Cardiology Flashcards
Ejection systolic murmur
- louder of expiration (2)
- louder on inspiration (2)
- also (1)
louder on expiration - aortic stenosis - hocm louder on inspiration - pulmonary stenosis - atrial septal defect also: tetralogy of Fallot
Pansystolic/holosystolic
- louder on inspiration (1)
- louder on expiration (1)
- also (1)
mitral/tricuspid regurgitation
- (high-pitched and ‘blowing’ in character)
- tricuspid regurgitation becomes louder during inspiration unlike mitral stenosis
during inspiration, the venous blood flow into the right atrium and ventricle are increased → increases the stroke volume of the right ventricle during systole
ventricular septal defect (‘harsh’ in character)
Late systolic murmur (2)
mitral valve prolapse
coarctation of aorta
Early diastolic murmur (2)
aortic regurgitation (high-pitched and ‘blowing’ in character)
Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)
Mid to late diastolic (2)
Mid-late diastolic
mitral stenosis ('rumbling' in character)
Austin-Flint murmur (severe aortic regurgitation, again is 'rumbling' in character)Continuous machinery like murmur
Continuous machine-like murmur
patent ductus arteriosus
Congenital heart disease
Acyanotic - most common types
1. Most common
& 4 others
Acyanotic - most common causes ventricular septal defects (VSD) - most common, accounts for 30% atrial septal defect (ASD) patent ductus arteriosus (PDA) coarctation of the aorta aortic valve stenosis
Cyanotic CHD
- most common & when does it present
- which is most common at birth
Cyanotic - most common causes
tetralogy of Fallot
transposition of the great arteries (TGA)
tricuspid atresia
Fallot’s is more common than TGA. However, at birth TGA is the more common lesion as patients with Fallot’s generally presenting at around 1-2 months
pharm cardiovert of af - 2 options
Cardiovert AF: amiodarone or flecainide
- Amiodarone if structural heart disease
rate control of AF
1st line
2nd line
1: B-blocker or rate limiting CCB (EG diltiazem)
2: If 1 doesn’t adequately control rate: combo with any 2 of - b-blocker, diltiazem and digoxin
what do you use to calculate risk of stroke?
can you write it out and say when to give anticoag (what score
CHA2DS2-VaS Congestive heart failure 1 Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke, TIA or thromboembolism 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female) 1
SCORES:
0 No treatment
1 Males: Consider anticoagulation. Females: No treatment (this is because their score of 1 is only reached due to their gender)
2 or more Offer anticoagulation
can you give verapamil and b-blockers together?
why?
NEVER
can cause bradycardia, heart block and fatal arrest or congestive cardiac failure
normal heart anatomy?
what does s1 and s2 represent
svc > RA > TV > RV > PV > pulm arteries
pulm veins > LA > MV > LV > AV > aorta
s1: M and T valves shut
S2: P and A valves shut
which murmurs are accentuated with inspiration? and which with expiration?
right sided murmurs: inspiration
rIght = Insp
bcos venous return to heart is increased
left sided: expiration
what is diastole?
whats systole?
D: ventricles relaxed and filling with blood
S ventricles contracting
aortic stenosis
- murmur
- pulse/pulse pressure?
- what heart sounds can you get?
- presentation?
- causes
ESM radiating to carotids (crescendo-descresendo)
Narrow pulse pressure, slow rising pulse
Can get a soft/absent S2, a reversed split S2 and an S4
presents: SOB, syncope, chest pain
causes: calcification >65, bicuspid <65, williams syn, rheumatic fever, HOCM
aortic regurg
- Early diastolic murmur
- Collapsing pulse, wide pulse pressure, nailbed pulsation + head bobbing
- Causes: aortic root dilation (dissection, HTN, syphilis, marfans, ehler-danlos), valve disease (rheumatic fever, IE, CTDs, bicuspid valve)
mitral stenosis
• Mid-late diastolic murmur (rumbling)
• Best heard in expiration & at apex w pt in left lat position
• Essentially need to rule out rheumatic fever (main cause)
• Loud S1, opening snap; low volume pulse
Malar flush
mitral regurg
Pansystolic blowing murmur- best heard at apex, radiates to axilla.
S1 may be quiet as a result of incomplete closure of the valve. Severe MR may cause a widely split S2
ECG may show a broad P wave, indicative of atrial enlargement
Causes: Post-MI, MV prolapse, IE, rheumatic fever, Congenital
cyanotic CHD which way is the shunt? why?
R to L shunt
blood is skipping the lungs so not getting oxygenated
acyanotic CHD (5)
• VSD 30% • ASD • PDA • Coarctation of aorta • AS NB in adults, ASD more common new diagnosis as usually present later
cyanotic CHD (3)
Tetralogy of fallot
Transposition of great arteries
Tricuspid atresia
hypertension mx
<55y old or type 2 diabetes
1. A (ACEi or ARB) 2. Add in C or D: A+C or A+D (d=thiazide-like diuretics)
55 or older with no T2DM or black african/afro-caribbean
1. CCB 2. Add in A or D: C+A or C+D (if black: consider ARB in pref to ACEi)
Step 3: A+C+D
Step 4 =resistant - 1st confirm high clinic BP with ABPM or HBPM. Check for postural hypotension. Discuss adherence. - Seek advice or start 4th drug ○ K<4.5: low dose spironolactone K >4.5: a or b-blocker
hypertension stages and tx targets
STAGES
1. Clinic >= 140/90
and then ABPM daytime av or HBPM average BP >= 135/85 mmHg
- Clinic BP >= 160/100
And ABPM/HBPM av BP >= 150/95 mmHg
Severe:Clinic systolic BP >= 180, or diastolic BP >= 110
TREATMENT TARGETS
<80y old: Clinic BP 140/90 mm; ABPM/HBPM 135/85 mmHg
Age > 80 years 150/90 mmHg 145/85 mmHg
when to treat htn
Clinic reading 140/90 or higher»_space; ABPM or HBPM
- 135/85 or higher: tx if <80 and any of:
○ Target organ damage
○ Established CV disease
○ Renal disease
○ Diabetes
○ 10y CV risk of 10% or higher
○ NB *consider tx if <60 and 10y risk <10%
If 150/95 or higher»_space; treat
ecg changes - which artery
ECG; Coronary artery
Anterior: V1-V4 Left anterior descending
Inferior II, III, aVF Right coronary
Lateral I, V5-6 Left circumflex
angina tx
All: aspirin + statin + sublingual GTN
1. B-blocker or CCB (verapamil or diltiazem)
a. Increase to max tol dose
2. B-blocker + CCB (if together then CCB needs to be nifedipine)
Alt: if on B or C and can’t tolerate B+C, can add in:
- Long-acting nitrate
- Ivabradine
- Nicorandil
- Ranolazine
If on B+C, only add 3rd drug whilst a/w PCI or CABG
causes of long QT
Drugs
A – AntiArrhythmics (Amiodarone, Sotalol, Flecainide)
A – AntiAnginals (Ranolazine)
B – AntiBiotics (Fluoroquinolones, Macrolides, Aminoglycosides)
C – AntiCychotics (Haloperidol, Quetiapine, Risperidone)
D – AntiDepressants (SSRIs, TCAs)
D – Diuretics
E – AntiEmetics (Ondansetron)
- antiarrhythmics: amiodarone, sotalol, class 1a antiarrhythmic drugs
- TCAs
- Antipsychotics: haloperidol
- chloroquine
- terfenadine
- Erythromycin, clarithromycin
- Methadone
Electrolytes
- Low calcium - Low `K - Low Mg
Medical problems
- Hypothermia - Myocarditis - SAH - MI/sig active myocardial ischaemic
Congenital
- Jervell-Lange-Nielsen syndrome - Romano-Ward syndrome
HF tx
1: ACEi + b-blocker
- Start one at a time
- B-blocker options: bisoprolol, carvedilol, and nebivolol.
- NB these drugs have NO effect on mortality if there is preserved ejection fraction
2nd line: aldosterone antagonist (mineralocorticoid rec antag)
- Spironolactone and eplerenone - Monitor K (as these drugs + ACEi cause hyperkalaemia)
3rd line: specialist should choose
Other • Annual influenza vaccine • One off pneumococcal vaccine ○ Usually need just one dose ○ but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
