Cardiology Flashcards
Red flags for chest pain?
> acute onset
exertional pain
substernal /left sided pain
quality = crushing, pressure
new murmur
associated SOB
radiation to left arm, jaw or back
distant heart sounds
chest wall crepitus
hypotension
difference >20mmHg in systolic be between arms
pulses paradoxus
hypoxia
What are the life threatening causes of chest pain to rule out?
1) MI (STEMI vs nstemi vs unstable angina)
2) PE
3) aortic dissection
4) tension pneumothorax
5) cardiac tamponade
6) oesophageal rupture
Differential in a pain with chest pain
Cardiac causes
>MI
>pericarditis
>angina
>pulmonary embolism
>pulmonary hypertension
>aortic dissection
Non cardiac causes
>peptic ulcer disease
>spontaneous pneumothorax
>gastro-oesophageal reflux
>herpes zoster
>musculoskeletal disorder
>anxiety
What causes an S3 sound?
The rapid filling and deceleration of blood in the ventricle during diastole when the ventricle reaches its diastolic limit (best heard in mitral region)
In what conditions will you hear a pathological S3?
Chronic mitral regurgitation
Aortic regurgitation
Dilated cardiomyopathy
Heart failure
Thyrotoxicosis
When is an S3 heart sound normal?
Young (less than 40)
Pregnancy
Athletes
What scoring system is used to determine likelihood of PE?
Wells score
What are secondary causes of hypertension?
ROPE
Renal disease
Obesity
Pregnancy induced
Endocrine (hyperthyroid, hyperaldosteronism)
Complications of hypertension
Ischaemic heart disease
Hypertensive retinopathy
Hypertensive nephropathy
Stroke (CVI)
Heart failure
Target organ damage caused by hypertension
1) Heart
>cardiomyopathy
>MI
>arrhythmias
>left ventricular hypertrophy
>aortic valve insufficiency
2) Aorta
>aortic dissection
>artherosclerosis
>aneurysm
3) Peripheral arteries
>artherosclerosis
4) Renal
>CKD
5) Brain
>stroke
>dementia
Side effect of ACE-I
Dry cough
Side effect of ARB
Angioedema
Presentation of hypertension
Usually silent
Non specific signs
>chest palpitations
>headaches in the early morning
>dizziness
>fatigue
>epistaxis
Risk factors for hypertension
Non-modifiable
>positive family history
>advanced age
>ethnicity
Modifiable
>obesity
>diabetes
>smoking
>excessive alcohol intake
>poor diet (high in salt)
>physical inactivity
>psychological stress
Difference between hypertensive urgency or hypertensive emergency
Both = BP >180/110
But urgency: no signs of end organ damage
Emergency: signs of end organ damage
Red flags in a hypertensive crisis
Dyspnoea
Chest pain
Altered mental status
Focal neurological deficit
Define heart failure
When the heart is unable to pump enough blood to meet the metabolic demands of the body due to pathological changes in the myocardium
What are the stages of heart failure according to the American heart association?
A = at risk
B = abnormal heart structure but no signs/symptoms (previous MI, elevated BNP, asymptomatic valvular disease, LVH)
C = abnormal structure and symptomatic HF
D = end stage (need of heart transplant)
What is the functional classification of HF according to the New York Heart Association?
I: No limit to physical activity. No sx HF
II: slight limitation to moderate/prolonged physical activity (sx after climbing 2 flights of stairs) Comfortable at rest
III: Marked limitations during physical activity including activities of daily living. ONLY comfortable at rest
IV: Confined to bed. Symptoms at rest
Define syncope
A sudden loss of consciousness due to decreased cerebral perfusion
Define presyncope
A lightheadedness where the patient things he or she will fall down
Most important to rule out in pt with acute chest pain:
> pulmonary emboli
MI
pericardial effusion
haemo/pneumothorax
aortic dissection
ruptures oesophagus
Causes of sinus bradycardia
Hypothermia
Hypothyroidism
Drugs
Causes of sinus tachycardia
Pregnancy
Exercise
Increased sympathetic activity
Other = anaemia, fever, drugs
Differential diagnosis for prolonged QT interval
Electrolyte imbalances
>hypokalaemia
>hypocalcaemia
>hypomagnesaemia
Hypothermia
Drugs (anti-arhythmic)
Congenital
Cardiomyopathy
CAD
CNS Injury
ECG changes in Hyperkalaemia
Initially peaked, tall, symmetrical T waves then
>ST segment depression
>prolonged QT interval
>widened QRS
>flattened P wave
>prolonged PR
Wolf Parkinson white syndrome ECG features
TRIAD
1) shortened PR interval <0,12secs
2) broad QRS complex >0,12secs
3) delta wave or slurred upstroke of QRS complex
Phases of an acute MI on ECG
1) tall upright/inverted T-waves
2) ST elevation (leads facing infarcted wall = upright, opposite leads = ST depression)
3) 8-12hrs after MI = new pathological Q wave
Cardiovascular causes of syncope
> tachyarrythmias (VT, a-flutter, a-fib)
bradyarrythmias (2nd or 3rd degree heart block, sinus bradycardia)
primary pulmonary hypertension
left ventricle outflow lesion (stenosis, hypertrophic cardiomyopathy)
left ventricle inflow obstruction (mitral stenosis)
What causes a 4th heart sound?
The atria contracting against the high pressures of the ventricles at the end of diastole
What are the pathological causes of S4 if palpable?
Ventricular hypertrophy
Ischaemic cardiomyopathy
Acute MI
Causes of left axis deviation on ECG
Wolf Parkinson white syndrome
Deep Q wave inferior infarct
Left anterior hemi-block
Primula ASD
Causes of right axis deviation on ECG
Wolf Parkinson white syndrome
Left posterior hemi-block
Antero-lateral infarct
Right ventricular hypertrophy
Differential for tall R wave in V1
Right ventricular hypertrophy
Right bundle branch block
Wolf Parkinson white syndrome
True posterior infarct
Duchesses muscular dystrophy
Define a Q wave
A negative deflection not preceded by a positive deflection
Causes of ST depression
Non-STEMI MI
Myocardial ischaemia
Digoxin
Ventricular hypertrophy with systolic overload
Posterior infarct (in septal leads)
Reciprocal changes of an infarct in opposite wall
Causes of ST elevation
Acute MI
Pericarditis
Ventricular aneurysm
Prinzmetal angina (ischaemia caused by coronary spasm)
Causes of flattened T waves
Ischaemia
Pericarditis
Myocarditis
Hypercalcaemia
Causes of peaked T waves
Acute MI
Hyperkalaemia
Causes of T wave inversion
Bundle branch block
MI
Myocardial myopathy
Ventricular hypertrophy
Wolf Parkinson white syndrome
Ventricular rhythms
Normal in septal leads of black patients
Causes of prolonged QT interval
Congenital
Hypomagnesaemia
Hypocalcaemia
Hypokalaemia
Drugs (TCA, anti-arrhythmics)
Ischaemia/infarction
Cause of shortened QT interval
Hypercalcaemia
Phases of acute MI on ECG
1) tall upright/inverted T waves
2) STEMI (elevated in leads facing wall, depressed in opposite)
3) new pathological Q wave
Causes of atrial fibrillation
Rheumatic heart disease
Ischaemic heart disease
Cardiomyopathy
Hypertensive heart disease
Thyrotoxicosis
Other
>alcohol
>PE
>pericardial disease
>digoxin toxicity
>chest infection, pain, surgery (triggers)
Precipitating causes of HF (acute or acute-on-chronic)
MI
PE
Intercurrent illness
Decreased meds/pt not taken meds
IV fluid overload
Increased demand (anaemia, pregnancy, thyrotoxicosis)
Arrthymia
Clinical features of infective endocarditis
FROM JANE
Fever
Roths spots (retinal haemorrhages) - yellow centre with red ring
Oslers nodes (painful immune complexes)
Murmur
Janeway lesions (non-tender macular microabscesses from septic emboli)
Anaemia
Nail bed haemorrhages
Emboli
Other:
Acute Renal injury
Neurological manifestations
Signs of PE
Arthritis
Splenomegaly
Common pathogens causing infective endocarditis
Staph aureus
Strep Viridans
Staph epidermidis
Enterococci
Fungal
Coxiella bernetti (can be culture neg) - gram neg doesn’t grow
Criteria used for infective endocarditis
Dukes Criteria
Major
1) Positive blood culture for typical organisms
>2 positive blood cultures from 2 different sites at least 24 hours apart
>persistently positive 12 hours apart
>1 positive culture for coxiella burnetti
2) vegetation’s seen on echo
Minor
>fever >38
>predisposing factor
>immunological phenomenon (splinter haem or janeway lesions)
>positive blood culture that doesn’t meet major criteria
>vascular abnormalities
2 major OR 1 major + 3 minor OR 5 minor
What does a PE look like on chest X-ray?
Wedge shaped infarct (Hampton Hump), Westermark sign, Fleisher sign
Signs of digoxin toxicity
CNS = headache, seizures, confusion
GIT = nausea and vomiting, anorexia
CVS = ECG changes (AV block, tachyarrhythmias)
Eyes = halos, altered colour perception
Other = gynaecomastia, rash
ECG = paroxysmal atrial tachycardia + AV block
First for second degree (Mobitz 1) AV block
How to tell if it’s a functional murmur
Usually systolic (hyper dynamic circulation)
Usually <3 grade
Midsystolic/continuous
Position dependent
AV firing rate of pacemaker cellls
40-60 per minute
Firing rate of purkinje fibre pacemaker cells
20-40 per minute
What is the normal ejection fraction?
60-65%
What does an increased troponin level indicate?
Myocardial necrosis (NOT ischaemia)
What can mimic acute coronary syndrome?
Cardiac
>left valvular disease
>hypertrophic CMO
>uncontrolled HPT
>pericarditis
>aortic dissection
Lung
>PE
>pneumonia
GORD
Arthritis
What does BNP stand for?
Brain natriuretic peptide
