Cardiology Flashcards
What is this murmur?
- crescendo-decrescendo
- early in systole
- Most likely Aortic Stenosis
Atrial Fibrillation
What are the causes?
- 6 cardiac
- 5 respiratory
- 2 endocrine
Cardiac
- hypertension (esp + LVH)
- atherosclerosis/coronary artery disease
- valve disease (esp mitral stenosis)
- congenital heart disease, ASD
- cardiomyopathy (dilated and hypertrophic)
- pericarditis, myocarditis
- cardiac surgery
- atrial myxoma
- sick sinus syndrome
- WPW
Respiratory
- pneumonia
- bronchial Ca
- asthma/COPD
- lung Ca
- PE
- carbon monoxide poisoning
- pleural effusion
- pulmonary hypertension
- pneumothorax
Endocrine/metabolic
- diabetes
- thyrotoxicosis
- alcohol (acute or chronic)
- Idiopathic
- Obesity
- sleep apnoea
- haemochromatosis
- sarcoid
- narcotics
- Genetic: autosomal dominant
Ejection Systolic Murmur
What are the causes?
- narrowed outlet
- aortic stenosis or sclerosis
- pulmonary stenosis
- HOCM
- increased stroke volume (flow murmur)
- pregnancy
- fever
- severe anaemia
- bradycardia (athletes)
- aortic regurgitation (+ EDM)
- Atrial Septal Defect (pulmonary flow murmur)
Atrial Fibrillation
What are the complications?
- Clotting, esp stroke
turbulent flow –> atrial clot –> embolises
- Bowel ischaemia (same mechanism)
Rarer:
- heart failure
- cardiomyopathy
- worsening angina
Aortic Stenosis
What is seen on the chest radiograph?
- valve calcification
- cardiomegaly (LVH)
- dilated descending aorta
Aortic Stenosis
What is seen on the ECG?
- P mitrale (m-shaped P wave = bulky L atrium)
- LVH + left strain pattern
- LBBB
- complete AV block
Atrial Fibrillation
Rate Control
- slow heart rate to ensure adequate filling
- rhythm remains abnormal
- anti-coagulate to avoid thromboemobolism
1st line = BB or rate-limiting CCB
- atenolol
- propranolol
- verapamil
- diltiazem
Target: 90bpm resting
Aortic Stenosis
European Society of Cardiology Classification
Signs of Aortic Stenosis
- slow rising pulse
- narrow pulse pressure
- LV and apical heave (non-displaced)
- LV pressure overload –> LV hypertrophy
- aortic thrill
- ejection systolic murmur
- harsh, high-pitched, musical
- crescendo-decrescendo
- aortic area radiating to carotids
- normal S1
- quiet S2 +/- reverse splitting (softens as stenosis worsens)
- +/- ejection click
- +/- S4
contracting ventricle gradually pushes blood over stiff valve then relaxes
Symptoms of Aortic Stenosis
(HAS 4 Ds)
Triad of exertional:
- dyspnoea (heart failure)
- angina
- syncope
Plus:
- dyspnoea
- dizziness
- death (sudden)
- distant emboli (if due to endocarditis)
What is this murmur?
- murmur throughout diastole
- loudest in the early phase (EDM)
- associated systolic flow murmur (due to increased stroke volume because blood is recycled)
- most likely to be Aortic Regurgitation
What is this murmur?
- murmur throughout systole
- (loud and blowing character)
- covering both heart sounds
- most likely to be Mitral Regurgitation
What is this murmur?
- murmur starts mid-diastole
- (low-pitched, rumbling)
- pre-systolic extenuation
- may start with opening snap
- covers S2
- most likely to be Mitral Stenosis
What is an Austin Flint murmur?
- mid-diastolic murmur
- accompanies aortic regurgitation (EDM)
- regurgitant jet of blood hits anterior leaflet of mitral valve as it descends
Causes of a Pansystolic Murmur
- mitral regurgitation
- tricuspid regurgitation
- VSD (including post-MI septal rupture)
Grades of Murmur
(1 - 6)
- heard by an expert in optimum conditions
- heard by a non-expert in optimum conditions
- easily heard
- with thrill
- heard over a wide area with thrill
- heard without stethoscope
Cardiac Enzymes
- time to peak
- amount increase
- time to normalising
Myoglobin - earliest rise, doubles, normalises within 24h
CK-MB - peaks at 24h, quadruples, normalises on day 5
Cardiac Troponin - peaks at 12h, rises 50x, normalises on day 7
- 12h troponin is sensitive and specific
- I is better than T
Out-dated enzymes:
- AST - d1 - 2
- LDH - d2
- CK
Diagnosis of Acute MI
- Troponin or CK-MB rise
- Ischaemic symptoms
- ECG ischaemia - ST depression, elevation or pathological Q waves
- Coronary artery intervention
Diagnosis of STEMI
- ST elevation > 2 small squares in chest leads (V1 - V3)
- ST elevation > 1 small square anywhere else
- new LBBB
- (posterior MI appearance)
Diagnosis of NSTEMI
- ST depression > 1/2 small square
- symmetrical T wave inversion > 2 small squares
- normal ECG BUT raised 12h troponin
Causes of a raised troponin
- myocardial necrosis -
- MI
- myocarditis
- arrhythmia
- right ventricular strain during PE
- sepsis
- subarachnoid (NB. these occasionally also cause chest pain! Consider if the patient is vomiting)
Heart Failure
Chest XR Findings
- cardiomegaly
- pulmonary oedema
- kerley B lines
- upper lobe diversion
- pleural effusion
Heart Failure
New York Heart Association Classification
- no symptoms, even during physical activity
- slight limitation of physical activity
- mild exertion causes symptoms
- symptoms at rest, unable to exert at all
Heart Failure
Ejection Fraction Cut-offs
- over 55% = normal (up to 70%)
- 40 - 55% = reduced
- < 40% = heart failure
- < 35% = risk of arrhythmias and death - ICD recommended
NB. EF may be normal in diastolic failure
What is S1?
- closure of mitral and tricuspid (atroventricular) valves
- start of ventricular systole
- may have normal inspiratory splitting
What is S2?
- closure of the aortic and pulmonary (semilunar) valves
- normal splitting = A before P on inspiration, no split on expiration
Causes of a quiet S2
- quiet A2
- aortic stenosis
- aortic regurgitation
- quiet P2
- pulmonary stenosis
Causes of a loud S2
- loud A2
- hypertension
- tachycardia
- loud P2
- pulmonary hypertension
Fixed Splitting of S2
- ASD
pressure eualises between the two atria –> AV valves close together
Increased (Wide) Splitting of S2
- RH contraction delayed = RBBB
- RH volume overloaded = VSD
- RH trying to empty against ++ resistance
- pulmonary hypertension
- pulmonary stenosis
- mitral regurgitation
emptying of the R heart is delayed –> P2 delayed further after A2 than normal –> increased split
Reverse Splitting of S2
- LH contraction delayed = LBBB
- LH trying to overcome ++ resistance
- left outflow obstruction and aortic stenosis
- PDA
- RV pacing
left heart emptying delayed –> A2 delayed –> moves after P2
What is S3?
rapid early filling of ventricles –> sound of blood bouncing of walls
Kentucky
low pitched sound
early diastole
- physiological
- young (< 30y)
- athletes
- pregnancy
- fever
- rapid filling
- mitral regurgitation
- VSD
- insufficient emptying (heart failure) (+ soft S1 and S2 and tachycardia)
- post-MI
- dilated cardiomyopathy
- pericarditis
Aortic Stenosis
Causes
- degenerative (calcification)
- > 60y or > 40y if underlying bicuspid valve
- congenital
- bicuspid valve
- subaortic membrane
- William’s syndrome = supravalvular aortic stenosis
- rheumatic
- subvalvular narrowing (HOCM)
ECG features of hypokalaemia
- U waves
- small/absent T waves (sometimes inverted)
- prolonged PR interval
- ST depression
- long QT
In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
Causes of long QT
Congenital
- Jervell-Lange-Nielsen syndrome (deafness, abnormal K channel)
- Romano-Ward (no deafness)
Drugs
- amiodarone
- stoalol
- class 1a anti-arrythmics
- tricyclic ADs
- fluoxetine
- chloroquine
- terfenadine
- erythromycin
Other
- electrolytes
- low Ca
- low K
- low Mg
- acute MI, myocarditis
- hypothermia
- subarachnoid
Contrainidications to Warfarin
- bleeding disorders
- hypertension (+ Warfarin = brain haemorrhage)
- adherence
- falls history
Can use aspirin 300mg
Causes of a loud S1
- mitral stenosis (valve not closing much)
- with tapping apex beat
- short filling time (SVT)
Causes of a soft S1
- prolonged filling
- long PR interval
- mitral regurgitation
Single S2
- tetralogy of Fallot
- severe AS and PS
- large VSD
- hypertension
What is a pericardial knock?
high pitched sound
early diastole
- restrictive pericarditis
- cardiomyopathy
What is S4?
atrial contraction against a stiff valve or hypertrophic ventricle
Tennessee
before S1
bell at apex
- ventricular hypertrophy
- hypertension
- aortic stenosis
- ventricular fibrosis
- MI
Thrombolysis
Contraindications
- already bleeding problem
- internal or heavy PV bleeding
- haemorrhagic stroke
- recent trauma or surgery
- vulnerable vessels
- aortic dissection
- oesophageal varcies
- BP > 200/120
- acute pancreatitis
- liver disease
- lung pathology with cavitation
- allergy
- cerebral cancer
Aortic Regurgitation
Causes
- aortic root dilation
- syphilitic aortitis
- aortic dissection
- rheumatic fever
- bicuspid
- calcification
- endocarditis
Associated with Ankylosing Spondylitis & Marfan’s
Aortic Regurgitation
Signs
when the ventricle relaxes, the pressure is higher in the aorta so blood falls back in through the incompetent valve - large changes in carotids –> bobbing, collapsing
- collapsing pulse
- hyperdynamic apex beat
- laterally displaced
- L volume overload –> dilation
- low diastolic BP –> wide pulse pressure
- Corrigan’s carotid pulsations
- de Musset’s head bob
- Quinke’s nail pulsations
- Traube’s pistol shot femorals
- Duroziez’s femoral murmurs
- early diastolic decrescendo murmur
- mid-diastolic rumble = Austin-Flint murmur
What is an Austin-Flint murmur?
regurgitant blood hitting the anterior leaflet of the mitral valve
causes a mid-diastolic murmur
Pan-Systolic Murmur
Causes
- Mitral regurgitation - apex radiating to axilla, blowing
- Tricuspid regurgitation - lower L sternum, pulsatile liver, v wave in JVP
- VSD - loud, L sternal border radiating to R, thrill
- harsh = ruptured septum post-MI
Mitral Stenosis
Causes
- malar flush
- heart failure - JVP, oedema
- atrial fibrillation
- tapping apex beat
- low rumbling mid-diastolic murmur (as filling passes stiff valve)
- accentuated by exercise
- pre-systolic extenuation
- opening snap (after S1) = stiff valve opening
- loud S1 (elevated LA pressure and stiff valve closing)
left atrial pressure overload –> left atrial dilation and pulmonary hypertension, left atrial thrombus
Causes pulmonary hypertension
- R ventricular heave
- pulmonary haemosiderosis (iron deposits, visible on chest xray)
Mitral Regurgitation
Signs
- displaced, diffuse apex beat
- irregularly irregular pulse
- congestion
- raised JVP
- parasternal heave (R)
- loud pansystolic murmur radiating to axilla
- radiates up the left sternum (outflow tract)
- loud, blowing
- soft S1
- S2 hidden in PSM
- S3
high pressure in ventricle and aorta pushes blood back over incompetent mitral valve
heart failure
Left Axis Deviation
Causes
increase left ventricular mass
- hypertension
- aortic stenosis
- ischaemic heart disease
- intraventricular conduction defect
- inferior MI
- WPW
Right Axis Deviation
Causes
Jervell & Lange-Nielsen Syndrome
- autosomal recessive congenital heart disease
- long QT
- sensorineural deafness
less than 10% long QT cases
Lenegre-Lev Syndrome
Lev’s disease
- fibrosis and calcification of electrical tissue –> complete heart block
?senile degeneration
can –> Stokes-Adams attacks
Romano-Ward Syndrome
- autosomal dominant long QT syndrome
- normal hearing
Stokes-Adams Attack
- pale, skip a beat –> collapse
- 30s syncope +/- 20s seizure
- recovery –> flushing
non-positional due to decreased cardiac output after a short period of asystole
Sick Sinus Syndrome
- slowed firing in SAN or sinoatrial block
- (may have AVN escape beats)
- usually due to SAN fibrosis
Managed with pacemaker
Sinus Bradycardia
Causes
- Cadiac
- disease of the sinoatrial node: ischaemia, infarct, degeneration, fibrosis, vagal stimulation, myocarditis
- IHD (60% people have SAN supplied by RCA)
- anti-arrhythmis drugs
- raised intracranial pressure
- hypoxia
- hypothermia
- underactive thyroid
- sepsis
- cervical or mediastinal tumours
Long QT
Causes
- Congenital
- Jervell & Lange-Nielsen
- Romano-Ward
- Electrolytes
- low K
- low Mg
- low Ca
- Drugs
- IA
- III
- tricyclics
- phenothiazines (chlopromazine)
- terfenadine
- CNS disease
- Organophosphates
- Mitral valve prolapse
- Acute MI
Atrial Flutter
Causes
Pacemaker Syndrome
- single chamber RV pacemaker
- retrograde conduction into the atrium
- causes cannon waves, high pulmonary arterial pressure and decreased cardiac output
management: replace with a dual chamber device
Mitral Stenosis
Causes
- rheumatic
- congenital
- severe calcification
Mitral Regurgitation
Causes
- rheumatic
- degeneration, calcification
- ischaemia, infarct
- prolapse
Endocarditis
Signs
- fever
- new murmur
- 1/3 if right-sided
- commonest is AR
- petechiae: conjuntiva, hands and feet, chest and abdo, oral mucosa and soft palate
- splinter haemorrhages
- osler’s nodes (nodules in digital pulps)
- clubbing
- Roth’s spots - retinal haemorrhaes with pale centres
- Janeway’s lesions (irregular macules)
- arthritis (asymmetric, sterile fluid or septic monoarthritis)
- splenomegaly
- meningism/itis
Rheumatic Fever
Diagnosis
Jones Criteria
- evidence of recent strep (scarlet fever, throat swab, ASOT, DNAase B titre)
+ 1 major or 2 minor
MAJOR
- arthritis - migratory, large joint, ++inflammed
- carditis - affecting the whole heart and sometimes the valves, tachycardia beyond what is expected for the temperature
- AR
- pericardial rub
- mitral valve most affected
- Carey Coombs murmur - diastolic filling
- Austin Flint
- Sydenham’s chorea (St Vitus’ Dance)
- Paediatric Autoimmune Neuropsychiatric Disorder Associated with Strep (PANDAS)
- Subcutaneous nodules - firm, painless, over extensor surfaces
- Aschoff bodies found in heart
- Erythema marginatum (annulare)
MINOR
- fever
- raised ESR and CRP
- arthralgia
- prolonged PR interval
Right-Sided Endocarditis
Staph aureus often infects right side because it is more virulent and can infect healthy valves
– needs an entry port therefore seen in IVDU
– needs urgent valve surgery as antibiotics won’t be fast enough
Strep viridans only infects damaged valves so tends to affect left sided valves in the elderly
What is the management of complete heart block?
- Basic resus
- Pacing
- pacing wire
- temporary external pacemaker
- because 3rd degree heart block reflects dysfunction of the AV node so it won’t respond to atropine. If ischaemic (post-MI), the node may recover.
Complications of an MI
- Re-infarct or extension of infarct
- Arrhythmia - especially VF
- Heart failure
- mitral regurg
- Embolism
- stroke
- PE
- Rupture, aneurysmal dilation
- Pericarditis
- early (day after, common)
- later (6 weeks, Dresslers’)
Pericarditis
Positional chest pain, imrpvoes sitting forward
Managed with NSAIDs
Early - common occurence the day after full thickness infarct
Late = Dressler’s syndrome - immune response 6 weeks after MI
Heart Failure
Signs
- Tachycardia
- S3
- Tachypnoea
- Cardiac asthma, wheeze
- Bilateral creps
- Raised JVP
- Peripheral oedema
… in approx order of onset
When venous pressure is higher than oncotic pressure –> flash pulmonary oedema
Acute Pulmonary Oedema
Management
- sit up
- high flow oxygen
- 40mg frusemide (vasodilation –> sudden relief)
- ACEi for remodelling and blocking fluid retention
Cardiogenic Shock
Definition
insufficient cardiac output to meet the circulatory demands of the body to the extent that the myocardium and brain and not perfused
Subendocardial MI
- infarct in the wall, septum or papillary muscles but not full thickness
- common after blood loss in surgery
- ST depression on ECG
- new T wave inversion likely
- abnormal cardiac enzymes
- risk of arrhythmia
Aortic Stenosis
Velocity Cut-offs
European Society of Cardiology
mild < 3 m/s
moderate 3 - 4
severe > 4m/s
Aortic Stenosis
Area Cut-offs
European Society of Cardiology
mild > 1.5 cm2
moderate 1 - 1.5 cm2
severe < 1 cm2
Aortic Stenosis
Gradient Cut-offs
European Society of Cardiology
mild < 30 mmHg
moderate 30 - 50 mmHg
severe > 50mmHg
