Cardiology Flashcards
Target of blood pressure
People with proteinuria >1 g/day, (with or without diabetes) < 125/75mmHg People with associated condition/s: 130/80 mmHg or end-organ damage:* • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA People with none of the following: 140/90 mmHg or lower if tolerated • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA
Pansystolic murmur
mitral regurgitation, tricuspid regurgitation, ventricular septal defect,
Midsystolic murmur
Aortic stenosis, pulmonary stenosis, hypertrophic cardiomyopathy, pulmonary flow murmur of an atrial septal defect
Late systolic
mitral valve prolapse, Papillary muscle dysfunction
early diastolic
aortic regurgitaiton, pulmonary regurgitation
Mid diastolic
mitral stenosis, tricuspid stenosis, atrial myxoma, austin flint murmur of aortic regurgitaion
presystolic
Mitral stenosis, tricuspid stenosis, atrial myxoma
differenciation of ulcers
Venous ulcer:around malleoli,associated with pigmentation, stasis eczema, an irregular margin, pale surrounding neo-epithelium, and a pink base of granulation tissue, skin is warm and oedema is often present Arterial ulcer: a regular margin and ‘punched out’ appearance. the surrounding skin is cold. the peripheral pulses are absent in large artery disease, samll vessel disease (eg. leucocytoclastic vasculitis, palpable purpura) Diabetic ( neuropathic) ulcer: are painless penetrating ulcer on sole of foot, and are associated with reduced sensation in the surrounding skin underling systemic disease: diabetes mellitus: vascular disease, neuropathy or necrobiosis lipoidica(front of leg), pyoderma gangrenosum, rheumatoid arthritis, lymphoma, haemolytic anaemia (samll ulcers over malleoli, e.g. sicle cell anaemia)
Collapsing pulse
aortic regurgitaiton, hyperdynamic circulation, arteriosclerotic aorta, peripheral arteriovenous fistula, patent ductus arteriosus
indications for surgery for aortic regurgitation
- Symptoms - dyspnoea on exertion 2. Worseing left ventricular function, such as low ejection fraction, 3. progressive left ventricular dilatation on serial echocardiograms: left ventricular end-systolic dimension of 5.5 cm
indications for surgery for mitral regurgitation
- NYHA class III and IV 2. left ventricular dysfunction, LVEF 45mm .4 in acute mitral regurgitation, operate if there is haemodynamic collapse 5. repair of a prolapsing posterior and often anterior leaflet is now undertaken earlier than valve replacement
Cholesterol target guidelines
LDL < 4.0 HDL > 1.0 Triglycrides <1.5
Treatment of aortic regurgitation
Valve replacement • 55 rule – before LVEDD > 55mm or LVEF <55% • Acute AR • Symptomatic with chronic severe AR Vasodilator therapy (nifedipine) delays need for AVR (if no LVF) Beta blockers contraindicated as prolong diastole and increase regurg fraction
common causes and association of AF:
advanced age (3% of 65 years old, >6% of people in their 80s hypertension mitral valve diseae ischaemic heart disease and myocardial infarction recent thoracic or abdominal surgery atrial septal defect wolff- Parkinson-white syndrome recent alcoholic binge pulmonary embolism thyrotoxicosis
findings suggestive of VT
QRS > 0.14secnds (if RBBB) or >0.16 seconds(if a LBBB) left axis deviation Atroventricular dissociation change from the pre-existing QRS morphology in pre-existing bundle branch block capture/fusion beats, BROAD COMPLEX TACHYCARDIA in a patient with ischemic heart disease is usually VT (95%)
Drugs that cause QT Prolongation
•clarithromycin •erythromycin •metaclopramide •haloperidol •TCA •methadone •droperidol
what electrolytes disturbance cause VT
•hypokalaemia •hyperkalaemia •hypomagnesaemia •hypocalcaemia
Diagnostic Criteria for LAFB
•Small Q waves with tall R waves (= ‘qR complexes’) in leads I and aVL •Small R waves with deep S waves (= ‘rS complexes’) in leads II, III, aVF left axis deviation
Diagnostic Criteria for LPFB
Right axis deviation (> +90 degrees)
Small R waves with deep S waves (= ‘rS complexes’) in leads I and aVL
Small Q waves with tall R waves (= ‘qR complexes’) in leads II, III and aVF
indication for Dual-chamber pacemakers
treat symptomatic bradycardia in people with sick sinus syndrome, atrioventricular block, or both
sick sinus syndrome + flow of electrical impulses between the upper and lower chambers of the patient’s heart is normal = use a single-chamber pacemaker,should be attached to the upper chamber of the heart
atrioventricular block + atrial fibrillation=should use a single-chamber pacemaker and attached to the lower chamber of the heart
indications for permanent pacemaker insertion
- intermittent or permanent complete heart block, with
a. symptomatic bradycardia
b. cardiac failure
c. arrythmias that require treatment with drugs that slow conduction
d. documented asystole of more than 3 seconds or escape rhythm with a rate <40 beats/min
e. confusional states that improve with temporary pacing - intermittent second degree AV block with symptomatic bradycardia
- sinus node dysfunction with symptomatic bradycardia
less certain indicaitons:
- asymptomatic complete heart block with HR >40 beats
- symptomatic type 2 second degree heart block
- bifascicular or trifascicular block with syncope of unknown aetiology
indications for cardiac resynch therapy
indication for implantable cardiac defibrillator?
Causes of secondary hypercholesteroleami
Nephrotic syndrome
obstructive jaundice
hypothyroidism
cushing syndorme
Thiazide diuretics
cyclosporin
anorexia nervosa
modified cardiovascular risk factors?
Inactivity:
Raise HDL and may slightly lower LDL in
proportion to the duration spent exercising
– Improve glycaemic control (and prevent
development of diabetes)
– Lower blood pressure (as much an ACEi)
– Treat moderate depression (as well as an SSRI)
– Reduce Falls
– Assist weight loss
• Elevated cholesterol
High Cholesterol – Testing
• ATP-III (by NCEP)Guidelines:
– Test Every 5 years in individuals aged 20 &
over
– Test more often in those with 1 or more other
risk factors for CVD
NHF Guidelines (2005) post ACS:
– Total Chol < 4.0
– LDL < 2.0
– Triglycerides < 1.5
Lipid Targets – No IHD
• Every 1.0 mmol reduction in LDL = 22%
reduction in mortality
• A 10% reduction in total cholesterol
confers an 11% relative reduction in all
cause mortality
• Smoking
• Poor glycaemic control (diabetes)
• Obesity
• Hypertension
Salt restriction to < 4g/day will produce a BP
drop of:
– 4 – 5 mmHg in hypertensive patients
– 2mmHg in normotensive patients
Increased dietary potassium intake
– Can lower BP by 4 – 8mmHg in hypertensive
– Can lower BP by 2mmHg in normotensive
– Obviously not in renal impaired
HTN – Dietary Measures
• Reduce alcohol intake
• Reduce caffeine intake
• Stop smoking
HTN –Weight loss
• Every 1% Reduction in weight results in a
1mmHg drop in BP
HTN - Exercise
• Aerobic exercise will reduce BP
– By ~6.9mmHg in hypertensive people
– By 1.9mmHg in normotensive people
Choice of Antihypertensive
• In absence of other comborbities:
– If under 55: ACEi or ARB
– If over 55: Calcium Channel Blocker
Exclude secondary cause if resistant
If has HTN & Orthostatic Hypotension
•
Consider role of:
– Alpha-blockers
– Autonomic neuropathy
– Dehydration
– Nocturnal hypertension (often with nocturia)
• Less likely with beta-blockers
• Less likely with ACEi
No Driving Periods:
After AMI
– 2 weeks private vehicle
– 4 weeks commercial vehicle
• After (elective) PCI
– 2 days private vehicle
– 4 weeks commercial vehicle
• After CABG
– 4 weeks private vehicle
– 3 months commercial vehicle
Cardiac Arrest:
– 6 months
• ICD Cannot hold commercial licence
– 2 weeks after Generator change
– 4 weeks after AICD therapy required for
symptoms
• PPM
– 2 weeks for private licence
– 4 weeks for commercial licence
Heart / Lung Transplant
– 6 weeks private licence
– 3 months commercial licence
• PE
– 6 weeks whatever the licence
• Cardiovascular Syncope (not triggered
vasovagal)
– 4 weeks private licence
– 3 months commercial licence
Undiagnosed syncope
– If one or more episode in 24 hours – 6
months
• 5 years for commercial
– If 2 or more episodes more than 24 hours
apart – 12 months
• 10 years for commercial
