Cardiology Flashcards
What is the pathophysiology of Acute Coronary Syndrome? (4)
It is the accumulation of Low Density Lipoproteins
Leukocytes attach onto the vascular endothelium and gain entry into the intima where they form Foam Cells
The remodelling of arteries and calcification, with Foam Cells causes Atherosclerotic Plaques
Plaque Rupture causes Platelet Activation and Occlusion
What are the 2 types of Myocardial Infarction and what causes them?
Type 1 Myocardial Infarction- due to an Atheromatous Plaque Rupture
Type 2 Myocardial Infarction- which occurs secondary to Ischaemia due to an Increase in Oxygen Demand or Decrease in Oxygen Supply due to (3)-
- Anaemia
- Sepsis
- Vasospasm
(In Type 2, you would treat the underlying cause as well)
What kind of Murmur is typically heard in Myocardial Infarction?
A Systolic Murmur- Mitral Regurgitation or Ventricular-Septal Defect
What are the symptoms of Acute Coronary Syndrome? (4)
Sweating
Anxiety
Nausea/ Vomiting
Central Chest pain which may radiate to the Left Arm and Neck
What 5 investigations should be ordered if Acute Coronary Syndrome is suspected?
Coronary Angiogram- Diagnostic
Perform ECG within 10 minutes
Measure Troponin levels- elevated in STEMI and NSTEMI but not in Unstable Angina
Perform a CXR if needed, to eliminate other potential causes
Work out their GRACE Score
What is the management for Unstable Angina/ NSTEMI? (5)
MONA B
- Morphine
- Oxygen (if<94%)
- Nitrates
- Aspirin
- Beta Blockers
DAPT (2)-
- Aspirin and Clopidogrel
- Aspirin and Prasugrel if Patient is gonna have PCI
Anticoagulation (2)-
- Unfractionated Heparin- if Coronary Angiography is planned or if Creatinine>265
- Fondaparinux- otherwise
If their GRACE Score is 89 or above AND they have an Unstable Angina or NSTEMI, then offer Immediate Angiogram and PCI
PCI should be performed within 120 minutes of Symptom Onset, otherwise offer Thrombolysis with (3) Alteplase, Tenecteplase and Streptokinase and offer Low-Molecular Weight Heparin unless (5)
- Haemorrhage
- Stroke, Head Trauma, Neurosurgery within the last 3 months
- Internal Bleeding
- Endocarditis
- Aortic Dissection
What is the management for STEMI? (5)
(Same as Unstable Angina/ NSTEMI but give Bivalirudin with Aspirin and not Prasugrel with Aspirin if a PCI is being performed)
MONA B
- Morphine
- Oxygen (if<94%)
- Nitrates
- Aspirin
- Beta Blockers
DAPT (2)-
- Aspirin and Clopidogrel
- Aspirin and Bivalirudin if Patient is gonna have PCI
Anticoagulation (2)-
- Unfractionated Heparin- if Coronary Angiography is planned or if Creatinine>265
- Fondaparinux- otherwise
If their GRACE Score is 89 or above AND they have an Unstable Angina or NSTEMI, then offer Immediate Angiogram and PCI
PCI should be performed within 120 minutes of Symptom Onset, otherwise offer Thrombolysis with (3) Alteplase, Tenecteplase and Streptokinase and offer Low-Molecular Weight Heparin unless (5)
- Haemorrhage
- Stroke, Head Trauma, Neurosurgery within the last 3 months
- Internal Bleeding
- Endocarditis
- Aortic Dissection
What are the 6 early complications and 2 late complications (after 2 weeks) of Acute Coronary Syndrome?
Early-
- Post MI Pericarditis
- Cardiac Arrest, most likely due to Ventricular Fibrillation
- Bradyarrhythmias- Heart Block is common after Inferior MI
- Cardiogenic Shock
- Ventricular Septal Defect/ Mitral Regurgitation
- Left Ventricular Wall Rupture- Ischaemia leads to a weakened ventricular wall and rupture which presents as a Cardiac Tamponade and Acute Heart Failure
Late Complications-
- Dressler’s Syndrome (An Autoimmune version of Pericarditis)
- Left Ventricular Aneurysm
What are the 2 common causes of Acute Decompensated Heart Failure?
Coronary Artery Disease
Hypertension
What is the pathophysiology of Acute Decompensated Heart Failure? (5)
The reduced cardiac output activates the Sympathetic Nervous System
This results in Tachycardia and an increased Myocardial Contractility, Peripheral Vasoconstriction and RAAS Activation- Salt and Water retention
Heart Failure patients are Hypovolaemic do BNP is released by Ventricular Myocytes due to stretch
This leads to Pulmonary and Venous Congestion
This leads to a Pulmonary Oedema (look out for shortness of breath)
This can also lead to a Peripheral Oedema due to Venous Congestion
What are the 6 signs of Acute Decompensated Heart Failure? What are the 3 signs of Congestive Heart Failure?
Coarse Bibasal Crackles
S3 heard
Stony Dull Percussion if Effusion is present
Dyspnoea due to Pulmonary Oedema (patient often has a history of Orthopnoea and Paroxysmal Nocturnal Dyspnoea)
Cardiogenic Wheeze
A reduced Left Ventricular Ejection Fraction (<40%)
Congestive Heart Failure (3)
- Pitting Oedema
- Peripheral Oedema
- Raised JVP
What is the 5 step management for Heart Failure? (3 for immediate and 2 for long-term)
- Oxygen if <94%
- Fluid Restriction
- An IV Diuretic- Loop Diuretic usually- like Furosemide
Long Term Treatment-
- ACE Inhibitor and Beta Blocker (Ramipril and Bisoprolol)- if Left Ventricular Ejection Fraction< 40%
- Loop Diuretic for Symptomatic Treatment of Oedema)
What is the pathophysiology of Pericarditis?
The pericardium is innervated by the Phrenic Nerve
It is the Inflammation of the Pericardium commonly caused by the COXSACKIE VIRUS
It may produce a Pericardial Effusion which develops into Cardiac Tamponade
What are the 5 other causes of Pericarditis? Aside from Coxsackievirus
TB
Systemic Autoimmune Diseases
Uraemia- secondary to Kidney Disease
Post-MI
Hypothyroidism
Where is the Pericardial Rub (sign of Pericarditis) heard?
It is heard at the Left Sternal Edge when the patient leans forward. It is High-pitched and Squeaky
What are the 4 symptoms of Pericarditis?
A sharp central chest pain which gets worse when the patient breathes in or lies down
Fever may also be present
Tachypnoea and Tachycardia
A Peripheral Oedema suggests a Right Sided Heart Failure secondary to Pericarditis
What 3 investigations should be ordered if Pericarditis is suspected?
Urea- High Urea suggests a Uraemic Cause
Transthoracic Echocardiogram and CXR to exclude Pericardial Effusion/ Cardiac Tamponade
ECG- PR Depression and ST Elevation
What is the management of Idiopathic/ Viral (2) Pericarditis and Bacterial (1) Pericarditis?
Idiopathic/ Viral Pericarditis
- NSAIDs and Colchicine
- NSAIDs, Colchicine and a low dose Prednisolone
Bacterial Pericarditis
- IV Antibiotics and Pericardiocentesis
Look out for evidence of Cardiac Tamponade (a Raised JVP/ Hypotension)- Perform Pericardiocentesis if suspected
What infection would make Constrictive Pericarditis likely?
TB
What is the pathophysiology of Angina Pectoris?
It is an imbalance in the Oxygen Supply and Demand which leads to Ischaemia
The Monocytes scavenge lipid deposits and transform into Foam Cells
Cytokines are released by Foam Cells which promotes SMC migration into the Intima from the Arteria Media
Could also be Non-Atheromatous due to Coronary Artery Vasospasm (Prinzmetal’s Angina)
What are the 7 signs of Angina Pectoris?
Central chest pain caused on exertion
Dyspnoea
Nausea
Sweating
S3 Heart Sound
Carotid Bruit/ Expansile Abdominal Aorta- suggests Peripheral Vascular Disease which increases the likelihood of Coronary Atherosclerosis
Hypertension
Xanthomata/ Xanthelasma- Hypercholesterolaemia
What investigations should be ordered in Angina Pectoris is suspected?
ECG
What is the management for Angina Pectoris?
GTN Spray for Symptomatic Relief
Antianginal Medication-
- Betablocker or non-dihydro Calcium channel blocker
- Betablocker and dihydro Calcium channel blocker
- Nitrates- patient can grow tolerant
Revascularisation-
- Percutaneous Intervention
- Coronary Artery Bypass Graft
What type of Tachycardia is Atrial Fibrillation?
Supraventricular Tachycardia
What are the causes of Atrial Fibrillation?
PIRATES
Pulmonary (PE and COPD)
Ischaemic Heart Disease- Including heart failure
Rheumatic Heart Disease- any valvular abnormality
Anaemia/ Alcohol/ Advancing Age
Thyroid Disease (Hyperthyroidism)
Electrolyte Disturbance- Hypo/Hyperkalaemia and Hypomagnesaemia
Sepsis and Sleep apnoea
What are the 4 red flag symptoms associated with Atrial Fibrillation and should be looked into further if present in AF?
Chest Pain
Syncope
Hypotension- suggests haemodynamic instability
Evidence of Heart Failure- Pulmonary Oedema
What 5 investigations should be ordered if Atrial Fibrillation is suspected?
ECG
TFTs- to check for Hyperthyroidism
Troponin- if MI is suspected
Transthoracic Echocardiogram- if an underlying Structural or Functional Heart Disease is suspected
What 4 Adverse Effects would suggest DC Cardioversion is needed in Atrial Fibrillation or Bradycardia?
Shock- Hypotension, Pallor, Sweating, Cold Clammy Extremities, Confusion or Impaired Consciousness
Syncope- Transient Loss of Consciousness
MI- Typical Ischaemic Chest pain or Evidence of MI on ECG
Heart Failure- if Pulmonary Oedema or Raised JVP
What is the management of Atrial Fibrillation?
If adverse effects are present- DC Cardioversion then Rhythm Control
Rate Control (3)
- Beta Blocker or Calcium Channel Blocker (same as first line for Angina)
- Add Digoxin if there is Atrial Fibrillation and Heart Failure
- Add Digoxin to either Bisoprolol or Diltiazem
Rhythm Control (2)
- Flecainide or Amiodarone (if there is no evidence of an Ischaemic or Structural Heart Disease)
- Otherwise Amiodarone
For Anticoagulation (3)
- DOAC
- Warfarin
- Heparin
What Heart Rate defines Bradycardia?
A Heart Rate lower than 50bpm
What is a Heart Block?
It is a disrupted passage of electrical impulse through the AV Node
What is a First Degree Heart Block?
It consists of a Prolonged PR Interval with No Missed Beats
What is a Second Degree Mobitz 1 Heart Block?
The PR Interval becomes longer and longer until a QRS Complex is missed, the pattern then resets
This is known as the Wenckebach Phenomenon
What is a Second Degree Mobitz 2 Heart Block?
Prolonged PR Intervals with thee QRS Complex becoming regularly missed
What are the 5 causes of First and Second Degree Heart Blocks?
Physical Fitness Drugs (Digoxin and Beta Blockers) Sick Sinus Syndrome Acute Myocarditis Ischaemic Heart Disease (especially Inferior Myocardial Infarction)
What is a Third Degree (Complete) Heart Block?
No impulses are passed from the atria to the ventricles so the P waves and QRS complexes are independent of each other
The Tissues distal to the AVN paces slowly as a result and the patient becomes Bradycardic
What are the 7 causes of a Complete Heart Block?
Idiopathic (Fibrosis) Congenital Aortic Valve Calcification Cardiac Surgery/ Trauma Ischaemic Heart Disease Digoxin Toxicity Infiltration (Abscess, Granulomas, Tumours, Parasites)
What are the 4 risk factors for Bradycardia?
Infections
Hypothyroidism
Hypo/Hyperkalaemia, Hypo/Hypercalcaemia
Hypothermia
What is the Cushing’s Triad for a Raised ICP?
Bradycardia
Hypertension
Irregular Respiration (Apnoea)
What are the Cannon A Waves seen in the JVP?
They are a sign of Complete Heart Block due to atrial contraction against a closed Tricuspid Valve
What 5 investigations should be ordered in a patient with Bradycardia?
ECG
TFTs- to check for Hypothyroidism
U and Es and metabolic panel- to check for Electrolyte Changes
Serum Digoxin Levels- check in patients who take Digoxin
ECHO- if LVEF<30 give them a Pacemaker
What is the management for Bradycardia? (4)
Atropine
Adrenaline, Isoprenaline and Aminophylline if Atropine does not work or if the patient has Heart Block
What 14 things can cause an Increased BNP level? (6 Cardiac Causes, 3 Respiratory Causes, 5 other causes)
Left Ventricular Hypertrophy Right Ventricular Overload Diastolic Dysfunction Atrial Fibrillation Acute Coronary Syndrome Valvular Heart Disease
Acute Pulmonary Embolism
Pulmonary Hypertension
COPD with Cor Pulmonale
Hyperthyroidism (causes Atrial Fibrillation)
Sepsis
Acute or Chronic Kidney Injury
Diabetes
Age>70
What can cause a Decreased BNP level?
Cardiac Drugs
What is the pathophysiology of a Cardiac Tamponade?
There is a reduction in the cardiac output due to a Raised Intrapericardial Pressure, secondary to Pericardial Effusion
It squeezes the heart chambers and reduces the Stroke Volume and Cardiac Output
What are the 6 causes of a Cardiac Tamponade?
Pericarditis (due to Infectious/ Uraemic reasons) Surgery Malignancy Trauma Aortic Dissection SLE/ Rheumatoid Arthritis
What are the 9 signs of a Cardiac Tamponade?
Dyspnoea
Chest Discomfort
Tachycardia
Peripheral Oedema (Heart Failure)
Pulsus Paradoxus (Systolic Blood Pressure reduced by over 10mmHg upon Inspiration)
Confusion due to a Decreased CNS Perfusion
Prolonged Capillary Refill Time
Cool Peripheries
Beck’s Triad (3)
- Hypotension
- Raised JVP
- Muffled Heart Sounds
What does the ECG look like for a Cardiac Tamponade?
There are alterations in the Amplitude of the QRS Complex
What 5 investigations should be ordered if Cardiac Tamponade is suspected?
Transthoracic Echocardiogram
ECG
Inflammatory Markers- suggest Pericarditis is the cause
Troponin- suggests MI is the cause
CXR- raised Cardiac Silhouette
What is the management of Cardiac Tamponade?
Pericardial Effusion with No Evidence of Tamponade-
- NSAIDs or Colchicine if the suspected Underlying Cause is Pericarditis
Pericardial Effusion with Evidence of Tamponade
- Pericardiocentesis
- Surgical Drainage if Blood or Pus is present
What are the 2 main complications of Cardiac Tamponade?
Cardiac Arrest (increased Intrapericardial Pressure may lead to a significantly reduced Cardiac Output and Cardiac Arrest)
Constrictive Pericarditis- which is likely in Tuberculosis
What is the pathophysiology of Congestive Heart Failure?
In normal physiology, an increased ventricular filling would result in an increased contraction and increased cardiac output
This mechanism fails in Congestive Heart Failure and compensatory mechanisms are activated- including an Increased Heart Rate, Catecholamine Release and activation of the RAAS. When these compensatory mechanisms are overexpressed, it can lead to a VICIOUS CYCLE
As both the Right and Left Hearts are affected, both Pulmonary and Peripheral Oedemas are present
What are the 7 signs of a Left-sided Heart Failure?
Dyspnoea
Orthopnoea/ Paroxysmal Nocturnal Dyspnoea
Cough with Pink Frothy Sputum
Peripheral or Central Cyanosis
Displaced Apex Beat
Coarse Bibasal Crackles
S3 Sound
What are the 7 signs of a Right-sided Heart Failure?
Swelling in legs
Raised JVP
Distended Abdomen
Fatigue and Weakness
Hepatosplenomegaly
Ascites
Peripheral Pitting Oedema
What is seen in the ECG of a Congestive Heart Failure patient?
a Broad QRS Complex with Left Ventricular Hypertrophy
What are the 6 steps in the management of Congestive Heart Failure, and 3 other considerations?
First Line- Beta Blockers and ACE Inhibitors
- Bisoprolol, Carvedilol and Nebivolol
Beta Blockers and ACE Inhibitors do NOT improve mortality in Heart Failure with a Preserved Ejection Fraction
Second Line- Aldosterone Antagonists (Spironolactone)
Third Line- Cardiac Resynchronisation Therapy/ ICD Defibrillator
- If QRS>120 and LVEF<35%
Digoxin- if the patient has Atrial Fibrillation and Heart Failure
Ivabradine if the Heart Rate is higher than 75 and LVEF<35% and the patient is already on suitable medication
Other Considerations (3)-
- Fluid Restriction
- Loop Diuretics (for Symptomatic Relief)
- Avoid Calcium Channel Blockers in Heart Failure Patients with a reduced LVEF
What are the 3 complications of Congestive Heart Failure?
Pleural Effusion
Acute Decompensation of Chronic Heart Failure (patients present with Acute Respiratory Distress Syndrome due to a significant Pulmonary Oedema)
Acute Renal Failure- due to reduced Cardiac Output and Drug Overdose
What is the blood pressure range for Hypertension?
a Blood Pressure higher than 140/90 (or 135/85 for Ambulatory)
What are the Renal (4), Endocrine (5), Medication (4) and Other (1) causes of Hypertension?
Renal-
- Renal Artery Stenosis
- Polycystic Kidney Disease
- Chronic Kidney Disease
- Glomerulonephritis
Endocrine-
- Primary Hyperaldosteronism
- Phaeochromocytoma
- Cushing’s
- Hyperthyroidism
- Acromegaly
Medication-
- Glucocortoids
- Ciclosporin
- Atypical Antipsychotics
- Combined Oral Contraceptive Pills
Other-
- Pregnancy
What are the 3 signs of Hypertension and 4 signs of Malignant Hypertension?
Asymptomatic (most common presentation)
Occipital Headaches which are worse in the Morning
Signs of an Underlying Cause
Malignant Hypertension (4)
- Hypertensive Retinopathy
- Visual Disturbances
- Cardiac Symptoms (Chest Pain)
- Oliguria/ Polyuria
What should be offered to all Hypertensive Patients?
Ambulatory Blood Pressure Monitoring, or Home Blood Pressure Monitoring if that is contraindicated
What is the 5 step management for Hypertension?
<55 years old or Type 2 Diabetes Mellitus
- ACE Inhibitor
- Add a Calcium Channel Blocker or a Thiazide Diuretc
> 55 years old or Black
- Calcium Channel Blocker
- Add an ACE Inhibitor or ARB or Thiazide Diuretic
Then give an ACE Inhibitor, ARB and a Thiazide Diuretic (all three of them)
Then if their Potassium level is more than 4.5, give them a Beta Blocker or an Alpha Blocker
- If their Potassium level is less than 4.5, give them an Aldosterone Antagonist
If treatment doesn’t work, give them a Direct Renin Inhibitor (Aliskiren)- which is similar to an ACE Inhibitor in efficacy
What are the 4 complications of Hypertension?
4Cs
Coronary Artery Disease
Cerebrovascular Event
Congestive Heart Failure
Chronic Kidney Disease
What is the pathophysiology of Infective Endocarditis?
It is a condition that occurs as a result of an abnormal endocardium due to a Rheumatic or Congenital Heart Disease, Valvular Pathology or Prosthetic Valves.
This leads to Turbulent Blood Flow and Thrombus Formation
This Thrombus then becomes infected due to bacteria
This bacteria damages the valves
What causes Acute and Subacute Infective Endocarditis and what is the appropriate treatment for each bacteria?
Acute- occurs Days to Weeks and is caused by Staphylococcus Aureus- Treat this with Rifampicin
Subacute- occurs Weeks to Months and is caused by Streptococcus Viridans- Treat this with Benzylpenicillin
What 2 conditions can cause Non-Bacterial Thrombotic Infective Endocarditis (Marantic Infective Endocarditis)?
Malignancy or SLE
What are the 5 organsims associated with Infective Endocarditis and what conditions are they associated with?
Staphylococcus Aureus (the Most Common)
Staphylococcus Epidermis (Indwelling Lines)
Streptococcus Viridans
Steptococcus Bovis (Colon Cancer)
Streptococcus Mitis and Streptococcus Sanguinis (poor Dental Hygiene- after a Dental Procedure)
What are the 9 clinical features of Infective Endocarditis?
FROM JANE (+ Splenomegaly)
- Fever/ Chills
- Roth’s Spots (White-centred Retinal Haemorrhages)
- Osler’s Nodes (Painful Nodules on Fingers and Toes due to Immune Complex Deposition)
- Murmurs (with or without evidence of Heart Failure)
- Janeway Lesions (Painless Plaques due to Septic Emboli)
- Anaemia
- Nails (Splinter Haemorrhage)
- Emboli (Septic Emboli may lead to Joint Pain)
Mild Splenomegaly
What 4 investigations should be ordered if Infective Endocarditis is suspected?
- Echocardiogram needed to confirm the diagnosis- First Transthoracic, then Transoesophageal
- Raised WCC and Neutrophilia
- ECG- may show a Prolonged PR Interval
- Urinalysis- Haematuria may be present- due to Glomerulonephritis occuring secondary to the Septic Emboli
What is the management for Infective Endocarditis (4)?
- IV Antibiotics (Rifampicin for Staphylococci and Benzylpenicillin for Streptococci)
- May require Central line or Peripherally inserted Central Catheter
- Second line- Surgery if (6)- Decompensated Heart Failure, Antibiotic Resistance, Severe Sepsis, Perivalvular Abscess, Intracardiac Fistulae, Prosthetic Valve Endocarditis
What are the 3 complications of Infective Endocarditis?
Congestive Heart Failure
Septic Embolism- which can result in a Stroke
Aortic Root Abscess- suspect in Aortic Valve Endocarditis that fails to improve within 72 hours of appropriate Antibiotics
When is Antibiotic Prophylaxis not recommended in Infective Endocarditis? (4)
As people undergoing these procedures will be receiving antibiotics as well
Dental Procedures
Respiratory Tract Procedures
Gastrointestinal Tract Procedures
Genitourinary Procedures (like Childbirth)
What do you do if a person at risk of Infective Endocarditis is receiving antibiotics for a Gastrointestinal or Genitourinary Procedure?
Offer the Antibiotics for Infective Endocarditis instead
What do you do if a person at risk of Infective Endocarditis is undergoing a Dental Procedure?
Do NOT offer them Chlorhexidine Mouthwash
What is the normal QT Interval range in Males and Females?
<430 in Males
<450 in Females
What are the 3 congenital causes of Long QT Syndrome (For LQT1, LQT2, LQT3)
KCNQ1 (LQT1)
KCNH2 (LQT2)
SCN5A (LQT3)
Which Cardiac Drugs (3), Antidepressants (2), Metabolic Conditions (3) and Conditions (4) can cause Long QT Syndrome?
Cardiac Drugs- Amiodarone, Procainimide, Sotalol
Antidepressants- SSRIs, Tricyclics
Hypokalaemia, Hypomagnesaemia, Hypocalcaemia
Myocarditis, Myocardial Infarction, Hypothermia, Subarachnoid Haemorrhage
What is Romano-Ward Syndrome and Jervell-Lange-Nielsen Syndrome in QT prolongation?
Romano-Ward Syndrome- QT prolongation without deafness
Jervell-Lange-Nielsen Syndrome- QT prolongation with deafness
What are the 3 types of Long QT Syndrome and what are the associated signs?
LQT1- Exertional Syncope (often occurs after Swimming)
LQT2- Syncope following Emotional Stress or Arousal
LQT3- Syncope at Night or at Rest
What is the 2 step management for Long QT Syndrome?
Beta blockers- Apart from Sotalol, because it is a cause of Long QT Syndrome
(Beta blockers prevent Ventricular Tachyarrhythmias)
ICD (Defibrillation) if (3) they have had a previous Cardiac Arrest or if the Beta blockers are not working or if their QT interval is Above 500
When are Right-sided and Left-sided Cardiac Murmurs the Loudest?
Right-sided Murmurs are loudest on Inspiration
Left-sided Murmurs are loudest on Expiration
What are the 3 common types of Ejection Systolic Murmurs and some facts about each? (3,2,0)
Aortic Stenosis
- It is associated with a Paradoxical S2 Splitting (heard during Expiration)
- It is associated with the SAD Symptoms (Syncope, Angina, Dyspnoea)
- It is associated with a Non-Displaced Heaving Apex Beat- which is suggestive of Left-Ventricular Hypertrophy
Hypertrophic Cardiomyopathy
- It is associated with a Paradoxical S2 Splitting (Heard during Expiration)
- It is associated with Syncope in Young Men
Pulmonary Stenosis
What are the 2 types of Late Systolic Murmurs?
Mitral Valve Prolapse (most common)
Tricuspid Prolapse
What are the 3 types of Pansystolic Murmurs and some facts about each? (3,3,2)
Tricuspid Regurgitation
- Happens in Infective Endocarditis (secondary to IV Drug Use)
- There would be Hepatic Pulsations and signs of Right Heart Failure
- Large V waves in JVP
Mitral Regurgitation
- Causes (3)- Ischaemic Heart Disease, Rheumatic Fever, Calcification
- The Apex Beat may be Displaced
- It radiates to the Axilla
Ventricular-Septal Defect
- It is a shunt between the Left and Right Ventricles
- It is associated with (2)- Tetralogy of Fallot and Down’s Syndrome
What is the main type of Mid-Systolic Murmur?
Atrial-Septal Defect- it is associated with a Fixed Splitting of S2
What are the 2 types of Early Diastolic Murmurs and facts about each? (6,1)
Aortic Regurgitation
- Decrescendo
- Collapsing Pulse
- The Apex Beat may be displaced (like Mitral Regurgitation)
- The Distension and Collapse of the Carotid Arteries is Visible
- There are Visible Pulsations on the Nail Bed when the Nail Bed is Compressed
- Each Heart Beat is associated with Head Bobbing
Pulmonary Regurgitation
- Commonly due to Pulmonary Hypertension
What are the 3 types of Mid-Late Diastolic Murmurs and facts about each? (3,1,1)
Mitral Stenosis
- Signs of Pulmonary Hypertension (Malar Flush, Right-Sternal Heave)
- Atrial Fibrillation
- Loudest Over Apex
Tricuspid Stenosis
- Wide-splitting S1
Austin-Flint-
- Severe Aortic Regurgitation
What causes a Mid-Late Blowing Diastolic Murmur?
Complete Heart Block
What 2 investigations should be done if a Murmur is heard?
Blood Cultures if the patient is Pyrexial
Echocardiogram to determine Mitral and Aortic Valvular Pathology/ the presence of Pericarditis/ Pericardial Effusion
What is the pathophysiology of Rheumatic Fever?
An Infection from a bacteria (commonly Streptococcus Pyogenes) following a Pharyngeal Infection typically causes the body to produce antibodies against the Bacterial M Protein
These Antibodies are also complimentary to Cardiac and Joint Tissue
Damage to the valves leads to Rheumatic Heart disease
Histologically Aschoff Bodies are found in Rheumatic Heart Disease
What is the demographic for Rheumatic Fever?
Typically occurs in 5-17 year olds in the Developing World
What are the 7 signs of Rheumatic Fever
Sore Throat
Pleuritic Chest Pain
Joint Pain
A Rash that doesn’t itch (Non-Pruritic)
Sydenham’s Chorea
Mitral Regurgitation if Acute, Mitral Stenosis if Chronic
Erythema Marginatum (Pink or Red Macules (flat) or Papules (raised) with a clear centre on the Trunk or Limbs)
What is the 3 step management plan for Rheumatic Fever?
Benzylpenicillin
Haloperidol or Diazepam if Sydenham’s Chorea is Severe
All patients should be put on Long-Term Antibiotics (Benzylpenicillin)
What is the main complication of Rheumatic Fever?
Atrial Fibrillation
What are the 4 types of Supraventricular Tachycardia?
Atrial Fibrillation
Wolff-Parkinson White Syndrome
Paroxysmal Supraventricular Tachycardia
Atrial Flutter
What 2 tests should be ordered if Supraventricular Tachycardia is suspected?
TFTs- as Hyperthyroidism is a cause of Secondary Supraventricular Tachycardia
U&Es- check for Hyper and Hypokalaemia and Hyper and Hypocalcaemia
When should DC Cardioversion be administered in patients with Supraventricular Tachycardia? (4)
Shock- Hypotension, Pallor, Sweating, Cold and Clammy Extremities, Confusion or Impaired Consciousness
Syncope
Myocardial Infarction- if they have an Ischaemic Chest Pain or if there is evidence of a Myocardial Infarction on the ECG
Heart Failure- look for a Pulmonary Oedema or Raised JVP
What should be done if Supraventricular Tachycardia is seen?
The electrolytes should be corrected
Most people do not need treatment
