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Phase 4 > Cardiology > Flashcards

Cardiology Flashcards

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1
Q

Describe hypertrophic obstructive cardiomyopathy (HoCM)

A

AD disorder

clinical features
- asymptomatic
- exertional dyspnoea
- syncope
- angina
- jerky pulse

  • ejection systolic murmur
    > louder on Valsalva, quieter on squatting
  • sudden cardiac death is mainly caused by ventricular arrhythmias (males > females)
  • can happen at rest or exercising
  • S4 heart sound
  • associated with Freidreich’s ataxia and Wolff Parkinson White

Echo
- systolic anterior movement (SAM) of anterior leaflet of mitral valve - mitral regurgitation
- asymmetric septal hypertrophy

ECG
- Non-specific ST segment and T wave abnormalities, progressive T wave inversion
- Deep Q waves

treatment
> ICD
> amiodarone (prevention)

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2
Q

Name scores used to determine risk of stroke in AF

A

CHA2DS2VASc
> CHF
> Hypertension
> Age >75
> Diabetes
> Stroke / TIA / VTE
> Vascular disease
> Age 65-74
> Female

If >=2 consider anticoagulation

ORBIT

prescribe DOAC even if single episode of paroxysmal AF

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3
Q

Describe the management of SVT

A

Regular narrow complex tachycardia

Acute management

vagal manoeuvres:
> Valsalva manoeuvre
> carotid sinus massage

intravenous adenosine
> rapid IV bolus of 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mg
> contraindicated in asthmatics - verapamil is a preferable option

DC electrical cardioversion

Prevention of episodes
beta-blockers
radio-frequency ablation

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4
Q

Describe Eisenmenger’s syndrome

A

Reversal of a left-to-right shunt in a cogenital heart defect due to pulmonary hypertension

Uncorrected left-to-right results in remodelling of the pulmonary microvasculature leading to pulmonary hypertension

associated with
- ventricular septal defect
- atrial septal defect
- patent ductus arteriosus

Features
- original murmur may disappear
- cyanosis
- clubbing
- right ventricular failure
- haemoptysis, embolism

CXR: cardiomegaly and pulmonary engorgement

Management: heart-lung transplant

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5
Q

describe the murmur associated with a VSD

A

Blowing pansystolic murmur

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6
Q

Describe the causes of infective endocarditis

A

IVDU (typically causing tricuspid lesion)
- staph aureus (most common)
> tricuspid regurgitation: pansystolic murmur heard loudest over left lower sternal edge, louder during inspiration

Post-valvular surgery (first 2 months post-surgery)
- staphylococcus epidermis (coagulase negative staph or CoNS)

Streptococcus bovis is associated with colon cancer

Streptococcus viridans is the most common cause in developing countries (streptococcus mitis, streptococcus sanguinis) - mouth and dental plaques, caused by poor dental hygiene or following dental procedures

Non-infective
- Systemic lupus erythematosus (Libman-Sacks)
- Malignancy: marantic endocarditis

Culture negative causes:
- prior antibiotics
- Coxiella burnetii
- HACEK: Haemophilus, actinobacillus, cardiobacterium, eikenella, kingella

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7
Q

Describe the management of NSTEMI

A

Aspirin + ticagrelor + fondaparinux
> give unfractionated heparin if patient is undergoing PCI

Clopidogrel instead of ticagrelor if patient at high risk of bleeding

Consider PCI
> coronary angiography within 72h if GRACE score >3%

Nitrates can be given if no hypotension present

Cannot drive for 4 weeks post-MI

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8
Q

describe the initial management of ACS

A
  • Aspirin 300mg
  • Oxygen if sats <94
  • Morphine if severe pain
  • Nitrates if not hypotensive
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9
Q

Describe the management of a STEMI

A

Coronary reperfusion therapy

  • Percutaneous coronary intervention (PCI)

> If presentation is within 12h of onset of symptoms and PCI can be delivered within 120 minutes
dual antiplatelet i.e. aspirin and one of the options below
if patient not on anticoagulant: prasugrel
if patient on anticoagulant: clopidogrel

  • Fibrinolysis if primary PCI cannot be given
    > alteplase + fondaparinux
    > repeat ECG in 60-90 mins and transfer for urgent PCI if ST elevation has not resolved
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10
Q

describe Brugada syndrome

A

Sodium channelopathy causing a high incidence of sudden death in patients with structurally normal hearts

Features
- ECG abnormality
> coved ST elevation in >1 of V1-V3 followed by a negative t wave

  • and one of the following criteria:
  • documented VF
  • polymorphic VT
  • family history of sudden cardiac death <45 yrs old
  • coved type ECGs in family members
  • syncope
  • nocturnal agonal respiration
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11
Q

describe mitral stenosis

A

main cause is rheumatic fever

features
- dyspnoea
- haemoptysis
- mid-late diastolic murmur
- loud S1
- opening snap (indicates mitral valve leaflets are still mobile)
- low volume pulse

CXR - left atrial enlargement

management
- if associated with AF, anticoagulate with warfarin / DOAC
- asymptomatic: monitor
- symptomatic: percutaneous mitral balloon valvotomy

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12
Q

which medication used in the treatment of angina can be associated with tolerance?

A

isosorbide mononitrate

may need changes in dosing regimes

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13
Q

list coronary arteries responsible for MI and the leads they are associated with

A

anteroseptal
> V1-V4
> LAD

inferior
> II, III, aVF
> RCA

anterolateral
> V1-6, aVL
> proximal LAD

lateral
> I, aVL +/- V5, V6
> left circumflex

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14
Q

describe the ECG features in posterior MI

A

ECG features
- tall R waves in V1 and V2
- confirmed by ST elevation and Q waves in posterior leads

affected vessel: left circumflex, right coronary

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15
Q

what kind of infarct can cause bradycardia or arrythmias?

A

right coronary infarct as this supplies AV node

> leads II, III and aVF

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16
Q

describe the management of acute heart failure

A

oxygen aiming for 94-98%

IV furosemide

nitrates if concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease
> contraindication - hypotension

If still hypoxic: CPAP

if hypotensive
> dobutamine
> norepinephrine
> mechanical circulatory assistance: intra-aortic balloon counterpulsation, ventricular assist devices

regular medications for heart failure like beta-blockers or ACEi should be continued unless shock, <50 bpm, 2nd or 3rd degree heart block

17
Q

describe arrhythmogenic right ventricular dysplasia (ARVD)

A

AD inherited cardiac disorder that is the second most common cause of sudden cardiac death after HOCM

pathophysiology - right ventricular myocardium is replaced by fatty and fibrofatty tissue

features
- palpitations
- syncope during exertion
- family history of sudden cardiac death in relative <40 years old

ECG findings
> epsilon wave: small positive deflection at the end of QRS
> T wave inversion in leads V1-3

Echocardiogram
> enlarged hypokinetic right ventricle with a thin free wall

management
- sotalol as antiarrhythmic
- catheter ablation to prevent VT
- implantable cardioverter defibrillator (ICD)

18
Q

describe Naxos disease

A

AR variant of ARVD

triad of ARVD, palmoplantar keratosis and woolly hair

19
Q

describe aortic stenosis and its management

A

clinical features of symptomatic disease
- chest pain
- dyspnoea
- syncope
- ejection systolic murmur radiating to carotids

features of severe aortic stenosis
- collapsing pulse
- thrill
- narrow pulse pressure
- S4
- left ventricular hypertrophy or failure

causes
- degenerative calcification
- bicuspid aortic valve
- post-rheumatic disease
- subvalvular: HOCM
- William’s syndrome: supravalvular aortic stenosis

investigations
- echocardiogram: assess pressure gradient and surface area of valve
> elevated aortic pressure gradient, reduced valve area, reduced left ventricular ejection fraction, LVH

management
- asymptomatic: observe
> consider surgery if valvular pressure gradient >40 mmHg and LVSD

  • symptomatic: valve replacement
    > surgical AVR if young
    > TAVI (transcatheter aortic valve replacement) if high risk
    > balloon valvuloplasty in children or adults not fit for valve replacement

nitrates are contraindicated, give furosemide for symptomatic relief

20
Q

Describe ventricular septal defect and its management

A
  • most common cause of congenital heart disease

aetiology
- associated with chromosomal disorders such as Down’s syndrome, Edward’s syndrome, Patau syndrome, cri-du-chat syndrome
- congenital infections
- acquired causes e.g. post-MI

Post-natal presentation
- failure to thrive
- features of HF
> hepatomegaly
> tachypnoea
> tachycardia
> pallor

Classically a pan-systolic murmur heard louder in small defects

Management
- small VSDs often close spontaneously - monitor
- large VSDs: medication for HF e.g. diuretics, surgical closure of defect

Complications
- aortic regurgitation
- IE
- Eisenmenger’s complex
- right heart failure
- pulmonary hypertension

21
Q

list complications following MI

A
  • left ventricular free wall rupture
    > within 48h
    > chest pain, muffled heart sounds
    > widespread ST elevation
  • left ventricular aneurysm
    > S3, S4 heart sounds
    > persistent ST elevation
    > gradual onset pulmonary oedema
  • ventricular septal defect
    > pansystolic murmur
    > acute pulmonary oedema
  • mitral valve prolapse
    > 2-7 days post-MI
    > sudden pulmonary oedema
    > sinus tachycardia
    > prominent murmur
  • Dressler’s syndrome
  • heart failure
  • re-infarction
  • death
22
Q

describe an atrial septal defect (ASD)

A

asymptomatic in childhood

only progress to give symptoms if they remain untreated to adulthood

murmur: ejection systolic murmur louder on inspiration
> murmur radiates to the back
> fixed S2 splitting

if left-to-right shunt exists, paradoxical embolisation can occur
> Stroke in young patients

23
Q

Describe the management of chronic heart failure

A

First-line for all patients:
- ACEi + beta-blocker
> start one drug at a time

Second-line
- aldosterone antagonist aka mineralocorticoid receptor antagonist e.g. spironolactone, eplerenone

  • SGLT2i

Third-line
- ivabradine
- sacubitril valsartan (ARNI)
- hydralazine + nitrate
- digoxin
- cardiac resynchronisation therapy (CRT)

offer annual influenza vaccine + one-off pneumococcal vaccine
> those with asplenia, splenic dysfunction of CKD need a booster every 5 years

24
Q

describe ECG changes associated with mitral stenosis

A

P mitrale
- left atrial hypertrophy/strain e.g. in mitral stenosis
- broad, notched (bifid) P waves
> most pronounced in lead II

25
Q
A

Phase 4 (14 decks)

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