Cardiology Flashcards
Define infective endocarditis (IE)F
- infection of endocardium or vascular endothelium of heart
Difference between early and late prosthetics
Early - within 1 year of op
Late - after a year post op
Give 4 risk factors for IE
- Poor dental hygiene
- young IV drug users
- young with congenital HD
- prosthetic valves
Name 3 bacteria that can cause IE
staph aureus - drug users
strep viridans - poor dental health
Staph epidermis - prosthetic valve surgery
Explain the pathophysiology of IE
Abnormal/ damaged endocardium have increased platelets deposition; bacteria adheres to this and causes vegetations
* typically around valves
* causing regurgitation
Signs and symptoms of IE
New regurgitant heart murmur
Fever
Headache and fatigue
Night sweats, malaise
peripheral stigmata
What are the peripheral stigmata of IE
- Osler’s nodes - small tender nodules found on tips of fingers or toes
- Splinter haemorrhages
- Roth spots - retinal haemorrhage
- Janeway lesions - non tender lesions on soles & palm
5 ways in which IE is diagnosed
- ECG - long PR interval
- Urinalysis - proteinuria and blood
- Echocardiogram (ECHO) - Detecting vegetation
- High CRP and ESR
- Blood cultures: 3 cultures from 3 different sites at different times
What is the scoring system for infective endocarditis
Duke’s criteria - definite/possible IE
What are the 2 different echocardiogram (ECHO) methods
Transthoracic 2D echo (TTE)
Transoesophageal echo (TOE)
PROS and CONS of TOE
TOE more invasive than TTE but has better visualisation sensitivity and specificity
Treatment of IE caused by s.aureus
IV Flucloxacillin
or Vancomycin + rifampicin if MRSA
Treatment of IE caused by s.viridans
Beta-lactam (e.g. benzylpenicillin, amoxicillin) + gentamicin
How is IE treated if it is unable to be treated by antibiotics
Surgery
* remove incompetent valve and replace with prosthetic
* remove large vegetations before they embolise
* replace infected devices
How long are patient’s with IE on antibiotics for
4-6 weeks
Complications of IE
Heart failure
Aortic root abscess
Sepsis
emboli
Stroke
Define aortic stenosis
Narrowing of the aortic valve
Normal valve area is 4cm²
Symptoms occur when area is 1/4th of normal
Systolic murmur
Causes of aortic stenosis (AS)
Congenital bicuspid valve
Age-related degenerative calcification
Explain the pathophysiology of AS
Narrowing of aortic valve
Decreased SV
Increased after load
increased LV pressure
Compensatory LVH
Presentation of aortic stenosis
SAD:
Syncope (collapse, exertional)
Angina (increased myocardial O2 demand)
Dyspnoea (due to heart failure)
Clinical signs of aortic stenosis
- Slow rising pulse and decreased pulse amplitude - severe
- Prominent S4 due to left ventricular hypertrophy
- Ejection systolic murmur radiating to carotids - crescendo-decrescendo
How is AS investigated
ECG: LVH
ECHO:
* LV size and function: hypertrophy, dilation and ejection fraction
* Aortic valve area (Doppler derived)
Treatment of AS
Healthy patient: open repair, valve replacement
At risk patient: TAVI (Transcatheter aortic valve implantation) - less invasive stents
Define aortic regurgitation (AR)
Leakage of blood into LV during diastole due to ineffective aortic valve
Diastolic murmur
Causes of AR
Congenital Bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis
Clinical signs of aortic regurgitation
- Wide pulse pressure
- Austin flint murmur - rumbling mid diastolic murmur at apex (severe)
- Early Diastolic blowing murmur - at left sternal border
- Collapsing pulse
Give 2 symptoms of aortic regurgitation
Exertional dyspnoea
Palpitations
Explain the investigation and diagnosis of AR
- Chest X-ray - enlarged cardiac silhouette and aortic root enlargement
- ECHO - evaluate AV and aortic root with measurements of LV dimensions
Treatment for AR
- IE prophylaxis
- Vasodilator - ACEi
- Surgical valve replacement if appropriate
Define mitral regurgitation
Backflow of blood from the LV to the LA during systole due to ineffective mitral valve
*Systolic murmur
State 3 causes of MR
Ischaemic MV
Rheumatic HD
Infective endocarditis
Risk factors of MR
Low BMI
Congenital HD
Mitral valve prolapse (floppy)
Female
Explain the pathophysiology of MR
Regurgitation into the left atrium 🡪 left atrial dilatation 🡪 left atrial enlargement 🡪 LVH (since ventricle needs to put in more effort to pump less blood) 🡪 pulmonary hypertension 🡪 right ventricular dysfunction
Presentation of MR
Exertion dyspnoea
Murmur: pansystolic murmur at the apex radiating to axilla
* Soft S1 & Prominent S3
* Chronic MR - intensity correlates with severity
* Displaced apical beat
3 investigations for mitral regurgitation
ECG - LA enlargement, AF & LVH with severe MR
Chest Xray - LA enlargement, central pulmonary artery enlargement
ECHO - est LA, LV size and function, Valve structure assessment
What drugs are used to treat MR
BB (atenolol), CCB - rate control
ACEi
Nitrates/ diuretics in acute MR
When is surgery for MR undergone
- Any symptoms at rest - valve replacement/repair
- ejection fraction <60%
Define mitral stenosis
Obstruction of LV inflow that prevents proper filling during diastole (diastolic murmur)
Normal MV area: 4-6 cm²
Symptoms begin at areas <2cm²
Causes of m.stenosis
Rheumatic heart disease (common)
Infective endocarditis
Mitral valve calcification
Explain the pathophysiology of m.stenosis
Thickening and immobility of valve > obstruction of blood flow from right atrium to right ventricle > left atrial pressure increases > LAH > pulmonary venous, arterial and right heart pressures increase > pulmonary oedema > pulmonary HTN > RVH > tricuspid regurgitation
Signs of m.stenosis
- pinkish-purple patches on cheeks
- prominent a wave in jugular venous pulsations
- Dyspnoea
Describe the diastolic murmur in mitral stenosis
Diastolic murmur:
* low-pitched diastolic rumble most prominent at apex
* heard best with patient lying on left side in held expiration
* intensity of murmur doesn’t correlate with severity of stenosis
Apart from a diastolic murmur, what other heart sounds can be observed in MS
- Loud opening S1 snap: heard at apex when leaflets are still mobile
- shorter S2 to opening snap interval indicates more severe disease
How is MS diagnosed
- ECG - may show AF and LA enlargement
- CXR - LA enlargement and pulmonary congestion. Occas calcified MV
ECHO - Assess MV mobility, gradient and MV area
What drugs may be used in the treatment of MS
- BBs & CCBs which control heart rate
- Diuretics for fluid overload
Define pericarditis
inflammation of the pericardium with or without effusion
What are the types of pericarditis
Fibrinous - dry
Effusive (wet):
* Purulent serous exudate - infection/malignancy
* Haemorrhagic exudate - bleeding
Give 4 infectious causes of pericarditis with examples
- Viral (m.common) - CMV, EBV
- Bacterial - TB (common)
- Fungal (v.rare)
• Parasitic (v.rare)
Give 4 non-infectious causes of pericarditis with examples
- Autoimmune (common) - rheumatoid arthritis
- Neoplastic - 2 metastatic tumours (breast and lung cancer)
- Traumatic and latrogenic - pericardial injury syndromes (Dressler’s syndrome)
- Chronic heart failure
What % of pericarditis cases are idiopathic
80-90%
Describe the type of chest pain in pericarditis
- Sharp, pleuritic chest pain in left anterior chest/epigastrium
- Chest pain radiates to trapezius ridge due to co-innervation of phrenic nerve
- Relieved by sitting forward and exacerbated by lying down
Apart from chest pain, describe other signs and symptoms of pericarditis
- Dyspnoea
- Hiccups
- Fever
- Cough
What is the main differential diagnosis for symptoms of pericarditis
Myocardial infarction/ischaemia
Describe the typical results of a clinical exam for pericarditis
Clinical exam:
* tachycardia
* pericardial rub - pathognomonic, crunching snow sound
* Signs of effusion
Describe the typical results of an ECG for pericarditis
- Widespread saddle shaped ST elevation
- PR depression
What may a chest X-ray show in someone with pericarditis show
- Normal in idiopathic
- Pneumonia common in bacterial
- Effusion may cause cardiomegaly
Treatment for pericarditis
- NSAIDS: Ibuprofen/ aspirin for 2w
- Colchicine for 3w - reduce recurrence
What are the possible complications of pericarditis
- Large pericardial effusion can lead to cardiac tamponade
- myocarditis
- constrictive pericarditis
Explain how pericardial effusion can lead to cardiac tamponade
Accumulation of fluid in pericardial space accompanying pericarditis. Large vol of fluid (enough to impair ventricle filling) = cardiac tamponade
Define cardiac tamponade
- The accumulation of pericardial fluid, blood, pus or air within the pericardial space
- This creates an increase in intra-pericardial pressure, restricting cardiac filling and decreasing CO
- Medical emergency
Signs of cardiac tamponade
- Beck’s triad - Hypotension, increased jugular venous pressure, muffled S1 & S2 heart sounds
- Pulsus paradoxus - fall in sys BP during inspiration
Gold standard investigation for cardiac tamponade
ECHO - late diastolic collapse of right atrium
Describe the ECG findings of cardiac tamponade
electrical alternans - varying QRS amplitude due to heart bouncing back and fourth in increased fluid
Treatment for cardiac tamponade
- Pericardiocentesis - drain excess fluid using needle and catheter
- NSAIDs + PPi
Define abdominal aortic aneurysm
Permanent dilatation in vessel wall diameter of >50%, which typically means a diameter of >3 cm
Give 5 RFs of AAA
Smoking - MAJOR
CT disorders - Marfan’s
Age
Atherosclerosis
Male
Explain the pathophysiology of AAA
- Inflammation and degeneration of smooth and elastic muscle (vascular tunica)
- Loss of structural integrity of the aortic wall and mechanical stress results in widening of the vessel
Difference between true and pseudoaneurysm
True - structural degeneration in all 3 layers of vascular tunica
Pseudo - not all 3 layers
Describe the presentation of AAA
- Usually asymptomatic till rupture
- If expanding fast: sudden central abdo pain radiating to flank,
- triad: abdo/back pain, pulsatile abdo mass and hypotension
- Cullen’s/ grey turners sign
What is the first line investigation for AAA and why
Abdo ultrasound
Cheap, easy, sensitive and specific
Where specifically are AAAs usually found
Below renal arteries (infrarenal)
Treatment for non-ruptured AAA
- manage RFs - smoking cessation
- Asymptomatic and < 5.5cm = monitor
- Symptomatic and >5.5cm or expanding rapidly = surgery
What is the major complication of AAA and how is it treated
Rupture of AAA
* Urgent surgery - EVAR (endovascular aneurysmal repair)
* maintain ABCDE and fluids
100% mortality unless treated immediately
Describe the 2 types of surgery that could be done for AAA
- EVAR - stent inserted through fem/iliac a. + less invasive. - more post op comp
- Open surgery. + fewer Cx, - more invasive
Define aortic dissection
Tear in tunica intima of aorta which leads to a collection of blood between the intima and medial layers
Give 5 RFs for AD
- Men aged 50-70
- Hypertension - most common
- CT disorder - ehlers danlos
- Smoking
- Trauma
Explain the pathophysiology of AD
- Blood dissects media and intima and pools in false lumen
- Blood can propagate distally or proximally
- Flow through the false lumen can occlude flow to end organs = organ failure
Signs and symptoms of AD
- Sudden and severe tearing chest pain radiating to back
- hypotension (linked to cardiac tamponade)
- Lower limb pain (B)
- Pulse deficit and diastolic murmur (A)
Describe the Stanford classification of AD
- A - proximal, involves ascending aorta and/ or arch - mc and more severe
- B - distal, descending thoracic aorta
Explain the diagnosis of AD
- CXR - shows widened mediastinum (>8cm)
- TOE - classify as A or B, shows intimal flap and false lumen
- CT (chest, abdo, pelvis) - definitive image
- ECG - exclude STEMI
What is the surgical treatment for AD
A - open repair
B - endovascular aneurysm repair
What is the medical treatment for AD
- Beta blockers, e.g. IV labetalol or CBB if CI (Verapamil)
- BB and partial alpha blocker - prevents reflex tachycardia & lowers BP
- Opioid analgesia (morphine)
- Vasodilator (Na nitroprusside)
Complications of AD
Cardiac tamponade
Aortic regurgitation
Pre-renal AKI
Define hypertension
Abnormally high BP:
* >140/90 mmHg in clinic
* >135/85 home readings (A)
Types of HTN
1) Essential - idiopathic (95%)
2) Known underlying cause (5%)
Causes of HTN
‘ROPE’
* Renal disease - CKD
* Obesity
* Pregnancy
* Endocrine - Conn’s (mc) , Cushing’s, phaeochromocytoma
Also: abnormal RAAS
Give 5 modifiable RFs of HTN
Sedentary lifestyle
High salt intake
Obesity
Alcohol intake
T2DM
Give 3 non-modifiable risk factors of HTN
- Age >65
- Family history
- Afro-caribb ethnicity
- Obstructive sleep apnoea
Describe the 3 stages of HTN
S1) 140/90 or 135/85(A)
S2) 160/100 or 150/95(A)
S3) 180/110 (immediate Tx)
Pathophysiology of HTN
Increased RAAS, sympathetic NS and TPR increases BP as BP = CO x TPR
Signs and symptoms of HTN
Mostly asymptomatic, found on screening
Malignant HTN:
* heart failure
* Blurred vision
* Headache
* Chest pain
* CKD
Describe the diagnosis of HTN
- Hospital bp reading >140/90mmHg
- ABPM (ambulatory) for 24h (as you move around) to confirm diagnosis - >135/85
Organ damage: - Fundoscopy - papilloedema
- Bloods - HbA1C and lipid profile
- Urinalysis - proteinuria, high albumin = end organ damage
- ECHO/ ECG - LVH
When are CCB used in first step treatment for HTN
- Black origin
- > (=) 55
- No T2DM
When are ACEi (/ARB) used in first step treatment for HTN
- non-black origin
- <55
- T2DM
nb - DM takes precedence i.e. if black + T2DM take ACEi
Describe the 2nd and 3rd step of HTN treatment
2) ACEi (e.g. ramipril) / angiotensin 2 receptor blocker + CCB
3) ACEi + CCB + thiazide-like diuretic (e.g. Indapamide)
SEs of ACEi
- Teratogenic effects
- Acute renal failure
- Hyperkalaemia
- Dry cough
Describe the 4th step of HTN treatment
ACEi + CCB + TLD + 1/2
* 1 - If k+ >4.5 mmol/L = a/b blocker
* 2 - If k+ < 4.5 = spironolactone (K sparing)
Give some possible complications of HTN
Heart failure
Increased IHD risk
CKD
Retinopathy - papilloedema
Define peripheral vascular disease (PVD)
Narrowing of peripheral blood vessels
PAD - arterial
Peripheral venous disease
Give 4 RFs of PVD
Smoking
>40
Diabetes
HTN
Explain the pathophysiology of PVD
- Least severe: commonly atherosclerosis leading to claudication of vessels
- Most severe: severe occlusion, blood supply barely adequate to meet metabolic demand = critical limb ischaemia
What are the 6 signs of acute limb ischaemia
Pulselessness
Pallor
Pain
Paralysis
Perishing with cold
Paraesthesia - tingling/numbness
What usually causes limb ischaemia
Embolic/thrombotic formation at site of critical limb ischaemia lesion
Signs and symptoms of P. venous disease
- red
- swollen
- warm
- Dull, achy, constant pain
Sx of PAD
Most patient are asymptomatic
* Intermittent claudication - limp
*Thigh/buttock pain that is quickly relieved on rest
How is PAD investigated
- Ankle brachial pressure index (ABPI): <0.9
- CT angiogram - stenosis or occlusions
How is peripheral venous disease investigated
D-dimer (blood clotting) and doppler ultrasound (blood flow)
How are PVDs treated
*ABPI <0.9 = Percutaneous transluminal angioplasty
* Anti-coagulants - heparin
* Anti-platelets - aspirin or clopidogrel
Complications of PAD
Acute limb ischaemia -> loss of limb
Complications of PVD
pulmonary embolism