Cardiology Flashcards
Describe hypertrophic obstructive cardiomyopathy (HoCM)
AD disorder causing cardiac hypertrophy, usually septal
clinical features
- asymptomatic
- exertional dyspnoea
- syncope
- angina
- jerky pulse
murmur: ejection systolic
> 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
management
> beta-blockers first-line
> ICD
> surgical myectomy, alcohol septal ablation, heart transplant
Name scores used to determine risk of stroke in AF
CHA2DS2VASc
> CHF
> Hypertension
> Age >75 (2)
> Diabetes
> Stroke / TIA / VTE (2)
> Vascular disease
> Age 65-74
> Female
If >=2 in females or >=1 males, consider anticoagulation
prescribe DOAC even if single episode of paroxysmal AF
Describe the management of SVT
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
Describe Eisenmenger’s syndrome
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
describe the murmur associated with a VSD
Blowing pansystolic murmur
Describe the causes of infective endocarditis
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
Describe the management of NSTEMI
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
describe the initial management of ACS
- Aspirin 300mg
- Oxygen if sats <94
- Morphine if severe pain
- Nitrates if not hypotensive
Describe the management of a STEMI
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
> Offer unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor + dual antiplatelet therapy if undergoing primary PCI with radial access
- Fibrinolysis if primary PCI cannot be given within 120 mins
> alteplase + fondaparinux
> repeat ECG in 60-90 mins and transfer for urgent PCI if ST elevation has not resolved
describe Brugada syndrome
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
describe mitral stenosis
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
which medication used in the treatment of angina can be associated with tolerance?
isosorbide mononitrate
may need changes in dosing regimes
list coronary arteries responsible for MI and the leads they are associated with
anteroseptal
> V1-V4
> LAD
inferior
> II, III, aVF
> RCA
> AV block can occur following inferior MI
anterolateral
> V1-6, aVL
> proximal LAD
lateral
> I, aVL +/- V5, V6
> left circumflex
describe the ECG features in posterior MI
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
what kind of infarct can cause bradycardia or arrythmias?
right coronary infarct as this supplies AV node
> leads II, III and aVF
describe the management of acute heart failure
SODIUM
- Sit up
- Oxygen aiming for 94-98%
- Diuretics: IV furosemide
- IV fluids should be STOPPED
- Underlying causes treated
- Monitor fluid balance
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
describe arrhythmogenic right ventricular dysplasia (ARVD)
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)
describe Naxos disease
AR variant of ARVD
triad of ARVD, palmoplantar keratosis and woolly hair
describe aortic stenosis and its management
clinical features of symptomatic disease (worse on exertion)
- chest pain
- dyspnoea
- syncope
- heart failure
- pulsus tardus et parvus (weak and late)
- murmur: ejection systolic murmur radiating to carotids
> fixed splitting of heart sounds
> Gallavardin phenomenon: auscultation at cardiac apex reveals a holosystolic murmur that sounds like mitral regurgitation
features of severe aortic stenosis
- collapsing pulse
- thrill during systole
- narrow pulse pressure
- S4
- left ventricular hypertrophy or failure
causes
- degenerative calcification
- bicuspid aortic valve
> click heard start of systole
- 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
Describe ventricular septal defect and its management
most common cause of congenital heart disease
aetiology
- associated with chromosomal disorders e.g. 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
murmur: pan-systolic murmur heard at the lower left sternal border
> louder in small defects
Management
- small VSDs often close spontaneously - monitor
- large VSDs:
> medication for HF e.g. diuretics
> pulmonary artery banding
> surgical closure: transvenous catheter closure, open heart surgery
Complications
- aortic regurgitation
- infective endocarditis
- Eisenmenger’s syndrome
- right heart failure
- pulmonary hypertension
list complications following MI
- left ventricular free wall rupture
- left ventricular aneurysm
- ventricular septal defect
> pansystolic murmur
> acute pulmonary oedema - mitral valve prolapse
> 2-7 days post-MI
> sudden pulmonary oedema
> sinus tachycardia
> late systolic murmur accompanied by mid-systolic click - Dressler’s syndrome
- heart failure
- re-infarction
> test with creatine kinase MB (CK-MB) - death
describe an atrial septal defect (ASD)
asymptomatic in childhood
only progress to give symptoms if they remain untreated to adulthood
murmur: mid-systolic, crescendo-descrescendo murmur heard loudest at upper left sternal border
> murmur radiates to the back
> fixed S2 splitting
if left-to-right shunt exists, paradoxical embolisation can occur
> Stroke in young patients with DVT (embolus bypasses lungs)
management:
> small: monitor
> large: catheter-based closure / open heart surgery
complications: stroke, pulmonary hypertension, right-heart failure, Eisenmenger syndrome
Describe the management of chronic heart failure
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: contraindicated in HR <70bpm
- sacubitril valsartan (ARNI)
- hydralazine + nitrate: more effective in Afro-Caribbean patients
- 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
describe ECG changes associated with mitral stenosis
P mitrale
- left atrial hypertrophy/strain e.g. in mitral stenosis
- broad, notched (bifid) P waves
> most pronounced in lead II
describe acute mitral regurgitation
More common infero-posterior infarction
causes: ischaemia or rupture of papillary muscle
features
- Acute hypotension
- pulmonary oedema
- early-to-mid systolic murmur
management
- vasodilator therapy
- emergency surgical repair.
describe
- left ventricular aneurysm
- left ventricular free wall rupture
left ventricular aneurysm
- ischaemic damage weakens myocardium resulting in aneurysm formation
- S3, S4 heart sounds
- ECG: persistent ST elevation and left ventricular failure
- thrombus may form within aneurysm increasing risk of stroke
- gradual onset pulmonary oedema
- management: anticoagulation
left ventricular free wall rupture
- occurs around 1-2 weeks after MI
- presents with acute heart failure secondary to cardiac tamponade
> raised JVP, pulsus paradoxus, diminished heart sounds
- ECG: widespread ST elevation
- management: urgent pericardiocentesis and thoracotomy
