Cardiology Flashcards
1
Q
What is the S1 heart sound due to?
A
Mitral and tricuspid valve closing
2
Q
What is the S2 heart sound due to?
A
Aortic and pulmonary valve closing
3
Q
What does the S3 heart sound show?
A
Shows rapid ventricular filling in early diastole
-Normal in young/pregnant patients
-Can be pathological: mitral regurgitation+ heart failure
4
Q
What is the S4 heart sound due to and in which conditions can it be heard?
A
Pathological ‘gallop’
Due to blood being forced into stiff hypertrophic ventricle
Seen in: LVH and aortic stenosis
5
Q
How long should the PR interval be?
A
0.12-0.2s
6
Q
How long should the QRS interval be?
A
0.08-0.1s
7
Q
What does the P wave show?
A
Atrial depolarisation
8
Q
What does the PR interval show?
A
AVN conduction delay
9
Q
What does the QRS complex show?
A
Ventricular depolarisation and atrial repolarisation
10
Q
What does the ST segment show?
A
Isovolemic ventricular relaxation
11
Q
What does the T wave show?
A
Ventricular repolarisation
12
Q
Which conditions can ECGs help diagnose?
A
MI(STEMI/NSTEMI)
Arrhythmias
Electrolyte disturbances
Pericarditis
Chamber hypertrophy
Drug toxicity, like digoxin
13
Q
What values does 1 small square of ECG paper stand for?
A
0.04s(horizontal)
0.1mV(vertical)
14
Q
What values does 1 big square of ECG paper stand for?
A
0.2s(horizontal-time)
0.5mV(vertical-amplitude)
15
Q
Which ECG leads corresponds to the RCA and which part of the heart does it show the function of?
A
aVF, 2, 3
Inferior
16
Q
Which ECG leads corresponds to the LAD and which part of the heart does it show the function of?
A
V1-V4
Anterior and septal
17
Q
Which ECG leads corresponds to the left circumflex artery and which part of the heart does it show the function of?
A
V5,V6,aVL,1
Lateral
18
Q
Which 2 conditions can ischaemic heart disease cause?
A
Angina
MI
19
Q
How does myocardial ischaemia cause anginal pain?
A
Decreased coronary artery flow
20
Q
Describe the features of stable angina
A
-Central crushing chest pain, radiating to neck/jaw
-Brought on with exertion
-Relieved with 5 mins rest/GTN spray
21
Q
What is the Levine sign?
A
‘Fist over chest’
Crushing chest pain: angina
22
Q
What is the QRISK score?
A
Predicts risk of CV in next 10 years
Takes into account:
-Age
-BP
-BMI
-Socioeconomic status
-Ethnicity
23
Q
What is the Grace score?
A
Predictor of mortality from MI in next 6months-3 years in ACS patients
24
Q
Which conditions make up ACS’s?
A
Unstable angina->NSTEMI->STEMI
25
Describe the features and cause of unstable angina
Pain at rest
Not relieved with inactivity/GTN spray
Severe ischaemia
26
What kind of infarction is an NSTEMI?
Partial infarction
27
What kind of infarction is a STEMI?
Transmural infarct
28
What causes Prinzmetal's angina?
Due to coronary vasospasm (NOT CV atherogenesis)
29
When is Prinzmetals angina commonly seen?
Cocaine users
30
What does the ECG of Prinzmetal's angina show?
ST elevation
31
What is decubitis angina?
Induced lying flat
32
Name some risk factors for angina
Obesity
T2DM
HTN
Smoking
Old age
Male
FHx
Cocaine use
33
What causes atherogenesis?
Endothelial injury induces cells to site via chemokines IL1, IL6, IFN gamma
34
What are the 3 stages of atherogenesis that lead to angina?
-Fatty streak
-Intermediate lesion
-Fibrous plaques
35
In which part of the vessel do fatty streaks form?
Intima
36
What are the components of a fatty streak?
T cells
Foam cells
37
What happens during intermediate lesion formation?
Platelets aggregate and adhere to site inside the vessel lumen
38
What are the components of intermediate lesions?
Foam cells
T cells
Smooth muscle cells
Platelets
39
What happens during formation of fibrous plaques?
Fibrous cap develops over large lesion
40
Describe the components of a fibrous plaque
Leisons: foam cells, T cells, smooth muscle cells, fibroblasts, lipids with necrotic core
41
What is the fibrous cap like in a patient with stable angina?
Fibrous cap is strong and less rupture prone
42
What hppens if the fibrous cap is prone to rupture?
->Prothrombotic state->platelet adhesion and accumulation->progressive luminal narrowing
43
Name some symptoms of ACS's
Central crushing chest pain radiating to jaw/neck, crescendo pattern
Hypotension
Tachycardia
'Impending sense of doom'
Palpitations
Nausea
Sweating
Fatigue
Dyspnoeic we lbreathing
44
What investigations are carried out to diagnose stable angina?
ECG: Should be normal at rest-exercise induced ischaemia-changes
CT angiography: looks for stenosed atherosclerotic arteries
45
Describe the treatment for stable angina
Symptomatic: GTN spray
Lifestyle modifications
Pharmacological:
1)CCB(CI: heart failure) or BB(CI: asthma)
2)CCB+BB
3)CCB+BB+antianginal like ivabradine/nitrates
46
Which extra drugs should be considered in patients with anigna?
ACEi
Aspiring
Statins
HTN treatment
47
What kind of CCB should be used to treat stable angina?
Non rate limiting-can cause excessive bradycardia
Amlodipine
NOT verapamil/diltiazem
48
What treatments cane be used for angina if pharmacological treatments aren't successful?
PCI: balloon stent of coronary artery
CABG: bypass graft
49
Name a disadvantage and advantage of using a PCI
Advantage: Less invasive
Disadvantage: risk of restenosis
50
Name a disadvantage and advantage od using a CABG
Advantage: Better prognosis
Disadvantage: More invasive
51
Describe the ECG changes seen after an MI
Hyperacute T waves
Pathologically deep alpha waves
LBBB
52
Describe the extent of occlusion in unstable angina, NSTEMI and STEMI
Unstable: partial occlusion of minor coronary artery
NSTEMI: Major occlusion of minor CA or minor occlusion of major CA
STEMI: Total occlusion of major CA
53
Describe the infarction seen in unstable angina, SNTEMI and STEMI
Infarction: none-ischamia only
NSTEMI: Sub endothelial infarction(area away from CA dies)
STEMI: transmural infarction
54
Describe the ECG changes seen in a patient with unstable angina
Often normal
May have ST depression/T wave inversion
55
Describe the ECG changes seen in a patient with an NSTEMI
ST depression
T wave inversion
No Q waves
56
Describe the ECG changes seen in a patient with a STEMI
ST elevation in local leads
Q waves
57
Why is creatine kinase a useful marker of myocardial damage?
Troponin has a shorter half like than CK
CK is a better marker after a few days
58
What are the 2 main markers for myocardial damage?
Troponin
Creatine kinase
59
What would you expect troponin and creatine kinase to be in an unstable angina patient?
Normal
60
What would you expect troponin and creatine kinase to be in an NSTEMI patient?
Elevated
61
What investigations are carried out to diagnose ACS?
ECG
Biomarkers
CT ANGIOGRAPHY to show extent of occlusion
62
Describe the acute treatment of ACS's
MONAC:
Morphine
O2: is sats<94%
Nitrates: GTN
Aspiring: 300mg
Clopidogrel: 75mg
63
What is the short term treatment for NSTEMI/unstable angina?
Use Grace score:
Low risk: monitor
High risk: Immediate angiogram and consider PCI
64
What is the short term treatment for a STEMI?
PCI: if within 12hr onset/2hrs of first medical intervention
Thrombolysis with alteplase if >12 hours, then PCI if this fails
65
What is the purpose of thrombolysis with alteplase?
clot buster: acts as tPa to activate plasmin: eats fibrin
66
Describe the long term prevention of ACS's
Beta blockers
Aspirin: Initially 300mg, life 75mg + clopidogrel (75mg)
Atorvastatin: 80mg (cholesterol)
ACE-i
67
Name some acute complications that can arise from ACS's
Heart failure due to ventricular fibrillation
Mitral incompetence
Left ventricular free wall rupture
Cardiogenic shock
68
Name some potential long term complications of ACS's
Dressler syndrome (AI pericarditis)
Heart failure
LV aneurysm
69
Define heart failure
Inability for the heart to deliver oxygenated blood to the tissues at a satisfactory rate for the tissue's metabolic requirements
70
Is heart failure a diagnosis or a syndrome?
Syndrome
71
What is the most common cause of heart failure?
IHD
72
Name some causes of heart failure
IHD
Cardiomyopathy
Valvular disease
Anything that increases cardiac work: pregnancy hyperthyroidism, obesity, htn, arrhythmias
73
Name some risk factors for developing heart failure
Age: >65
Smoking
Obesity
Previous MI
Male
74
What is cor pulmonale?
RH failure due to disease of lungs and pulmonary vessels
75
Describe the pathophysiology of heart failure
Frank-Starling law: High preload=high afterload-high CO
In failing heart: Dysfunctional Frank Starling law in failing hearts: low CO
76
Describe the compensatory mechanisms for heart failure
1)RAAS and SNS activation initially works to maintain cardiac output:
Increases aldosterone and ADH
increases Adr/NAd
77
What happens when heart failure compensatory mechanisms stop working
Heart undergoes cardia remodelling(lowers CO( in repsonse to compensation
Heart is less adapted to function and RAAS and SNS activations exacerbates fluid overload-> congestive heart failure
78
What is congestive heart failure?
Heart failure affecting both left and right circuits
79
How can heart failure be classified?
Acute or chronic
By ejection fraction
80
What is a normal ejection fraction?
50-70%
81
Describe hear failure with a preserved ejeciton fraction
>50%
Diastolic failure: pump function preserved, filling issues
E.g. hypertrophic cardiomyopathy, LVH, aortic stenosis
82
Describe heart failure with a reduced ejection fraction
<40%
Systolic failure: low CO due to pump issues
E.g IHD
83
What kind of oedema does LHS failure result in and why?
Pulmonary oedema: pulmonary vessel backlog
84
What kind of oedema does RHS failure result in and why?
Peripheral oedema: Systemic venous backlog
85
Describe the symptoms of heart failure
3 cardinal non-specific: SOBASFAT
SOB, ankle swelling, fatigue
Also:
Orthopnoea
Oedema
S1+S2+S3+S4
Increased JVP
Bibasal crackles (pulmonary oedema)
Hypotension
Tachycardia
86
Describe the NY heart association classification of heart failure severity
1)No limit on physical activity
2)Slight limit on moderate activity
3)Marked limit on moderate and gentle activity
4)Symptoms even at rest
87
How is heart faiure diagnosed?
Bloods: BNP>400
ECG: abnormal, e.g. LVH evidence
CXR: ABCDE (alveolar bat wing oedema, kerley bluyes, cardiomegaly, dilated upper lobe vessels, pleural effusion)
Echo: assess heart chamber dimension
88
What abnormalities can be used to detect heart failure on a chest x-ray?
ABCDE
Alveolar bat wing oedema
Kerley B lines(horizontal lines in lower lung fields)
Cardiomegaly
Dilated upper lobe vessels
Pleural effusion
89
Describe the treatment for heart failure
Conservative: lifestyle changes: lose weight, exercise, smoking + alcohol cessation)
Pharmacological: ABAL
ACEi+BB
Spironolactone and furosemide
Consider cardiac resynchronization therapy
Surgery:
Revascularisation
Valve surgery
Heart transplant
90
What is an abdominal aortic aneurysm?
Permanent aortic dilation exceeding 50% where diameter >3cm
91
Where are aortic aneurysms commonly found?
Below renal arteries
92
What is the biggest risk factor for AAA's?
Smoking
93
Name some risk factors for developing AAA's
Connective tissue disorders: EDS, Marfans
Smoking
Obesity
HTN
Trauma(atherosclerosis)
fHx
Ageing
94
Describe the pathophysiology of AAA's
Smooth muscle, elastic and structural degeneration in all 3 layers of vascular tunic (intima, media, adventitia) with leukocyte infiltrate
95
What is the difference between a true aneurysm and a pseudo aneurysm?
All 3 layers: true aneurysm
Not all 3: pseudo aneurysm
96
At what size does an aortic aneurysm have an increased rupture risk?
>5.5cm
97
Describe the symptoms of an AAA
Asymptomatic until ruptured
Sudden epigastric pain radiating to flank
Pulsatile mass in abdomen
Hypotension
Tachycardia
98
What is a differential diagnosis for a ruptured AAA?
Acute pancreatitis
Typically non-pulsatile and more associated with Grey Turner and Cullen signs
99
How are AAA's diagnosed?
Abdominal US to assess aorta
100
Describe the treatment of a non ruptured AAA
Conservative: manage RF's: smoking cessation, weight loss, statins, BP treatment
aSx and <5.5cm: Monitor
>5.5cm or growing rapidly: surgery
101
What surgical procedures can be used for non ruptured AAA's?
EVAR: endovascular repair: stent inserted through femoral/iliac artery-less invasive but more post-op complications
Open surgery: more invasive but fewer complications
102
Describe the treatment for a ruptured AAA
Stabilise: ABCDE, fluids, transfusion then surgery
AAA graft surgery to replace weakened walls with graft
103
What are the main causes of thoracic aortic aneurysms? How are they treated?
Marfans/EDS
Atherogenesis
Monitor with CT/MRI
If symptoms: immediate surgery
104
What is an aortic dissection?
Tear in intima leading to blood dissecting through media and separating the layers apart
Due to mechanical wall stress
105
What is the main risk factor for an aortic dissection?
Hypertension
106
Name some risk factors for aortic dissections
Connective tissue disorders: Marfans, EDS
fhX of AAA/AD
Trauma
Smoking
107
Where are the most common locations for an aortic dissection?
1)Sinotubular junction-where aortic root becomes tubular, near aortic valve
2) Just distal to left subclavian artery in descending thoracic aorta
108
Descirbe the Stanford classification for AD's
A: proximal to left subclavian artery (ascending arch)
B: distal to left subclavian artery (descending thoracic)
109
In which location are aortic dissections more commonly found?
Stanford classification A: proximal to left subclavian artery (2./)
110
Describe the pathophysiology of an aortic dissection
Blood dissects media and intima and pools in false lumen->decreased perfusion to end organs->organ failure and shock
111
Describe the symptoms of an aortic dissection
Sudden onset ripping/tearing chest pain
Shock, hypotension
New aortic insufficiency murmur
Neurological deficit (syncope etc due to affected carotid perfusion)
Decreased left arm peripheral pulse, decreased radial if left subclavian involved) or radio-radial differences
Cardiac tamponade
112
How are aortic dissections diagnosed?
CXR: widened mediastinum: >8cm-suspicious
TOE: transoesophageal echo: more invasive than TTE but very sensitive-shows intimal flap/false lumen
CT angiogram: intimal flap, false lumen, rupture/leak
113
When is a CT angiogram used over TOE to diagnose aortic dissections?
CT angiogram more used if patient is hemodynamically stable
114
Describe the surgical treatment of an aortic dissection
Open repair for type A
EVAR more for B (stent)
If hypotensive: IV fluids, blood transfusions, adrenaline etc
115
Describe the medical preventative treatment for an aortic dissection
Special BB: esmolol or labetalol: bb and partial ab-prevents reflex tachycardia to keep BP low
Vasodilator: sodium nitroprusside
116
What are the aims of medical preventative treatment for aortic dissections?
SBP: 100-120
HR:60
117
Name some complications of aortic dissections
Cardiac tamponade
Aortic insufficiency(regurgitation)
Pre-renal AKI
Ischaemic stroke
118
What baseline values count as hypertension?
In clinic:
>140/90mmHg
At home:
>135/85mmHg
119
Describe the causes of hypertension
Primary: idiopathic:95%
Secondary: Underlying cause-5%
120
Name some secondary causes of hypertension
CKD-often from diabetic nephropathy
Iatrogenic
Pregnancy
Endocrine: Conn's, Cushing's, phaeochromocytoma
121
Describe the risk factors for developing hypertension
Increasing age
Black ethnicity
Overweight
Lack of exercise
Smoking
Diabetes
Stress
High salt intake
fHx
122
Describe the staging of hypertension
Stage 1:
140/90 in hospital or 135/85 at home
Stage 2:
160/100 in hospital or 150/95 at home
Stage 3:
180 and/or 110: start immediate treatment
123
Describe the pathophysiology of hypertension
All mechanisms will increase RAAS and SNS activity(so also CO) and increase TPR
BP=TPR x CO so BP will increase
124
Describe the symptoms of hypertension
Mostly asymptomatic
Might have pulsatile headaches
Consider signs of secondary causes (pheochromocytoma sx etc)
125
What is malignant hypertension?
Markedly raised diastolic (180/12)
Black males: 30-40
126
Describe the signs/symptoms of malignant hypertension
LVH/heart failure
Blurred vision(papilloedema, retinal haemorrhage)
Haematuria and renal failure(glomerulonephritis)
Headaches: risk of cerebral haemorrhage
127
What investigations are done to diagnose patients with hypertension?
BP reading in hospital >140/90mmHg
ABPM for 24 hrs to confirm diagnosis >135/85
Assess end organ damage
Fundoscopy: papilloedema
Urinalysis, eGFR, serum creatinine, glucose-renal function and diabetes risk
Echo/ECG: LVH risk
128
What is the 1st line treatment for a patient<55 with hypertension?
ACE inhibitor
129
What is the 1st line treatment for a patient with T2DM and hypertension?
ACEi
130
What is the 1st line treatment for a patient >55 with hypertension?
CCB
131
What is the 1st line treatment for a black African patient with hypertension?
CCB
132
Describe the treatment for hypertension
Either ACEi or CCB
2)ACEi+CCB
3)ACEi+CCB+thiazide like diuretic: bendorflumethiazide
4)ACEi+CCB+TLD+4th drug(a/b blocker or sipronolactone depending on potassium levels)
133
Name some complications of hypertension
Heart failure
Increased IHD risk
CKD
Increased cerebrovascular risk
134
What is a DVT?
Thrombus in deep leg vein
Less concerning: below calf(most common): minor veins, anterior and posterior tibial)
More concerning: above calf(less common but life-threatening): occlusion can impede distal flow
135
What is Virchow's triad?
Risk factors for developing a blood clot
Hypercoagulability
Venous stasis
Endothelial injury
136
Give some examples of things that cause hypercoagulability
Pregnancy
COCP
Obesity
APS
Sepsis
DIC
Malignancy
137
Give some examples of things that cause endothelial injury and explain how
Smoking
Trauma/surgery
Endothelial cells normally secrete anticoagulant, chemicals damage endothelial cells so they can't secrete it
138
What causes venous stasis?
Usually laminar flow->aggregation of clotting factors
Immobility-long flights, post op
139
How does a PE cause cor pulmonale?
Increases peripheral vascular resistance->increased RV straining to overcome this->RVH->RV fails secondary to increased pulmonary pressure
140
Name 3 conditions that commonly present with pleuritic chest pain and how can you tell the difference between them
PE-normal CXR
Pneumothorax
Pneumonia
141
Describe the symptoms of a PE
Sudden onset pleuritic chest pain
Dyspnoea (+/-haemoptysis)
Evidence of DVT
Tachycardia, hypotension, increased JVP, ankle oedema
142
What scoring system is used to assess DVT/PE
Well's score
143
How would you diagnose a PE?
D-dimer, CTPA
ECG-sinus tachycardia, S1Q3T3(cor pulmonale), T wave inversion of anterior and inferior leads, new RBBB
CXR-normal
144
What test is diagnostic for PE?
CTPA
145
What is a D-dimer test?
Measure of clot burden-protein released into blood when blood clot fibrinolysed
Sensitive but not specific
146
Which would you do first: a D-dimer or a CTPA?
D-dimer
147
Describe the treatment for a PE
If massive: Thrombolytics->alteplase (clot buster)
Non-massive: DOAC:
1st line apixaban/rivaroxaban
CI: renal impairment: LMWH
148
Describe the symptoms of a DVT
Unilateral swollen calf with engorged leg veins: typically warm
If complete occlusion of a large vein@ severe ischaemia-leg turns blue
149
What score indicates the presence of a DVT?
Wells score>1
e.g. calf swelling >3cm, pitting oedema etc
150
How are DVT's diagnosed?
D-dimer first-if raised:
Duplex ultrasound-diagnostic
151
Describe the treatment for a DVT
DOAC anticoagulation
Apixaban/rivaroxaban
LMWH if CI(renal impairment)
Mobilisaton, compression stockings
152
Name a differential diagnosis for DVT and how can you tell between them?
Cellulitis(usually Staph.aureus/strep.pyogenes): will show leukocytosis on FBC, DVT should be normal
D-dimer and DUSS can confirm DVT
153
What is peripheral vascular disease?
IHD of lower limb arteries
154
Name some risk factors for developing peripheral vascular disease
Smoking
htn
ageing
obesity
CKD
T2DM
155
What are the different types of peripheral vascular disease?
Intermittent claudication(least severe)->atherosclerotic, partial lumen occlusion, pain on exertion
Critical limb ischemia (more severe)->large occlusion, blood supply struggles to meet metabolic demand. Pain at rest and risk of gangrene/infection
156
What is acute limb ischaemia?
Total occlusion of vessel due to embolic/thrombotic formation at site of critical limb ischaemia lesion
157
What are the 6P's: PVD
Pulselessness
Pallor
Pain
Persistingly cold
Paralysis
Parasthesia
158
When are the 6P's present and what is their significance?
Acute limb ischaemia
Also in chronic limb ischaemia
The more you have the more limb-threatening
All6: emergency
159
What are the 3 consequences of BV supplying region occlusion?
1)Irreversible nerve damage(<6hrs)
2)Irreversible muscle damage(6-10hrs)
Skin changes last to appear: sign of gangrene
160
Describe the symptoms of PVD
Ankle brachial pressure index <0.9 or lack of lower leg pulse
Skin changes on leg: colour, ulcerations, warmth
Bruits
Positive Buerger test
Some of 6P's: most characteristic
161
What are bruits?
Pulsatile regions due to turbulent blood flow
162
What is the Buerger test?
Elevate leg for 1 minute: pallor then reactive hyperaemia
163
What classification is used for PVD?
Fontaine classification 1-4
164
Describe the 4 stages of the fontaine classification
1)asymptomatic
2)intermittent claudication
3)chronic limb ischaemia: pain at rest
4)ischaemic ulcers->gangrene
165
Describe the diagnosis of PVD
ABPI-compare blood in posterior and anterior tibial artery to brachial artery with doppler US
0.5-0.9: intermittent claudication
<0.5: critical chronic limb ischaemia
Colour duplex US: assess degree of stenosis
CT angiography if surgery considered(GS but too invasive)
166
Describe the treatment for intermittent claudication
RF management:
smoking cessation
lower BMI
BP control: ACEi
Statins
Antiplatelts: clopidogrel, aspirin
T2DM drugs
167
Describe the treatment for chronic limb ischaemia
Revascularisation surgery: PCI if small, bypass if big
Amputation if severe
168
Describe the treatment for acute limb-threatening ischaemia
Surgical emergency: revascularisation within 4-6hrs or high amputation risk
169
Name some complications that can arise from PVD
Amputation
Permanent limb weakness
Rhabdomydysia
Increased risk of cerebrovascular events and CVD
170
What is pericarditis?
Inflammation of the pericardium with/without effusion
171
Is pericarditis without effusion dry or wet?
Dry
172
Is pericarditis acute or chronic?
Typically acute, can be chronic
173
What are the 2 types of pericarditis?
Dry: fibrous: wihtout effusion
Wet: with effusion
174
What are the 2 types of wet pericarditis?
Exudative
Haemorrhagic: bleeding
175
What kind of things cause exudative pericarditis?
Malignancy
Infection
176
Name the causes of pericarditis
Idiopathic
Viral: Coxsackie virus
Bacterial: TB
Fungal: histoplasmosis in immunocompromised patients
Autoimmune: SLE, RA, Sjorgens
Dressler' syndrome (post MI)
Neoplastic (lung, breast)
177
What is the most common cause of pericarditis?
Viral: Coxsackie
AI also very common
178
Describe the pathophysiology of pericarditis
Inflammation causes narrowing of the pericardial space so the inflamed pericardial layers rub against each other leading to further inflammation
179
Describe the signs and symptoms of pericarditis
Severe sharp pleuritic chest pain with referral to left shoulder (phrenic), relieved when sitting forward and worse laying flat or on inspiration
Pericardial friction rub on auscultation
May have signs of RHS failure: SOB, peripheral tachycardia, tachycardia
180
What does a pericardial friction rub sound like and when can it be heard?
Heard when patient leans forward, squeaky leather to and for sound
181
What is constrictive pericarditis?
Granulation tissue formation in the pericardium results in impaired diastolic filling: sign of poor heart prognosis
182
What is a differential diagnosis for pericarditis?
MI-central crushing chest pain not related to lying down, no pericardial rub
183
How is pericarditis diagnosed?
ECG diagnostic: widespread saddle-shaped ST elevation and PR depression
CXR: cardiomegaly, pneumonia seen in bacterial pericarditis
ESR:high in autoimmune
WCC: high in infection
184
What ECG changes can be seen in pericarditis?
Widespread saddle-shaped ST elevation
PR depression
185
Describe the treatment for idiopathic, viral and bacterial pericarditis
NSAID's like aspirin for 2 weeks
Colchicine (antiinflammatory) for 3 weeks
Antibiotics if bacterial
186
Name some complications of pericarditis
Pericardial effusion->cardiac tamponade
Myocarditis
Constrictive pericarditis
187
What is pericardial effusion?
Accumulation of fluid in the pericardial space
188
How does pericarditis lead to cardiac tamponade?
Pericardial effusion->if large volumes of fluid that are enough to impair ventricular filling->cardiac tamponade
189
Describe the cause and risk factors of cardiac tamponade
Cause: pericarditis
RF: pericarditis related: viral, IA etc
190
Describe the signs and sympotms specific to cardiac tamponade
Beck's triad: hypotension, increased JVP, muffled S1+S2 heart sounds
Pulsus paradoxicus: fall of systolic BP of >10mmHg on inspiration
191
What is Beck's triad?
Seen in cardiac tamponade
Hypotension, increased JVP, muffled S1+S2 heart sounds
192
How is pulsus paradoxicus different to Kussmaul's sign?
Pulsus paradoxicus: fall in systolic BP >10mmHg on inspiration
Kussmaul's sign: Paradoxical increase in JVP with inspiration
193
How can cardiac tamponade be diagnosed?
ECG: electrical altermans: carying QRS amplitudes due to heart bouncing back and forth in extra pericardial fluid
CXR: big globular heart
Echo: diagnostic
194
What ECG changes can be seen in cardiac tamponade?
Electrical altermans
Varying QRS complexes due to heart bouncing in extra pericardial fluid
195
What is the treatment for pericardial effusion?
Treat underlying cause e.g. NSAID's and colcichine
196
What is the treatment for cardiac tamponade?
Urgent pericardiocentesis
197
What is infective endocarditis?
Infection of endocardium due to causative bacteria colonising abnormal endothelium and causing vegetation
198
Describe the causes of infective endocarditis
Bacteria:
S.aureus(mc in IVDU, T2DM, surgery)
S.Viridans (poor dental hygiene)
S. bovis(colon cancer), p.aeruginosa
HACEK organisms
199
Which bacteria tends to cause acute infective endocarditis?
S.aureus: sx onset days-weeks
200
Which bacteria tends to cause subacute infective endocarditis?
S. viridans: sx onset weeks-months
201
Which 2 clinical findings mean IE should be considered as a diagnosis?
Fever and new murmur
202
Name some risk factors for developing infective endocarditis
Male, elderly with prosthetic valves
Young IVDU
Young with congenital heart defect
Rheumatic heart disease
203
Which valve does IE typically affect and how is this different in IVDU?
Typically: Mitral valve(left side)
IVDU: Tricuspid(right side)
204
Describe the pathophysiology of infective endocarditis
Abnormal/damaged endocardium have higher platelet deposition which bacteria can adhere to and cause vegetation
Typically around valves
Can cause regurgitation (aortic and mitral insufficiency-> increased risk of heart failure
205
Describe the signs and symptoms of IE
Non specific: fever, non-specific new valve regurgitation, sepsis/emboli of unknown origin, petechiae
Specific:
Osler nodes(finger nodules)
Janeway lesions (painful marks on hands)
Splinter hemorrhages
Roth spots (retinal haemorrhage)
206
Which criteria are used to diagnose infective endocarditis?
Duke criteria
207
Describe the Duke criteria
Used to diagnose IE
2 major or 1 major+2 minor
Major:
>2 positive blood cultures
TOE echo shows vegetation
Minor:
Immunological signs
IVDU
Septic emboli
1 positive blood culture
Pyrexia
208
Describe the diagnosis of IE
ECG: prolonged PR-aortic root abscess
High ESR, CRP, neutrophilia
TOE echo: GS
Blood cultures: 3 sites over 24 hours
209
Describe the treatment of IE
S aureus: vancomycin and rifampicin (+gentamicin if prosthetic valve)
S viridans: Benzylpenicillin and gentamicin
For 4-6 weeks
Surgery to replace valve is incompetent
210
Name some potential complications of infective endocarditis
Heart failure
Aortic root abscess
Septic emboli->sepsis
211
What is regurgitation and what does it lead to?
Defective, floppy valve: leaks through
Causes insufficiency and proximal chamber dilation-loss of structural chamber integrity and strength
212
What is stenosis and what does it lead to?
Narrowed valve/lumen->increased upstream pressure
Causes proximal chamber hypertrophy and dilation
Heart becomes rigid: poorly compliant
213
Which main valve disorders cause murmurs?
Aortic regurgitation and stenosis
Mitral regurgitation and stenosis
214
How are murmurs best heard?
RILE
Right side defects(pulmonary/tricuspid valves)-insipration
Left side defects(aortic/mitral valves)-expiration
215
After which heart sounds do systolic and diastolic murmurs occur?
Systolic: after S1
Diastolic: after S2
216
Are most murmurs systolic or diastolic?
Systolic
217
In which valvular conditions can you hear systolic murmurs?
ASMR:
Aortic stenosis
Mitral regurgitation
Also:
Mitral valve prolapse
Tricuspid regurgitation
218
In which valvular conditions can you hear diastolic murmurs?
ARMS:
Aortic regurgitation
Mitral stenosis
219
Where is the aortic valve found?
Between the left ventricle and aorta
220
What is aortic stenosis?
Narrowing of the aortic valve resulting in obstruction to the left ventricular stroke volume
221
What is the normal area of the aortic valve?
3-4cm2
222
At what lumen size would you begin to experience symptoms with aortic stenosis?
1/4 of lumen size so 0.75-1cm2
223
What is the most common valve disorder?
Aortic stenosis
224
What changes to he heart does aortic stenosis result in?
LV dilation and hypertrophy
225
Name 2 conditions that can cause S4
Aortic stenosis
Hypertrophic cardiomyopathy-associated with sudden death in young men
226
Describe the causes of aortic stenosis
Calcificied aortic heart disease
Congenital bicuspid aortic valve(normally tricuspid)
Rheumatic heart disease
227
Describe the pathophysiology of aortic stenosis
Narrowing of aortic valve->decreased stroke volume->increased afterload->increased LV pressure->compensatory LVH->increased oxygen demand->ischaemia
228
Describe the signs/symptoms of aortic stenosis
Syncope
Angina
Dyspnoea
Ejection systolic crescendo-decrescendo murmur
229
How can aortic stenosis be diagnosed?
ECG
CXR: LVH, calcified aortic valve
Echo: LV size and function, doppler derived gradient and valve area
230
Describe the murmur associated with aortic stenosis
Ejection systolic crescendo-decrescendo
Radiating to carotids
Right sternal border
2nd IC space
Prominent S4:LVH
Narrow pulse pressure + slow rising pulse
231
Describe the treatment for aortic stenosis
Surgical aortic valve replacement
TAVI(transcutaneous Aortic Valve Implantation)-more at risk patients, stents valve open
232
What is mitral stenosis?
Stenosis of the mitral valve->prevents proper LV filling
233
What is the normal lumen size of the mitral valve and at what size would you expect mitral stenosis symptoms?
4-6cm2
Sx when <2cm2
234
Name some risk factors for developing mitral stenosis
Men
Hx of rheumatic fever
Ageing
235
Name some causes of mitral stenosis
Rheumatic heart disease-most common, post strep pyogenes infection
Valve calcification-older patients
Infective endocarditis
236
Describe the pathophysiology of mitral stenosis
RHD disease causes mitral reactive inflammation-exacerbated over years with calcification->obstruction of blood flow from left atrium to left ventricle->LA pressure increases causing hypertrophy and dilation
237
Describe the symptoms of mitral stenosis
Malar cheek flush
Dyspnoea
Dyspnoea
Haemoptysis
Oedema
Low pitched mid diastolic murmur
238
Describe the murmur and heart sounds associated with mitral stenosis
Low pitched mid diastolic murmur
Loudest at apex
Best heard on expiration with patient lying on LHS
239
Describe the investigations carried out to diagnose mitral stenosis
Echo: assess valve area, gradient, mobility
ECG: AF and left atrial enlargement
CXR: Pulmonary oedema, LA enlarged
240
Describe the surgical treatment of mitral stenosis
Mitral valve replacement
Percutaneous mitral balloon valvotomy
241
Which heart condition is associated with mitral stenosis and why?
AF
Causes left atrium hypertrophy->more chances of embolisation as blood is actively pumped from LA harder->Afib
