures (dental treatment, IV cannulae, permanent pacemaker)
what are the predisposing factors in endocarditis
rheumatic HD, mitral valve prolapse, IVDU (tricuspid lesion), prosthetic valves, congenital HD, hypertrophic cardiomyopathy
what organisms occur in the mouth
alpha haemolytic strep -viridans (50% of cases)
what organisms occur in native and prosthetic valve
staph aureus and staph epidermis strep viridans less common and occurs later (>60 days) post valve surgery
what organisms occur in prolonged hospitalisation
enterococci (gut)
what organisms occur in IVDU
staph aureus
what is high clinical suspicion in endocarditis
new valve lesion/regurgitant murmur, embolic event of unknown origin, sepsis of unknown origin, haematuria, glomerulonephritis, suspected renal infarction, fever
what is other symptoms of endocarditis
anorexia and weight loss, splinter haemorrhage, clubbing, splenomegaly, olsers nodes, janeways lesions and roth spots
what are olsers nodes
red-purple, raised tender lumps with pale centre fingers and toes occur at any time of endocarditis and last from hours to several days
what are janeway lesions
non tender, often haemorrhagic and occur mostly on palsm and soles (base of thumb and little finger)last days to weeks acute endocarditis
what are roth spots
retinal haemorrhages with white or pale centres
what investigations are used in endocarditis
blood cultures - at least 3 sets of samples (6 bottles)serological tests can be sent if diagnosis suspected but blood negative FBC (normochronic, normocytic anaemia is common)U&Es, LFTs (Alk phos raised) CRP (raised in any infection)m urine (proteinuria and haematuria)Echo CXR
treatment of clinical endocarditis, culture results awaited, no suspicion of staphylococci
penicillin and gentamicin
treatment of suspected staphylococcal endocarditis (IVDU, recent IV devices or cardiac surgery)
vancomycin and gentamicin
treatment of streptococcal endocarditis
penicillin and gentamicin
treatment of enterococcal endocarditis
ampicillin/amoxicillin and gentamicin
treatment of staphylococcal endocarditis
vancomycin or flucloxacillin or benzylpenicillin and gentamicin
