Cardiology Flashcards
Causes of Reversed splitting of second heart sound
1- Aortic stenosis
2- LBBB
3- HOCM
Causes of Fixed splitting of second heart sound
1-ASD
2-VSD
Cerebral infarct following treatment of a DVT
Patent Foramen Ovale
Pulse pressure
Decreased aortic compliance with increasing age leads to increased pulse pressure.
Long QT syndrome Type 1
KCNQ1 gene isolated to chromosome 11.
KCNQ1 codes for voltage gated potassium channel. This is a slow delayed rectifier potassium channel mutation.
Long QT syndrome
1- Romano ward syndrome
LQT1
LQT2
LQT3
2- Jervell and Lange Nielson syndrome
3- Anderson and Tawil syndrome
4- Timothy syndrome
5- Acquired causes
DRUGS ASH-FECT
Electrolyte abnormalities HypoKMC
Prolonged QT
QTc >440ms in men and >460ms in women
Mitral Stenosis
-Diastolic Murmur
-Apical Thrill
-Right ventricular heave/ Loud P2
-Pulm Regurg ( Graham steel Murmur)
-Low pulse pressure
-Soft S1
Mitral Regurgitation
-pansystolic murmur
- Small volume pulse
-Presence of S3
- Displaced and hyperdynamic apex
Aortic Regurgitation
-Quincke sign
-Corrigans pulse
- Corrigans sign
-De Musset sign
- Duroziez sign
- Traube sign
- Austin Flint murmur
- Aurgyl Robertson pupils
- Muller sign
Aortic Stenosis
- Slow-rising pulse with narrow pulse pressure
- S4
- Presence of precordial thrill
- Absent A2
- Paradoxically split A2
- Symptoms of syncope or left ventricular failure
HCM
- Jerky pulse with large tidal wave.
- Large A waves in JVP.
- Double apical impulse.
- Left sternal edge systolic thrill with harsh ejection systolic murmur radiating to the axilla.
- often accompanied by MR.
- often paradoxical splitting of S2.
- The ejection systolic murmur increases with the Valsalva maneuver and decreases with squatting.
Classification of Haemorrhage
Classification of haemorrhage:
Parameter I II III IV
Blood loss (ml) <750 750-1500 1500-2000 >2000
Blood loss (%) <15% 15-30% 30-40% >40%
Pulse rate (beats/min) <100 >100 >120 >140
Blood pressure Normal Normal/Decreased Decreased Decreased
Respiratory rate (breaths/min) 14-20 20-30 30-40 >35
Urine output (ml/hour) >30 20-30 5-15 Negligible
CNS symptoms Normal Anxious Confused Lethargic
Arrhythmogenic right ventricular cardiomyopathy
- autosomal dominant pattern
-The right ventricular myocardium is replaced by fatty and fibrofatty tissue
-ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV. This is best described as a terminal notch in the QRS complex. Echo shows an enlarged, hypokinetic right ventricle with a thin free wall.
Rx is Sotalol, Catheter ablation, and ICD.
Naxos Disease
-an autosomal recessive variant of ARVC
- a triad of ARVC, palmoplantar keratosis, and woolly hair
Coarctation of aorta
-Difference in blood pressures between the right and left arms.
-Radiofemoral delay
-Systolic murmur and thrill
-Headache and nose bleeds occur due to hypertension.
-Chest radiograph demonstrates evidence of rib notching and may demonstrate an indentation of the aortic shadow at the site of the coarctation.
-Rx is balloon angioplasty and stenting.
Macrophages
Macrophages are involved in coronary artery plaques
Dapagliflozin
Dapagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor shown to reduce the risk of worsening heart failure and cardiovascular death in patients with heart failure with preserved and mildly reduced ejection fraction. It is an appropriate addition to the current regimen for symptomatic relief and long-term cardiovascular benefit in this patient population.
Antibiotic prophylaxis against Infective Endocarditis
According to NICE guidelines, antibiotic Prophylaxis against infective endocarditis (CG64) is not recommended in common cardiac valve abnormalities.
Prophylaxis is only recommended in those patients who are at highest risk of adverse outcomes on the development of endocarditis. These patient groups include:
acquired valvular heart disease with stenosis or regurgitation
hypertrophic cardiomyopathy
previous infective endocarditis
structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
valve replacement.
Constrictive pericarditis
Constrictive pericarditis typically impedes late diastolic ventricular filling, which produces an elevated jugular venous pressure (JVP), with prominent x and y descent.
Other signs include:
- Oedema
- Ascites
- Hepatomegaly
- Orthopnoea
- Dyspnoea.
ACS ( Poor prognostic Factors)
ACS- poor Prognostic factors
- age
- development (or history) of heart failure
- peripheral vascular disease
- reduced systolic blood pressure
- Killip class*
- initial serum creatinine concentration
- elevated initial cardiac markers
- cardiac arrest on admission
- ST segment deviation
Heart Failure Rx
- AB
-AS
-ISD
First-line therapy
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
generally, one drug should be started at a time. NICE advise that clinical judgement is used when determining which one to start first
beta-blockers licensed to treat heart failure in the UK include bisoprolol, carvedilol, and nebivolol.
ACE-inhibitors and beta-blockers have no effect on mortality in heart failure with preserved ejection fraction
Second-line therapy
The standard second-line treatment is an aldosterone antagonist
these are sometimes referred to as mineralocorticoid receptor antagonists. Examples include spironolactone and eplerenone
it should be remembered that both ACE inhibitors (which the patient is likely to already be on) and aldosterone antagonists both cause hyperkalaemia - therefore potassium should be monitored
There is an increasing role for SGLT-2 inhibitors in the management of heart failure with a reduced ejection fraction
these drugs reduce glucose reabsorption and increase urinary glucose excretion
examples include canagliflozin, dapagliflozin and empagliflozin
the evidence base shows SGLT-2 inhibitors reduced hospitalisation secondary to heart failure and cardiovascular death
international guidelines widely recommend their usage. In terms of NICE, a technology appraisal from 2021 support the use of dapagliflozin as an add-on to optimised standard care
Third-line therapy
Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
ivabradine
criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
sacubitril-valsartan
criteria: left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period
digoxin
digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation
hydralazine in combination with nitrate
this may be particularly indicated in Afro-Caribbean patients
cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
Other treatments
offer annual influenza vaccine
offer one-off pneumococcal vaccine
Naftidrofuryl
Naftidrofuryl is a 5-HT2 receptor antagonist which can be used for peripheral vascular disease
