Cardiology Flashcards
Cause of non-pulsatile JVP waveform
SVC obstruction
Kussmaul’s sign
JVP rise during inspiration - Constrictive pericarditis
JVP a waves signify what?
atrial contraction
Causes of cannon a waves (regular, irregular)
Regular: AVNRT, VT
Irregular: complete Heart block
Causes of large A waves
Tricuspid stenosis
Pulmonary stenosis
Pulmonary hypertension
Causes of absent A waves
Atrial fibrillation
What does a JVP C wave signify
Closure of tricuspid valve, start of systole (not seen normally)
What does the X descent of JVP signify
fall of atrial pressure during systole
What does the JVP V wave signify?
Passive atrial filling against closed tricuspid valve
What does the JVP Y descent signify?
Fall of atrial pressure as tricuspid valve opens
Cause of Giant V wave?
Tricuspid regurgitation
Beck’s Triad?
Cardiac tamponade:
Low BP, raised JVP, muffled heart sounds
What do you see in Tamponade?
Beck’s triad (low BP, raised JVP, muffled HS)
Absent Y (limited RV filling) TAMPAX
Pulsus paradoxus
Rarely Kussmaul’s sign (more for constrictive pericarditis)
Electrical Alternans
What do you see in constrictive pericarditis
X and Y descents are present (as opposed to absent Y in tamponade)
Kussmaul’s sign
What causes variable intensity of S1?
Complete heart block
What causes loud S2?
Hypertension (atrial or pulmonary)
Hyperdynamic states
Atrial septal defect without pulmonary hypertension
What causes soft S2?
Severe Aortic Stenosis
What causes a fixed split S2?
Atrial Septal defect
What causes a widely split S2?
Deep inspiration
RBBB
Pulmonary stenosis
Severe mitral regurgitation
What causes a reversed split S2?
LBBB
Severe aortic stenosis
Right ventricular pacing
WPW type B
Patent Ductus Arteriosus
Causes of S3
Caused by diastolic filling of ventricle:
LVF
DCM
Constrictive pericarditis (pericardial knock)
MR
Causes of S4
Caused by atrial contraction vs stiff ventricle, coincides with p wave
Aortic stenosis
HOCM (double apical beat in HOCM due to palpable S4)
HTN
Explain the physiological mechanism behind Valsava in lowering cardiac output
Increased intrathoracic pressure –> reduced venous return –> reduced cardiac output
What is the normal range of left atrial pressure?
6-12mmHg
Causes of high left atrial pressure
LVF
MS
MR
AS
age>20
How do you measure pulmonary capillary wedge pressure?
Via Swan-Ganz catheter to estimate pulmonary pressure, by inflating balloon in pulmonary artery.
Useful for working out if HF or ARDS is cause of pulmonary oedema and can titrate dose of diuretic drugs
What pressure counts as pulmonary hypertension?
> 20mmHg
How do you officially diagnose pulmonary HTN?
Cardiac catheterisation
Risk factors for developing pulm HTN
COPD
HIV
Cocaine
Anorexigens (eg fenfluramine)
Genetics predisposition of idiopathic pulmonary hypertension
10% autosomal dominant
Signs of pulmonary HTN?
Right ventricular heave
Loud P2
Prominent A waves
Tricuspid Regurgitation
How to manage pulmonary HTN?
Vasodilator testing with nitric oxide:
If positive (pressure drop):
- calcium channel blocker
If negative (no pressure drop):
- prostacycline analogues
- Endothelin receptor antagonists
- Phosphodiesterase inhibitors
Cause of pulsus alternans
Severe LVF
Causes of prolonged PR
Idiopathic
IHD
Digoxin
Hypokalaemia
Rheumatic fever
Aortic root abscess
Lyme disease
Sarcoidosis
Myotonic dystrophy
LBBB Causes
My CHAD FucKs Prime
MI
CDM
HTN
AS
Digoxin
Fibrosis
HyperKalaemia
ASD Primum
ECG changes with hypothermia
Bradycardia
J Waves (Osborne)
1st degree HB
Long QTc
Arrhythmias
Causes of aortic stenosis
Calcification commonest >65 yrs
Bicuspid Aortic valve commonest <65 yrs
William’s syndrome (supravalvular)
post-rheumatic fever
HOCM (subvalvular)
Features of severe Aortic stenosis
Slow rising pulse
Soft/absent S2
narrow pulse pressure
Delayed ESM
S4
Thrill
Displaced apex beat
LV hypertrophy/failure
What pressure counts as severe AS?
> 40mmHg
Treatment of AS
Surgical AVR in low surgical risk
TAVR in high surgical risk
Balloon valvuloplasty in children with no calcification and adults with critical AS not fit for AVR
Causes of aortic regurgitation?
Causes due to valve disease:
- Rheumatic fever (commonest in developing world)
- Calcific valve disease
- Connective tissue disease
- Bicuspid aortic valve
(Acute - infective endocarditis)
Causes due to aortic root disease:
- Bicuspid aortic valve (afffects both valves and aortic root)
- Spondylarthropathies (ankylosing spondylitis)
- HTN
- Syphilis
- Marfan’s
- Ehler-Danlos
(Acute: aortic dissection)
What is an Austin-Flint murmur?
mid-diastolic murmur in sevvere aortic regurgitation, due to partial closure of anterior mitral valve cusps
Causes of mitral stenosis
Rheumatic fever
Mucopolysaccharidoses
Carcinoid
Endocardial fibroelastosis
Features of Mitral stenosis
Loud S1
Opening snap (indicates MV leaflets are still mobile)
Low volume pulse
Malar flush
Atrial fibrillation (LA enlargement)
Features of severe MS
Increased length of murmur
Opening snap closer to S2
Normal area of mitral valve
4-6cm2. Tight is <1cm2
What is recommended for anticoagulation in MS with Atrial fib
Warfarin
Treatment of mitral stenosis
Percutaneous mitral balloon valvotomy
Mitral valve surgery - commissurotomy/valve replacement
Contraindications to mitral balloon valvotomy?
Area>1.5cm2
Left atrial thrombus
Moderate/severe MR
Severe calcification
Severe aortic/tricuspid disease
Severe coronary disease requiring CABG
Features of tricuspid regurgitation
Giant V waves
Tall C waves
Pulsatile hepatomegaly
Left parasternal heave (due to RVH)
Causes of TR?
RV infarct
Pulm HTN
Rheumatic heart disease
Infective Endocarditis
Ebstein’s anomaly
Carcinoid
What is Ebstein’s anomaly?
Tricuspid valve displaced towards RV, atrialising the RV (low insertion of tricuspid alve)
What causes Ebstein’s anomaly?
Exposure to lithium in-utero
Associations with Ebstein’s anomaly?
PFO
ASD (80%)
WPW
Features of Ebstein’s anomaly
Prominent A waves
Hepatomegaly
Giant V waves + TR
RBBB (widely split S1, S2)
Causes of dilated CDM
Idiopathic
Ischaemic
Myocarditis (Coxsackie B, HIV, Diptheria, Chagas)
Peripartum
HTN
Iatrogenic (doxorubicin)
Substance (ETOH, Cocaine)
Inherited (autosomal dominant)
Duchenne Muscular Dystrophy
Infiltrative (Haemochromatosis, sarcoidosis)
Selenium deficiency (Keshan disease)
Beri-Beri (wet)
Causes of restrictive cardiomyopathy
Amyloidosis (e.g. secondary to myeloma, most commonly)
Haemochromatosis
Post-radiation fibrosis
Loffler’s syndrome
Endocardial fibroelastosis
Sarcoidosis
Scleroderma
Beri beri (wet)
Inheritance/genetics for HOCM
Autosomal dominant
MHC beta (15-25%)
MYH7 (70%)
MYBPC3 (cardiac myosin binding protein C) (15-25%)
Does HOCM cause predominantly systolic or diastolic dysfunction?
Diastolic
Treatment for HOCM
ABCDE
Amiodarone
Beta blocker
Cardioverter
Dual chamber pacemaker
Endocarditis prophylaxis
What drugs do you avoid in HOCM
ACE inhibitors
Nitrates
Ionotropes
Factors for poor prognosis in HOCM
Syncope
FHx of sudden death
Young age at presentation
Non-sustained VT 24-48hrs
Septal wall thickening
BP changes on exercise
Inheritance pattern of arrhythmogenic right ventricular cardiomyopathy
Autosomal dominant
ECG features in ARVC
T inversion in V1-3
Epsilon wave
Treatment for ARVC
Sotalol
Catheter ablation
ICD
What is Naxos disease
Autosomal recessive ARVC
with palmoplantar keratosis, woolly hair
What defect is there in longQT syndrome (receptors)
K channel alpha subunit defect, in Chromosome 11
Types of long QT
1: exertional syncope (swimming)
2: emotional stress/exercise/auditory stimuli
3: at night/rest
Drug causes of long QT
THEM CO SATS 1a
TCAs
Haloperidol
Erythromycin
Methadone
Chloroquine
Ondansetron
Sotalol
Amiodarone
Terfenadine
SSRI/SNRI
1a anti-arrhythmics
Electrolyte causes of long QT
Low K, Ca, Mg
Some causes of long QT
Drugs (THEM CO SATS 1a)
Electrolytes
Genetic
Hypothermia
MI
Myocarditis
SAH
Inherited causes of long QT
Jervell-Lange-Nielson: Autosomal recessive, deaf, KCNQ1 mutation
Romano-Ward: Autosomal dominant
Types of Wolff-Parkinson White Syndrome
Type A: left sided accessory pathway, dominant R in V1
Type B: right sided accessory pathway
Associations of WPW
HOCM
Mitral Valve Prolapse
Ebstein’s
Thyrotoxicosis
ASD secundum
Gene mutation for WPW
PRKAG2
Treatment for WPW
Sotalol
Amiodarone
Flecainide
Avoide AV blocking nodes in AFib
DVLA restrictions for PCIs and PPMs
1 week
DVLA retrictions for CABG, ACS
4 wks
DVLA restrictions for ICDs
6 months
1 month if prophylactically
permanent ban for Group 2 vehicles
DVLA restrictions for heart transplant
6 wks
DVLA restrictions for arrhythmia - catheter ablations
2 days
DVLA restrictions for aortic aneurysms 6.5cm
ban
Features of complete heart block
wide pulse pressure
cannon a wave
variable intensity s1
Factors for increased risk of asystole in bradycardia
Complete Heart block + broad QRS (if narrow QRS, AV junctional pacemaker still providing haemodynamically stable heart rates)
Recent asystole
Mobitz Type II
Ventricular pause >3s
Brugada genetics
SCN5A (Na channel) mutations 20-40%
CACNB2 (Ca channel) less common
KCNE3 (K channel) less common
What can you give in Brugada to make the diagnosis more obvious?
Flecainide/ajmaline
ECG features in Brugada
Convex ST elevation in V1-3 with T inversions
Treatment for Brugada
ICD
Which cardiac enzyme rises first?
myoglobin
Which cardiac enzyme is useful to look for reinfarction?
CK-MB (returns to normal after 2-3 days)
What does Troponin-T bind to?
Binds to tropomyosin, to form torponin-tropomyosin complex, which regulates actin
When does troponin-T rise, peak and return to normal?
rises 4-6hrs
peaks 12-24hrs,
returns to normal 7-10 days
What composes of the cardiomyocyte’s thin filament?
Actin, Tropomyosin, Troponin-T
What does troponin-C bind to?
Ca
What does Troponin I bind to?
Actin, holds troponin-tropomyosin complex in place
LDH rise, peak, return to normal time in an MI?
rises 24-48hrs, peaks 72hrs, returns to normal 8-10 days
Where is BNP from?
Left ventricular myocardium, in response to strain
What factors/conditions increase BNP
LVH
Ischaemia
Tachycardia
RV overload
Hypoxaemia
GFR<60
Sepsis
COPD
Diabetes
Age>70
Cirrhosis
What factors/conditions reduce BNP?
Obesity
Diuretics
ACE inhibitors
Beta blockers
ARBs
Aldosterone antagonists
Effects of BNP
Vasodilation
Diuresis
Natriuresis
Supression of sympathetic nervous system, RAAS
Where is ANP from?
Right and left (right>left) atrial myocytes, in responseto blood volume
What is ANP degraded by?
Endopeptidases
Effects of ANP
Natriuresis
Lowers BP
Antagonises Angiotensin II and aldosterone
Features of cholesterol embolisation
Eosinophilia
purpura
renal failure
livedo reticularis
Causes/risk factors for cholesterol embolisation
Renal disease
Post vascular surgery/angiography
severe atherosclerosis in large arteries
Causes of myocarditis
Coxsackie B
HIV
Diptheria
Clostridia
Lyme disease
Chagas
Toxoplasmosis
Autoimmune
Doxorubicin
Time period post-PCI for restenosis
3-6 months
Time period post-PCI for stent thrombosis
1 month
Drug-eluting stents risks for restenosis and stent thrombosis?
Reduces restenosis rates
Increases stent thrombosis (need to give clopidogrel for longer- at least 6 months)
Down’s syndrome cardiac associations
Endocardial cushion defects
VSD
ASD Secundum
Tetralogy of Fallot
Isolated PDA
Large vessel arteritis in 10-40yr old Asian women
Takayasu’s arteritis
Features of Takayasu’s arteritis
Aortic regurgitation 20%
Carotid bruit
Claudication
Association with renal artery stenosis
How to investigate/diagnose Takayasu’s arteritis?
Vascular imaging (MR/CTA)
How to treat Takayasu’s
steroids
Associations of aortic dissection
HTN
Trauma
Bicuspid Aortic valve
Marfan’s
Ehlers-Danlos
Turner’s
Noonan’s
Pregnancy
Syphilis
Major criteria for Rheumatic fever
CASES
carditis
polyarthritis
sydenham’s chorea
erythema marginatum
subcutaneous nodules
When does rheumatic fever present?
2-4 wks post strep pyogenes infection (Type 2 hypersensitivity)
What can you see histologically in rheumatic fever?
Aschoff bodies (granuloma with giant cells)
Anitschkow cells (enlarged macrophages with ovoid, wavy, rod-like nucleus)
Poor prognosis in ACS
Age
HF
PVD
reduced SBP
Killip class (crackles, S3, pulm oedema, cardiogenic shock)
Initial serum creatinine,
high cardiac markers,
cardiac arrest on admission
ST segment deviation
Cyanotic heart disease:
Tetralogy of Fallot
Transposition of great arteries
Tricuspid atresia
Tetralogy of Fallot
VSD
RVH
Right ventricular outflow tract obstruction, pulmonary stenosis
Overriding aorta
When does tetralogy of Fallot present?
1-2 months
What causes tetralogy of Fallot?
Anterosuperior displacement of infundibular septum
What XR feature can you see for Tetralogy of Fallot?
boot shaped heart
What causes transposition of the great arteries?
Failure of aorticopulmonary septum to spiral
What increases risk of getting TGA
diabetic mothers
What sign do you get (heart sounds) for TGA
Loud S2
CXR of TGA
Egg-on-side appearance
Treatment for TGA
Prostaglandins to maintain PDA + surgery
What is tricuspid atresia?
Absent Tricuspid valve and hypoplastic RV
Causes of VSD
Down’s
Edward’s
Patau
cri-du-chat
congenital infections
post-MI
Complications of VSD
Aortic regurgitation
Infective endocarditis
Eisenmenger’s
RHF
Pulm HTN
Heart sound in ASD
Fixed splitting of S2
ECG features for ASD primum
RBBB + LAD
Prolonged PR
ECG features for ASD Secundum
RBBB+RAD
Which is more common: ASD primum or secundum?
Secundum (70%)
ASD Primum
RBBB+LAD, prolonged PR, abnormal AV valves, earlier than secundum
ASD secundum
70%) Holt-Oram syndrome (tri-phalangeal thumbs), RBBB+RAD
Patent ductus arteriosus causes
premature babies
high altitude
maternal rubella in 1st trimester
Features of PDA
Left subclavicular thrill
cont mach murm
wide pp
collapsing pulse
heaving apex
PDA treatment
indomethacin/NSAID (inhibits prostaglandin synthesis)
Give prostaglandin E1 if there is another congenital heart disease (cyanotic) to keep duct open pre-surgery
Coarctation of aorta associations
males
Turner’s
bicuspid AV
berry aneurysms
neurofibromatosis
Features of coarctation of aorta
Mid systolic murmur loudest over back
apical click from aortic valve
notching of inferior border of ribs (collateral vessels - not seen children)
Neuro-vascular associations with patent foramen ovale
Migraines
Strokes
Multifocal atrial tachycardia
pacemaker origin at least 3 sites in atria, distinctive p waves, chronic lung disease association
Rx: correct hypoxia, electrolytes, rate-limiting Ca channel blocker
Xanthomas in familial hyper-triglyceridaemia
eruptive xanthoma
Xanthomas in familial hyper-hypercholesterolaemia
tendon xanthoma
Pre-eclampsia risk factors
HTN
CKD
SLE
antiphospholipid
DM
nulliparity
age>40
BMI>35
Fhx
multiple pregnancy
BP fluctuation in pregnancy
falls in 1st half (vasodilation, increased volume) by 5-10 systolic, 10-15 diastolic → gradually rises in 2nd half.
What do you give for mothers at high risk of pre-eclampsia and when?
Give 75mg aspirin from 12wks
What investigation measures LVEF most accurately?
MUGA scan
MIBI scan
technetium 99 + methoxyisobutyl isonitrile, with SPECT - stress + rest, to assess for reversible or fixed ischaemia
Duke’s criteria for IE
path criteria +ve or 2 major or 1 maj + 3 minor or 5 minor
Major:
echo findings
new regurg
2 or more cultures
serology or gene target assays
Minor:
past heart condition
IVDU
fever
vascular or immunological phenomena
Culture negative causes of IE
Coxiella burnetii, Bartonella, Brucella, HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
Valves commonly effected in IE
MR commonest. TR commonest in IVDU
Treatment for native valve blind IE
amoxicillin
Treatment for prosthetic valve blind IE
vanc + rifampicin + low dose gent
Poor prognosis for IE
S aureus
Prosthetic valve
Culture negative
Low complement
Indications for surgery in IE
Severe valve incompetence
Aortic abscess
Abx resistance
Fungal
HF refractory to medical treatment
Recurrent emboli after abx
Syndrome X (cardiac)
angina-like pain on exertion, ST depression on exercise stress test (downsloping), normal angiography.
Rx: nitrates
Catecholaminergic polymorphic ventricular tachycardia
Inherited, aut dom, 1:10,000. RYR2 receptor defect in myocardial sarcoplasmic reticulum, dysfunctional Ca regulation, thus excessive AP with adrenaline. VT on exercise/emotion, syncope, cardiac death before 20yrs.
Rx: beta blockers, CRT
Beta blocker usage in HTN
declined sharply due to ASCOT-BPLA study demonstrating it’s less likely to prevent stroke + potential impairment of glucose tolerance
HF NYHA classification
I- no symptoms/limitations
II - mild symptoms with ordinary activity
III - marked limitation of physical activity but comfortable at rest
IV - symptoms present at rest.
Rx for chronic HF
1st line ACEi + b-blocker (bisop, carvedilol, nebivolol) in HFrEF
2nd line: spiro or eplerenone, SGLT-2 inh
3rd line: ivabradine, sacubitril-valsartan, digoxin, hydralazine + nitrates or CRT.
Offer annual flu vaccine + one-off pneumococcal vaccine (every 5 yrs if splenic dysfunction or CKD)
Atrial myxoma:
75% left atrium. females. Clubbing
A fib, mid-diastolic murmur
Echo - pedunculated heterogeneous mass attached to fossa ovalis of interatrial septum
Factors suggesting VT rather than SVT
AV dissociation, fusion/capture, +ve QRS concordance in chest leads, marked LAD, IHD hx
How to prevent SVT
beta blockers, radio-frequency ablation
Atrial flutter location of re-entry circuit
right atrium
Where to ablate in atrial flutter?
radiofrequency ablation of tricuspid valve isthmus (critical part of circuit)
Atrial fibrillation cardioversion rules
Can cardiovert if <48hrs with heparinisation. Amiodarone if structural heart disease, flecainide/amiodarone without structural heart disease
If >48hrs 3 wk anticoagulation then cardioversion or TOE then heparinisation + cardioversion. Then anticoagulant 4 weeks
If high risk of failure, give 4 wks amiodarone or sotalol pre-cardioversion
