Cardiology Flashcards
What is an aneurysm?
A permanent and irreversible dilatation of a blood vessel by at least 50% of the normal expected diameter; it is a true aneurysm if it affects all three muscle layers.
What are the key diagnostic factors for an unruptured abdominal aortic aneurysm?
PATIENTS WITH AAA ARE USUALLY ASYMPTOMATIC, UNLESS RUPTURE OCCURS
Presence of risk factors
Pulsatile abdominal mass (uncommon)
Abdominal, flank or back pain
What are the risk factors for AAA?
Cigarette smoking
Family history
Increased age
What are the key diagnostic factors for a ruptured abdominal aortic aneurysm?
Abdominal, flank, or back pain
Hypotension
Loss of consciousness
Pallor
Abdominal distension
Fever (for infectious AAA)
What investigations are required for AAA?
Aortic ultrasound
CT angiography for operative planning
ESR/CRP if infective cause suspected
FBC (possible anaemia if ruptured, leukocytosis if infectious AAA)
Cross match and clotting screen
Blood cultures (infectious AAA)
What is the management plan for unruptured asymptomatic AAA?
<3cm: no further action
3-4.4cm: rescan every 12 months
4.5-5.4cm: rescan every 3 months
>5.5cm: refer within 2 weeks to vascular surgery for probably intervention
What is the management plan for unruptured symptomatic AAA?
Urgent surgical repair
What is the management plan for ruptured AAA?
Urgent surgical repair and resuscitation measures (high mortality)
What are the symptoms and signs of infective endocarditis?
Fever/chills
Cardiac murmur (most common is aortic regurgitation)
Night sweats, malaise, fatigue, anorexia, weight loss, myalgias
Arthralgia
Headache
Shortness of breath
Janeway lesions, Osler’s nodes, Roth spots, splinter haemorrhages
What are the investigations for infective endocarditis?
Blood culture (3 sets from different venepuncture sites)
Echocardiography (trans-thoracic vs trans-oesophageal - mainly TTE)
FBC (normocytic anaemia, leukocytosis)
CRP (elevated)
Serum U&Es, glucose (urea elevated)
LFT
Urinalysis (microscopic haematuria, proteniuria)
ECG
What is used to diagnose IE?
Modified Duke criteria for diagnosis of infective endocarditis: clinical criteria for definite IE requires two major criteria, one major and three minor criteria, or five minor criteria
What are the major criteria for Duke’s?
Positive blood cultures for IE typical microbe (2x 12 hours apart)
Echocardiogram showing valvular vegetation/endocardial innvolvement
What are the minor criteria for Duke’s?
TIMER acronym
Temperature >38 degrees
Immunological phenomena (Osler’s nodes, Roth spots)
Microbiological evidence (positive blood culture not meeting major criterion)
Embolic phenomenon (conjuctival haemorrhage, Janeway lesions)
Risk factors (congenital heart disease, IV drug users)
How is infective endocarditis treated?
Antibiotic therapy
Consider surgery (to remove infected tissue and repair/replace affected valves)
What organism is the most common cause infective endocarditis?
S. aureus
Differentiate between a STEMI and an NSTEMI
Presentations and symptoms are similar
STEMI is an infarction that extends the entire thickness of the myocardium (complete blockage of artery), whereas NSTEMI is infarction that is limited to the inner layer of the ventricular wall (partial blockage of artery)
Differentiate between an NSTEMI and unstable angina
In NSTEMI, troponin levels are elevated
NSTEMI patients may also be clinically unstable (e.g., low blood pressure, shock, left ventricular failure)
What causes ACS?
Atherosclerotic plaque may become inflamed and rupture, exposing substances that promote coagulation and promoting a blood clot on top of the clot
Coronary artery embolism
Coronary spasm (cocaine use)
Coronary artery dissection
How does myocardial infarction present?
Central crushing chest pain that can radiate to arms, back or jaw
Marked sweating
Nausea and vomiting
Dyspnoea
Fatigue
Shortness of breath
Pallor
Syncope
What are the ECG changes in NSTEMI?
ST-depression, T-wave inversion
What are the ECG changes in STEMI?
ST-elevation, with reciprocal ST-depression in electrically opposite leads
Location of infarction can be determined by area of ST-elevation
what medication is given for all people with ACS?
IV morphine if severe pain
oxygen if sats <94%
nitrates - use in caution if patient is hypotensive
aspirin 300mg
How is STEMI treated?
300mg aspirin
PCI if presentation within 12 hours and possible within 120 minutes - with unfractionated heparin
prasugrel if patient not taking anticoagulant - otherwise clopidogre
OTHERWISE, fibrinolysis with antithrombin
How is NSTEMI/unstable treated?
fondaparinux
calculate GRACE score
if low risk (<3%): aspirin, ticagrelor (if bleeding risk low)/clopidogrel (if bleeding risk is high)
if high risk (>3%): coronary angiography within 72 hours, PCI, unfractionated heparin
What medication is given for secondary prevention of ACS?
ACEi
beta-blocker
dual antiplatelet therapy (aspirin and second antiplatelet) - ticagrelor if low bleeding risk, clopidogrel if high bleeding risk
statin
How is angina treated?
Aspirin
Statin
Sublingual GTN spray
1. CCB (verapamil/diltiazem) or beta-blocker
2. Amlodipine and beta-blocker
3. Consider long-acting nitrate (isosorbide mononitrate), ivabradine, nicorandil, ranolazine
What are the key diagnostic factors for aortic stenosis?
Exertional dyspnoea
Fatigue
Exertional syncope
Chest pain
What murmurs are heard with aortic stenosis?
Ejection systolic murmur heard at the left sternal edge with crescendo-descendo pattern
Murmur radiates to carotid and heard loudest leaning forward on end expiration
S2 diminished and single
What are the risk factors for aortic stenosis?
Advanced age
Congenitally bicuspid valve
Rheumatic fever
Chronic kidney disease
What investigations are considered for aortic stenosis?
Transthoracic Doppler echocardiogram
ECG (left ventricular hypertrophy, absent Q-waves, atrioventricular block, hemiblock, or bundle branch block)
CXR (may be normal, can show lung pathology)
How is aortic stenosis treated?
Balloon valvuloplasty (if not suitable for aortic valve replacement)
Surgical aortic valve replacement (SAVR) for low-risk and <75
Transcatheter aortic valve replacement (TAVI) for >75 and co-morbidities
What are the examination findings of aortic stenosis?
Regular, small volume, slow-rising pulse (‘pulsus tardus et parvus’)
Narrow pulse pressure
Apex beat heaving and displaced (LV dysfunction and dilatation)
Ejection systolic murmur
How is clinically stable, symptomatic aortic stenosis treated? (age >80 years)
Transcatheter aortic valve replacement
Long-term infective endocarditis antibiotic prophylaxis
Consider long-term anticoagulation and statins
What murmurs are heard with aortic regurgitation?
Early decrescendo, high-pitched diastolic murmur heard over aortic area - with patient sitting forwards and in expiration
Corrigan’s pulse (collapsing pulse) heard at carotid
Austin-Flint murmur heard at apex (early diastolic, rumbling murmur)
Describe the presentation of acute aortic regurgitation
Early diastolic murmur
Collapsing pulse
Wide pulse pressure
Mid-diastolic Austin-flint murmur in severe AR
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)
What are some signs of cardiogenic shock?
Pallor and sweating
Mottled extremities
Rapid and faint peripheral pulse
Jugular venous distension
Altered mental status
Urine output <30ml/hour
Severe SOB and tachycardia
Describe the presentation of chronic aortic regurgitation
Widened pulse pressure
Fatigue and weakness (progressive LV dysfunction)
Paroxysmal nocturnal dyspnoea (progressive LV dysfunction)
What are the risk factors for aortic regurgitation?
Bicuspid aortic valve
Rheumatic fever
Infective endocarditis
Connective tissue disorders, e.g. Ehlers Danlos or Marfan’s
How is aortic regurgitation investigated?
ECG
CXR (cardiomegaly)
Echocardiogram (colour Doppler and pulsed-wave Doppler)
Cardiac catheterisation (before surgery)
How is acute AR treated?
Ionotropes
Vasodilators
Aortic valve replacement/repair
How is asymptomatic chronic AR treated?
If LVEF <55%, aortic valve replacement and vasodilator therapy
If LVEF >55%, reassurance and monitoring
How is symptomatic chronic AR treated?
Aortic valve replacement and vasodilator therapy
How does mitral stenosis present?
Dyspnoea and orthopnoea
History of rheumatoid fever
Raised JVP
Haemoptysis (if bronchial vein rupture due to increased pulmonary venous pressure)
Hoarseness (enlarged LA compresses left recurrent laryngeal nerve)
Dysphagia (enlarged LA compresses oesophagus)
Peripheral oedema and ascites
Atrial fibrillation (SA node cells irritated as LA dilates)
What murmurs are heard in mitral stenosis?
Mid-diastolic, low-pitched rumbling murmur heard in left lateral decubitus position
Loud P2 (pulmonary hypertension)
Loud S1
What are the risk factors for mitral stenosis?
Streptococcal infection (rheumatic fever)
Female sex
Amyloidosis
SLE
How is mitral stenosis investigated?
ECG (AF, LA enlargement, RV hypertrophy)
CXR
Trans-thoracic echocardiography
How is progressive asymptomatic mitral stenosis treated (valve area >1.5mm2)?
No therapy required
How is severe asymptomatic mitral stenosis treated (valve area <1.5mm2)?
No therapy generally required, consider balloon valvotomy
How is severe symptomatic mitral stenosis treated (valve area <1.5mm2)?
Diuretic (furosemide)
Balloon valvotomy, valve replacement or repair
Consider beta-blocker (atenolol) or ivabradine for rate control
What murmur is heard with mitral regurgitation?
Loud pansystolic murmur at the apex radiating into the axilla
Diminished S1 - incomplete closure of the valve
S3 heart sound (left ventricular dysfunction)
How does mitral regurgitation present?
Mostly asymptomatic - symptoms due to left-sided heart failure, arrhythmias, pulmonary hypertension
Fatigue
Dyspnoea
Oedema
What are the causes of mitral regurgitation?
coronary artery disease or post-MI - damage to papillary muscles or chordae tendinae
mitral valve prolapse
infective endocarditis
rheumatic fever
congenital
what are the symptoms of acute pericarditis?
pleuritic chest pain relieved by sitting forwards
non-productive cough, fever, dyspnoea
percardial friction rub
What are the risk factors for pericarditis?
Male sex, aged 20-50
Viral infections (e.g. Coxsackie B, mycobacterium tuberculosis)
Dressler syndrome (following an MI)
Uraemic pericarditis (high levels of urea irritate serous pericardium)
Cancers
Autoimmune disorders (RA, SLE)
Mediastinal radiation
What is constrictive pericarditis?
When inflammation persists, immune cells initiate fibrosis of the serous pericardium - this makes it hard for ventricles to expand
Therefore, stroke volume decreases and HR increases to compensate
what are the features of constrictive pericarditis?
dyspnoea
right sided heart failure - raised JVP, ascites, hepatomegaly, oedema
pericardial knock - loud S3
positive Kussmaul’s sign
pericardial calcification on CXR
How is pericarditis investigated?
ECG (saddle-shaped ST elevation, PR depression)
transthoracic echocardiography
ESR and CRP
troponin (elevated troponin indicates myopericarditis)
How is pericarditis treated?
NSAID (aspirin or NSAID) and PPI (omeprazole)
Colchicine (to prevent recurrent pericarditis)
Consider corticosteroid - prednisolone, e.g. no infectious cause and contraindication to NSAIDs
IV antibiotics if purulent pericarditis
Consider immunosuppresants (azathioprine) if recurrent disease
How is cardiac tamponade investigated?
Echocardiogram (enlarged pericardium or collapsed ventricles) - 1st line
ECG: electrical alternans