Cardiology Flashcards
Indications for Lipid lowering therapy
1) Primary prophylaxis if CVD High Risk i.e. a 15% chance of CV event in 5 years
2) Secondary prophylaxis post ACS or stroke
Causes of heart failure
Causes of secondary hypertension
- Primary Aldosteronism (low K) High Aldos low Renin
- Renovascular hypertension (High Renin and Aldos)
- Liddles syndrome
- Licorice
- Cushings
- OSA
ECG of LVH
- V1 S wave >35mm
- V5/6 R wave >35mm
- LAD
- LV Strain: ST depression / TWI V5-6
Blood pressure treatment target
< 140
<120 if mod - High cardiovascular risk
Conservative BP Management
- Weight loss (1kg reduced systolic by 2mm/Hg) –> Aim BMI <25 and Waist <94cm M or <80cm women
- CPAP
- Exercise
- Alcohol reduction
- Salt reduction (between 3-5grams)
Management strategy for uncontrolled Hypertension
- poor adherence 1
- hyperaldosteronism(investigateandaddspironolactone)orotherrareprimarycause
(e.g. Cushing’s syndrome, coarctation) and recommend: - attempted weight loss
- salt and alcohol restriction
- exercise
- sleep apnoea treatment (if indicated).
Evaluation for Heart Transplant
Immunosuppresion in Heart Transplant
Ciclosporin or Tacrolimus
Diltiazem often used as cyclosporin agent to reduce dose required.
*SE = Hyperlipidaemia and Hypertension
Routine tests post heart transplant
- Weekly biopsy 1 weeks then fortnightly for 1 month then 6 monthly routinely
- Twice annual CAG -> at risk of premature CAD (allograft arteriopathy) and as denervated heart it is typically painful
Survival post Cardiac Transplant
1 year –> 90%
5 year –> 75%
10 year –> 50%
Treatment of Cardiac Allograft Rejection
Endomyocardial biopsy
3 days Methylprednisolone
Rebiopsy
- Other Rx: ATG, Muronumab
Aetiology of Atrial Fibrillation
- Advancing age
- OSA
- Alcohol use
- WPW
- Hypertension
- Mitral valve disease (MR or MS)
- HCM
- IHD
- Recent thoracic or abdominal surgery
- ASD
- PE
- Thyrotoxicosis
Dominant A wave
Pulmonary hypertension
Tricuspid stenosis
Pulmonary stenosis
Canon A Wave
AV Block
Ventricular Tachycardia
Dominant V Wave
Tricuspid regurgitation
Elevated Central venous pressure
-Right heart failure
-Tricuspid stenosis / regurgitation
-Pericardial effusion / constrictive pericarditis
-SVC obstruction
-Fluid overload
-hyperdynamic circulation (fever, anaemia, thyrotoxicosis)
Apex beat
-Sustained -> pressure loaded i.e AS / HTN
-Hyperkinetic / volume overloaded in MR / AR
-Double impulse in HCM
Left Parasternal impulse
Right ventricular hypertrophy or Left atrial enlargement
1st heart sound
Loud: Mitral stenosis, Tricuspid stenosis.
Soft: mitral regurgitation, left bundle branch block, 1st degree heart block
Second Heart sound
Aortic:
-Loud: hypertension, mechanical valve.
-Soft: Aortic Stenosis, Aortic regurgitation.
Pulmonary:
- Loud: pulmonary HTN,
- Soft: Pulmonary Stenosis
Fixed Split S2:
* heard throughout entire cardiac cycle best at P2
- Pulmonary stenosis
- Pulmonary hypertension
- ASD
- RBBB
Reversed Splitting (P2 first)
*Split heard only during expiration
- LBBB
- Aortic stenosis
Third Heart sound
Rapid filling of compliant ventricle.
*differs from split S2 as it is low pitched (should disappear with diaphragm and be present with bell) Also best heart at a apex as opposed to P2
May be normal under 40YOA
aetiology:
- AR
- MR
- LVF
Fourth heart sound
*Always pathological
Filling of poorly compliant ventricle
Aetiology:
- Aortic stenosis
- Hypertension
- Ischaemic heart disease
- HCM
Differential diagnosis of murmur
Mitral Stenosis
TTE severity: <1cm
Causes:
- Rheumatic
- Mitral annular calcificacation (Calcific)
- Congenital
- After mitral valve repair
Signs of severity:.
- Small pulse pressure
- Early opening snap
- Diastolic thrill at apex
- Presence of pulmonary Hypertension (Loud P2, Split S2, RHF, Heave)
- Length of the diastolic murmur (louder worse)
Investigation:
- ECG: Pmitrale, AFib, RAD
- CXR: big left atrium, mitral annular calcification, pruned peripheral arteries, large central pulmonary arteries
Treatment:
- Surgery when symptomatic and valve area <1cm
Mitral Regurgitation
Cause:
Chronic
- Myxomatous degeneration
- Mitral valve prolapse
- Rheumatic
- Papillary muscle dysfunction secondary to ischaemia or LV failure
- Connective tissue disease (RA or Ank Spond)
Acute:
- ACS
- Infective endocarditis
Signs of severity:
- Enlarged LV
- Pulmonary hypertension
- S3
- Soft 1st heart sound
- Small volume pulse
- LV failure
Management:
- Consider surgery if Class III / IV symptoms
- Evidence of reduced LV function
Mitral valve prolapse
Present in 3% of adults
Late systolic murmur
- Longer with Valsalva
- Shorter with ISM Handgrip
Associations:
- Marfans
- ASD
Complications:
- MR
- Infective endocarditis
Aortic Regurgitation
Aetiology:
- Rheumatic
- Congenital (Bicuspid valve)
- Seronegative Arthropathy (Ankylosing Spondylitis)
- Marfans
- Dissection / Aortic aneurysm
- Old age
- Infective endocarditis
Signs of severity:
- Collapsing pulse
- Wide pulse pressure
- Length of diastolic murmur
- Third heart sound
- Soft A2
- Austin fint murmur (diastolic rumble caused by limitation to mitral inflow)
- Left ventricular failure
Management:
- Symptoms
- Worsening LV function
- LV dilatation end systolic > 5.5cm
Aortic Stenosis
Aetiology:
- Bicuspid aortic valve
- Calcific
- Rheumatic
Signs of severity:
- Plateau pulse
- Soft s2
- S4
- Signs of LV failure
- Aortic Thrill
- Paradoxical splitting S2
Tricuspid regurgitation
Aetiology:
- Functional due to RHF
- Endocarditis
- Rheumatic
- Congenital (Ebsteins)
- Right Vent papillary infarction
Signs:
- Enlarged V wave
- Elevated JVP if assoc. RHF
- Pansystolic murmur loudest LLSE on inspiration
- RV heave
- Enlarged pulsatile liver
- Ascites
More circle appearing one is mitral valve replacement
Pulmonary Stenosis
Aetiology:
- Congenital (Noonans)
- Carcinoid syndrome
Signs:
- Peripheral cyanosis
- Giant A waves + Elevated JVP
- RV heave
- Harsh ejection systolic murmur at LUSE on inspiration
- S4
How to measure pulsus paradoxes
Listen to when 1st kortakoff sound heard this is systolic blood pressure with expiration.
Deflate until 1st kortakoff sound heard constantly during inspiration and expiration.
If the difference is >10mmg this is a positive pulsus paradoxus
Hypertrophic Cardiomyopathy
Signs:
-Ejection Systolic murmur loudest at LLSE
-Louder with Valsalva / Sit to stand.
-Sharp jerky pulse
-Prominent A wave due to forceful contraction agains non-compliant ventricle
-apex beat double or triple impulse
- S4
Investigations:
- ECG: LV hypertrophy, conduction defects
- TTE: hypertrophy of septum >1.3 LV free wall, Systolic anterior motion of mitral valve
Atrial septal defect
Types: Secundum and non-secundum (ostium primum)
Signs:
- Fixed split S2
- pulmonary systolic ejection murmur louder on inspiration
- Pulmonary hypertension
Investigation:
- TTE: Doppler detection at atrial level, shunt on bubble study, may need TOE
Management:
- Repair all defects if left to right shunt. If reversal of shunt no intervention
- Percutaneous for secundum
- Non-secundum need surgical closure q
Ventricular septal defect
Aetiology:
- Down syndrome
Signs:
- pansytolic murmur loudest at LLSE
- Louder with Isometric handgrip
Management:
- Closure if left to right shunt is moderate to severe >1.5 to 1 (Qp:Qs)
Indicates shunt is present
PDA
Continous machine like murmur due to connection from aorta to pulmonary artery.
Loudest at supraclavicular fossa
Coarctation
Assoc with Turners
Typically distal to left subclavian.
Hypertension in arms not legs
CXR findings: small aortic nuckle, rib notching
Cyanotic Congenital Heart defects
- TOF
- Eisenmengers secondary to ASD, VSD, PDA
- Truncus arteriousus
Eisenmengers Signs
Cyanosis
Clubbing
Pulmonary hypertension (RV heave, palpable P2, loud P2)
Collapsing Pulse
Feel at Wrist and forearm. rapidly raise above head.
If felt in forearm not wrist this is positive.
Assoc: AR and high output states (Thyrotoxicosis / pregnancy)
Hypertensive Retinopathy
- AV nipping / silver wiring
- Cotton wool spots
- Flame haemorrhages
- Papilloedema
Hypertension Examination
General inspection:
- Cushings, Acromegaly.
Radial pulse / delay to indicate coarctation
Blood pressure both arms and legs.
Fundoscopy
Cardiovascular: signs of complications ie. LVH, S4, LV failure.
Abdomen: Renal bruits, abdominal aneurysm, renal/ adrenal masses.
Marfans Findings
-Enlarged arm span (greater than height)
-Sclerodactyly
-Dislocated lens
-High arched palate
-Long narrow face
-pectus carinatum / excavatum
-Scoliosis
-Aortic regurgitation murmur or mitral valve prolapse, aortic root dilatation
Causes of peripheral oedema
- Drugs (CCB)
- Cardiac failure
- Nephrotic syndrome
- Cirrhosis
- Hypoalbunaemia
- Protein loosing enteropathy
- Myxoedema
- Compression of IVC
Cardiac Driving Restrictions
