Cardiology Flashcards
Pulsus parodoxus
Greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or
absent pulse in inspiration
* Severe asthma, cardiac tamponade
Slow-rising/plateau
- Aortic stenosis
Collapsing
Aortic regurgitation
* Patent ductus arteriosus
* Hyperkinetic (anemia, thyrotoxic, fever, exercise/pregnancy)
Pulsus alternans
Regular alternation of the force of the arterial pulse
* Severe LVF
Bisferiens pulse
‘Double pulse’ - two systolic peaks
* Mixed aortic valve disease
Jerky’ pulse
Hypertrophic obstructive cardiomyopathy*
S1 heart sound
Closure of mitral and tricuspid valves
* Soft if long PR or mitral regurgitation
* Loud in mitral stenosis
* Variable intensity in complete heart block
Causes of a loud S2
Hypertension: systemic (loud A2) or pulmonary (loud P2)
* Hyperdynamic states
* Atrial septal defect without pulmonary hypertension
Causes of a soft S2
Aortic stenosis
Causes of fixed split S2
Atrial septal defect
Causes of a widely split S2
Deep inspiration
* RBBB
* Pulmonary stenosis
* Severe mitral regurgitation
Causes of a reversed (paradoxical) split S2 (P2 occurs before A2)
LBBB
* Severe aortic stenosis
* Right ventricular pacing
* WPW type B (causes early P2)
* Patent ductus arteriosus
S3 heart sound
Caused by diastolic filling of the ventricle
* Considered normal if < 30 years old (may persist in women up to 50 years old)
* Heard in left ventricular failure, constrictive pericarditis
* Gallop rhythm (S3) is an early sign of LVF
s4 sound
may be heard in aortic stenosis, HOCM, hypertension
* caused by atrial contraction against a stiff ventricle
* in HOCM a double apical impulse may be felt as a result of a palpable S4
Kussmaul’s sign
paradoxical rise in JVP during inspiration seen in constrictive pericarditis. Kussmaul’s sign → constrictive pericarditis
JVP ‘a’ wave
a’ wave = atrial contraction
* Large if atrial pressure e.g. Tricuspid stenosis, pulmonary stenosis, pulmonary
hypertension
* Absent if in atrial fibrillation
Cannon ‘a’ waves
caused by atrial contractions against a closed tricuspid valve
* Are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm,
single chamber ventricular pacing
Regular cannon waves
- Ventricular tachycardia (with 1:1 ventricular-atrial conduction)
- Atrio-ventricular nodal re-entry tachycardia (AVNRT)
Irregular cannon waves
Complete heart block
c wave JVP
‘c’ wave
* Closure of tricuspid valve
* Not normally visible
‘v’ wave JVP
Giant v waves in tricuspid regurgitation
‘x’ descen
Fall in atrial pressure during ventricular systole
y’ descent
Opening of tricuspid valve
Left ventricular ejection fraction
stroke volume / end diastolic LV volume) * 100%
Stroke volume
end diastolic LV volume - end systolic LV volume
ECG normal variants:
- Junctional rhythm
- First degree heart block
- Wenckebach phenomenon
LBBB is always pathological
ECG changes may be seen in hypothermia:
Bradycardia
* ‘J’ wave - small hump at the end of the QRS complex
* First degree heart block
* Long QT interval
* Atrial and ventricular arrhythmias
Digoxin ECG features:
Down-sloping ST depression (‘reverse tick’)
* Flattened/inverted T waves
* Short QT interval
* Arrhythmias e.g. AV block, bradycardia
Causes of ST depression:
Normal if upward sloping
* Ischemia
* Digoxin
* Hypokalemia
* Syndrome X
LBBB
Diagnosis: criteria to diagnose a left bundle branch block on ECG:
* Rhythm must be supraventricular in origin (P wave present)
* QRS duration ≥ 120 ms (3 small squares)
* QS or rS complex in lead V1(note: r is small-not capital = small-not tall r in ECG)
* RsR wave in lead V6.
Prolonged PR interval causes
Causes:
* Idiopathic
* Ischemic heart disease
* Digoxin toxicity
* Hypokalemia*
* Rheumatic fever
* Aortic root pathology e.g. Abscess secondary to endocarditis
* Lyme disease
* Sarcoidosis
* Myotonic dystrophy
causes of left axis deviation
- Left anterior hemiblock
- Left bundle branch block
- Wolff-parkinson-white syndrome* - right-
sided accessory pathway - Hyperkalemia
- Congenital: ostium PRIMUM ASD,
tricuspid atresia - Minor LAD in obese people
Causes of right axis deviation (RAD)
Right ventricular hypertrophy
* Left posterior hemiblock
* Chronic lung disease
* Pulmonary embolism
* Ostium SECUNDUM ASD
* Wolff-parkinson-white syndrome* - left-
sided accessory pathway
* Normal in infant < 1 years old
* Minor RAD in tall people
Isolated systolic hypertension (ISH)
common in the elderly, affecting around 10% of people older than 70 years old. The Systolic Hypertension in the Elderly Program (SHEP) back in 1991 established that treating ISH ↓ both strokes and ischemic heart disease. Drugs such as thiazides were recommended as first line agents. This approach is not contraindicated by the 2006 NICE guidelines which recommend treating ISH in the same stepwise fashion as standard hypertension
Hypertension: initial treatment
Patients < 55-years-old: ACE inhibitor
* Patients > 55-years-old or of Afro-Caribbean origin: calcium channel blocker or thiazide
diuretic
The target blood pressure
140/90 mmHg
Causes of secondary HTN
Renal - accounts for 80% of secondary hypertension o Glomerulonephritis
o Pyelonephritis
o Adultpolycystickidneydisease o Renal artery stenosis
Endocrine disorders
o Cushing’s syndrome
* Others
New drugs
o Primary hyperaldosteronism including Conn’s syndrome
o Liddle’s syndrome
o Congenital adrenal hyperplasia (11-β hydroxylase deficiency) o Pheochromocytoma
o Acromegaly
Direct renin inhibitors
Aliskiren (branded as Rasilez)
* By inhibiting renin blocks the conversion of angiotensinogen to angiotensin I
* No trials have looked at mortality data yet. Trials have only investigated fall in blood pressure.
Initial trials suggest aliskiren ↓ blood pressure to a similar extent as angiotensin converting
enzyme (ACE) inhibitors or angiotensin-II receptor antagonists
* Adverse effects were uncommon in trials although diarrhea was occasionally seen
* Only current role would seem to be in patients who are intolerant of more established
antihypertensive drugs
Examples of centrally acting antihypertensives include:
Methyldopa: used in the management of hypertension during pregnancy
* Moxonidine: used in the management of essential hypertension when conventional
antihypertensives have failed to control blood pressure
* Clonidine: the antihypertensive effect is mediated through stimulating α-2 adrenoceptors in the
vasomotor center.
The blood pressure target
140/90 mmHg (normal and diabetes)
If there is end-organ damage the target
is 130/80 mmHg
HTN and diabetes
ACE inhibitors are first-line*. Otherwise managed according to standard NICE hypertension
guidelines
* BNF advises to avoid the routine use of beta-blockers in uncomplicated hypertension,
Pericarditis Features
Features
* Chest pain: may be pleuritic. Is often relieved by sitting forwards
* Other symptoms include non-productive cough, dyspnea and flu-like symptoms
* Pericardial rub
* Tachypnea
* Tachycardia
Pericarditis causes
Causes
* Viral infections (Coxsackie)
* TB
* Uremia (causes ‘fibrinous’ pericarditis)
* Trauma
* Post MI, Dressler’s syndrome
* Connective tissue disease
* Hypothyroidism
Pericarditis ECG changes
Widespread ‘saddle-shaped’ ST elevation
* PR depression (most sensitive)
Myocarditis: causes
- Viral: coxsackie, HIV
- Bacteria: diphtheria, clostridia
- Spirochetes: Lyme disease
- Protozoa: Chagas’ disease, toxoplasmosis
- Autoimmune
- Drugs
strongest risk factor for developing infective endocarditis
is a previous episode of endocarditis.
Other factors include:
* Previously normal valves (50%, typically acute presentation)
* Rheumatic valve disease (30%)
* Prosthetic valves
* Congenital heart defects
* Intravenous drug users (IVDUS, e.g. Typically causing tricuspid lesion)
Most common cause of endocarditis
Streptococcus viridans
* Staphylococcus epidermidis if < 2 months post valve surger
streptococcus viridans - endocarditis
most common cause - 40-50%) → has good prognosis
Staphylococcus epidermidis - endocarditis
ass/w prosthetic valves
Staphylococcus aureus - endocarditis
especially acute presentation, IVDUS)
Streptococcus bovis endocarditis
associated with colorectal cancer
Bacteroides fragilis endocardtis
endocarditis is very rare complication of colonic resection, bacteria reaches
heart via venous return, this is why it affects right > left side → Treat with Metronidazole
Culture negative causes (BP-CHB) endocarditis
Brucella
* Prior antibiotic therapy
* Coxiella burnetii
* HACEK: Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
* Bartonella
Poor prognostic factors endocarditis
- Staph aureus infection
- Prosthetic valve (especially ‘early’, acquired during surgery)
- Culture negative endocarditis
- Low complement levels
Diagnosis endocarditis
Pathological criteria positive, or
* 2 major criteria, or
* 1 major and 3 minor criteria, or
* 5 minor criteria
Major criteria endocarditis
- Positive blood cultures
* Two positive blood cultures showing typical organisms consistent with infective endocarditis,
such as Streptococcus viridans and the HACEK group.
* Persistent bacteremia from two blood cultures taken > 12 hours apart or three or more positive
blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis.
* Positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci.
* Positive molecular assays for specific gene targets - Evidence of endocardial involvement
* Positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation
or dehiscence of prosthetic valves), or
* New valvular regurgitation
Minor criteria endocarditis
Predisposing heart disease
* Microbiological evidence does not meet major criteria
* Fever > 38oc
* Vascular phenomena: major emboli, splenomegaly, clubbing, splinter hemorrhages, petechiae
or purpura
* Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots (boat shaped
hemorrhages in retina)
* Elevated CRP or ESR
Current management guidelines endocarditis
Initial blind therapy - flucloxacillin + gentamicin (benzylpenicillin + gentamicin if symptoms
less severe)
* Initial blind therapy if prosthetic valve is present or patient is penicillin allergic - vancomycin
+ rifampicin + gentamicin
* Endocarditis caused by staphylococci - flucloxacillin (vancomycin + rifampicin if penicillin
allergic or MRSA)
* Endocarditis caused by streptococci → benzylpenicillin + gentamicin (vancomycin +
gentamicin if penicillin allergic)
Initial blind therapy - endocardtisis
Initial blind therapy - flucloxacillin + gentamicin (benzylpenicillin + gentamicin if symptoms
less severe)
Initial blind therapy if prosthetic valve is present or patient is penicillin allergic - vancomycin
+ rifampicin + gentamicin
endocarditis treatment when caused by staphylococc
- flucloxacillin (vancomycin + rifampicin if penicillin
allergic or MRSA)
endocarditis treatment when caused by streptococci
benzylpenicillin + gentamicin (vancomycin +
gentamicin if penicillin allergic)
Heart Failure: treatments
ACE inhibitors (SAVE, SOLVD, CONSENSUS)
* Spironolactone (RALES) (improved prognosis not mortality)
* β-blockers (CIBIS)
* Hydralazine with nitrates (VHEFT-1)