Cardiology Flashcards
Rheumatic fever definition
AI disease
type II hypersensitivity
Abs to group A strep cross react w/cardiac tissue
affects joints, heart, brain, skin
Rheumatic fever
JONES MAJOR CRITERIA
CASES Carditis Arthritis Sydenham's Chorea Erythema marginatum Subcutaneous nodules
Rheumatic fever
JONES MINOR CRITERIA
fever >38.5
arthralgia
high ESR / CRP
prolonged PR
Constrictive pericarditis is associated with
c
previous Cardiac surgery
Connective tissue disease
Radiotherapy
Signs of constrictive pericarditis
Kussmaul’s sign
pericardial knock
Kussmaul’s sign
JVP paradoxically rises on inspiration
seen in constrictive pericarditis
Pioglitazone SE
fluid retention in 10%
(especially if with NSAIDs, CCBs)
Sulphonylurea SE
photosensitivity rash
Statins, fibrates SE
myositis
Drugs causing photosensitivity rash
amiodarone, thiazides, ACEi, ARBs, sulphonylurea
Mx pulseless VT or refractory VF
amiodarone 200mg made up to 20ml 5% dextrose
Peripartum cardiomyopathy
When does it present
few weeks either side of delivery
Peripartum cardiomyopathy
Signs and Symptoms
Cause
Mx
Signs/Sx fo HF
Aetiology unknown / idiopathic
Mx = echo, diuretics, BB, vasodilators
Peripartum cardiomyopathy means higher risk of
ventricular arrhythmias and cardiac arrest
RFs for IE
valvular HD (stenosis, regurg)
congenital HD / surgically corrected CHD
previous IE
hypertrophic cardiomyopathy
Worse prognosis in IE if
staph aureus acute IE HF IVDU prosthetic valve infection aortic valve infection
Why would culture be negative in IE
ABx treatment
fungal infection
inadequate testing
Rhabdomyolysis definition
muscle symptoms and CK >10x ULN
Features of rhabdomyolysis
AKI
raised AST
brown urine
urine myoglobin
Blood tests for myopathy
CK
TFTs (hypothyroidism -> high cholesterol and high CK)
MOA statins
2
HMG CoA reductase inhibitors
Decrease hepatic cholesterol synthesis
HTN Mx
<55
not afrocarribean
T2DM
What if intolerance or high risk HF/HF?
ACE inhibitor
or ARB
HF - thiazide
HTN Mx
> 55 or afrocarribean
1st line
2nd line
1st line = CCB
(not ACEi as afro-carribean lower renin levels and less responsive to ACEi)
2nd line = thiazide
MOA cocaine induced MI
coronary artery vasospasm
as a-adrenergic receptor stimulation SM cells
Rx cocaine-induced MI
nitrates and calcium antagonists
Type MI and artery affected
I, aVL, V5-6
Lateral
Circumflex artery
Type MI and artery affected
V1-4
Anterior
LAD
Type MI and artery affected
II, III, aVF
Inferior
RCA
Most specific for MI on ECG
Q wave evolution
Causes of raised cardiac enzymes
MI
PE
Renal failure
Sepsis
MOA Ezetimibe
inhibits cholesterol absorption
Management symptomatic WPW
ablation
WPW ECG features
delta wave
Features atrial myxoma
rare benign cardiac tumour
usually left atrium
Signs of atrial myxoma
1/3
1/3 emboli
1/3 systemic infl (high ESR)
1/3 ASx
Signs atrial myxoma
LA dilatation
sudden death
mid diastolic click
What is Carney’s complex?
familial multiple neoplasia (various tumours including myxoma)
primary adrenal hypercortisolism
lentigines and naevi of the skin
Mx of HF
1st line
2nd line
HF and AF
1st line = ACEi and BB (e.g. carvedilol)
2nd line = Spironolactone
HF and AF = digoxin
Statin muscle disorders
myalgia vs myositis
myalgia = muscle Sx + CK normal
myositis = muscle Sx + CK <10x ULN
cause statin induced myopathy
incidence statin myopathy and rhabdomyolysis
unknown aetiology
myopathy - 1 in 10,000
rhabdomyolysis 0.44 in 10,000
Ix for ?statin induced myopathy
CK
TFTs (hypothyroidism -> high triglycerides and high CK)
RFs for statin induced myopathy
age >80 female low BMI xs alcohol vigorous exercise untreated hypothyroidism infection/surgery/trauma cyt p450 inhibitors
drugs causing rhabdomyolysis
statins
neuroleptics
clofibrate, aminocaproic acids
fibrates MOA
decrease triglycerides
by increasing lipoprotein lipase activity
signs cholesterol emboli in legs
LL petichial rash
pulses intact (chol. crystals small)
high WCC and eosinophilia (infl reaction to cholesterol)
Rx of
Type A aortic dissection
Type B dissection
Type A - surgery
Type B - IV labetolol (aim SBP 100-120)
High urea leads to which kind of pericarditis? why?
fibrinous pericarditis
uraemia -> fibrin exudation onto pericardial surfaces
Lipid abnormalities in T2DM
High triglycerides
Small dense LDL molecules
Commonest cause of Mitral Regurg
Myxomatous degeneration
Commonest cardiomyopathy and cause of sudden death
Hypertrophic cardiomyopathy
What is hypertrophic cardiomyopathy?
LVH without identifiable cause
Likely cause death in LT haemodialysis pt?
Why?
MI
as dialysis -> arterial calcification
Cause myocarditis
Cocksackie B virus
Aliskiren (for HTN) MOA
renin inhibitor
5 days post MI
Pulmonary oedema + systolic murmur
Cause?
Ix?
Acute LV failure
(due to: mitral valve prolapse, VSD, acute pericardial effusion/ haemorrhage)
Ix = R heart catheterisation + oximetry
(to check LA pressures and confirm MV prolapse)
Previous MI
Persistent ST elevation, apex displacement, CP and LOC
Cause?
LV aneurysm post MI
LOC would be due to cardiac syncope or TIA from LV thrombus
CI to thrombolysis for acute MI
recent surgery
would to angioplasty instead
Rx Torsades de Pointes
IV Mg
Flash pulmonary oedema
BG HTN
Arteriopath (e.g. smoker)
Renal artery stenosis
Type of pain more specific for myocardial ischaemia
Jaw radiation
NB pain relief can occur with MI or oesophageal spasm
Beck’s triad
sign of?
CARDIAC TAMPONADE
Raised JVP
Hypotension
Muffled heart sounds
AND pulsus paradoxus (> 10mmHg fall SBP on inspiration)
TriCuspid valve JVP waveform
C wave
triCuspid
PDA murmur
continuous machinery murmur
What is eisenmenger’s syndrome?
Features?
Reversal L->R shunt causing pulmonary HTN and causes R-> shunt
Get peripheral cyanosis + toe clubbing
Describe pathological Q waves
> 1mm wide
2mm deep
in V1-V3
nicotinic acid
MOA
SEs
reduce cholesterol and triglyceride synthesis
increase HDL cholesterol
SE = vasodilation
Mitral stenosis murmur
diastolic
loud first HS
opening Snap
Commonest reason for bioprosthetic valve replacement
calcification prosthetic valve
Commonest echo findings Marfan’s
dilatation aortic sinuses
-> dilated aortic root
Glycaemic control for DM post MI
s/c insulin for 6 weeks
then switch to metformin
Features significant PE
RV strain
high troponin
cerebral infarct in young person
with no palpitations
Cause?
PFO (causes paradoxical emboli)
No palps hence unlikely AF
Marker for early cardiac damage (in first 3h of MI)
GPBB
isoenzyme glycogen phosphorylase in cardiac muscle
When does troponin I and T rise in MI
3-12 hours after CP onset
peak 24-48 hours
baselin at 5-14 days
Features malignant hypertension
Papilloedema
Convulsions
Pulmonary oedema
Rx malignant hypertension
IV nitroprusside
Why is labetolol not first line in malignant HTN
can lower BP too rapidly
leading to cerebral infarcion in watershed areas
Ebstein’s anomaly echo
Downward tricuspid valve displacement
Hypoplastic RV
ASD
Cause Ebstein’s anomaly
Foetal lithium exposure
Ebstein’s anomaly ECG features
RBBB
Features tricuspid regurg
TRICUSPID REGURG
Pansystolic murmur
Raised JVP
Pulsatile hepatomegaly
Dose Adr in cardiac arrest
10ml of 1 in 10,000
CI to BB
asthma
heart block
Causes of AS
calcified aortic valve
rheumatic disease (-> fibrosis)
bicuspid aortic valve - GET EJECTION SYSTOLIC CLICK
SE 2 hours after taking atenolol
fatigue (common)
ECG features hypercalcaemia
Bradycardia
Long PR
Short QT
Causes pan-systolic murmu
Mitral regurg
Tricuspid regurg
VSD
Hypocalcaemia ECG features
Long QT
Mx Narrow complex tachycardia
if haemodynamically stable:
- carotid massage
- valsalva maneouvre
- IV adenosine (unless asthma
if haemodynamically UNSTABLE
- DC cardioversion
How to calculate EF
EF = Stroke volume/ end diastolic volume
Artery supplying AVN and SAN
RCA
MOA adenosine
coronary vasodilatation
depression SAN and AVN conduction
Main factors affecting coronary blood flow
myocardial oxygen consumption
independently maintained regardless of BP
increase in O2 requirement -> more adenosine produced -> vasodilation
Marfan’s syndrome inheritance
AD
Features of Marfan’s syndrome
Mv prolapse Aortic regurg Retinal detachment, glaucoma, cataracts, dislocated lens Flat feet Arachnodactyly pNeumothorax Scoliosis, pectus excavatum + carinatum
Examples HTN disorders of pregnancy
Chronic HTN
Gestational HTN
Preeclampsia-eclampsia
Preeclampsia + chronic HTN
Paracetamol OD:
Staggered doses
Single OD
Staggered - give NAC (high risk liver failure)
Single OD - level +/- NAC
Rx benzodiazepine OD
Flumazenil
Assessment opiate OD
Check for
respiratory depression
Pinpoint pupils
Rx amitriptyline OD + VT and QRS widening
Sodium bicarb for VT + TCA OD
What are biological assays for?
ASsess POTENCY of different preparations
What is a sequential trial
Data analysed after results available
Trial continues until clear benefit seen
Turner’s syndrome cardiac features
HTN in 10%
Aortic coarctation (low LL pulse, difference BP in UL and LL)
Horseshoe kidneys -> renal dysfunction
Commonest congenital birth defect
VSD
Brugada syndrome
structurally normal heart
ventricular arrhythmia
ECG ST elevation V1-3
45M collapsed whilst jogging
ECG, bloods, CXR normal
Dx?
Prognosis?
Exercise-induced VT
(normal tests rule out structural HD and rhythm disturbance)
Has no impact on mortality
75M
previous MI, on amiodarone
Long QT now
Mx?
Stop amiodarone (-> iatrogenic long QT)
73M wt loss and palps for 3m
On Amiodarone
TSH low
total t4 high
Next Ix?
serum free T4 concentration
51M Indian SOB wt loss
CXR calcification on cardiac outline
Cause?
TB ->constrictive pericarditis
tb likely to cause calcification
75M just had stenting inferior MI
persistent low BP
ECG 2nd degree HB, HR 40, SOB
Rx?
temporary pacing wire (so can wait for MI to resolve)
Target BP for anti HTN in pregnancy
135/85
Good clinical indicators for ACS chest pain
typical pain >15 mins
nausea and sweating
75M
AF
had anticoag then cardioverted
Drug most likely to maintain sinus rhythm?
Amiodarone
54M
doxorubicin + trastuzumab fr breast Ca
Signs of HF
Cause?
Dilated cardiomyopathy
Markers worse prognosis HF
high BNP
Anaemia
Hyponatraemia
High uric acid
Pulsus alternans (alternation force of arterial pulse)
is sign of?
severe LV dysfunction
jerky pulse sign of
HOCM
Good marker to detect re-infarction 72h post MI
CK MB
Rx for remission granulomatosis with polyangiitis
Methylprednisolone
Cyclophosphamide
Commonest site VSD
Perimembranous septum
Reversible causes dilated cardiomyopathy
selenium deficiency
Carotid artery stenosis
80% R and 90% L
ASx
Next step in Mx?
D/c and OPT f/up
as ASx
Wide fixed splitting second HS
uncomplicated ASD
17F
Hx of collapses
Echo LV and septal hypertrophy and septum has ground glass appearance
HOCM
2nd degree HB + RBBB
risk of?
complete HB
High cholesterol and triglycerides
Normal ApoB
palmar xanthoma (orange creasis)
xanthomata elbows + knees
Type III hyper lipidaemia (remnant hyperlipidaemia)
occurs abnormal ApoE receptor function - needed to clear chylomicron remnant
Very high triglycerides
N/H cholesterol
Chylomicronaemia
no increase risk atherosclerotic disease
Pelvic artery calcification on XR after NOF fracture
Mx?
Do nothing
when to start nicotinic acid for hyperlipidaemia
statin failing
specialist can add on nicotinic acid
64F
blackouts
ECG complete HB
and p wave asystole (no QRS complexes)
transcutaneous pacing
low frequency mid diastolic murmur
Austin flint murmur
in AR
CI thrombolysis
previous haemorrhagic stroke
GI/ heavy vaginal bleeding
recent stroke or surgery
severe uncontrolled HTN
CPR >half hour
Troponin I and T
levels rise at
peak at
baseline
rise 3-12 hr after pain
peak 24-48 hr
baseline after 5 days
CK MB
levels rise at
peak at
baseline at
rise 3-12 hours
peak at 24 hours
baseline after 3 days
cardiac marker quickest to return to baseline
CK MB
Most sensitive early marker for MI
myoglobin
Commonest cause mitral stenosis
rheumatic HD
CHD, calcification SLE…
73M given cocaine injection for bronchoscopy
ECG shows anterior MI
Rx?
Nitrates (as MOA is vasoconstriction not thrombosis)
amiodarone (MOA) blocks which channels
K channels
