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Cardiology Flashcards

1
Q

How do you differentiate between AS and HOCM?

A

Valsalva - AS will be softer and HOCM will be louder

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2
Q

What are the differential diagnoses of an ejection systolic murmur?

A

Ejection systolic murmur may occur during a hyperdynamic state requiring more blood to be pumped out (tachycardia).

  • AS
  • HOCM
  • Atrial Septal Defect (normal S1, S2; fixed splitting of S2, doesn’t vary between inspiration/expiration)
  • Pulmonary stenosis (louder on inspiration)
  • Anaemia
  • Hyperthyroidism
  • Pregnancy
  • Sepsis (normal S1, S2)
  • End stage liver failure
  • Coarctation of aorta (normal S1, S2; radio-femoral delay)
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3
Q

What are the triggers of AF?

A

P - PE/COPD

I - Ischaemia

R - Rheumatic fever

A - Anaemia

T -Thyrotoxicosis

E - Endocarditis

S - Sepsis/SSS

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4
Q

What are the differential diagnoses of a pan-systolic murmur?

A
  • Tricuspid regurgitation
  • Mitral regurgitation
  • Ventricular septal defect (normal heart sounds)
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5
Q

What are the causes of mitral regurgitation?

A
  • Mitral valve prolapse
  • Rheumatic heart disease
  • IHD –> rupture of chordae tendinae/valve attachment
  • Dilated cardiomyopathy
  • Infective endocarditis
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6
Q

What are the features of aortic stenosis?

A
  • Syncope
  • Angina
  • Dyspnoea
  • Harsh ejection systolic murmur best heard at aortic area radiating to carotids
  • Narrow pulse pressure
  • Low volume/plateau/slow-rising carotid pulse
  • Softer A2
  • LVH
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7
Q

How do you differentiate between aortic stenosis and aortic sclerosis?

A

Aortic sclerosis has no radiation to the carotids, no apex beat displacement, a normal A2 and no thrill

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8
Q

What are the signs of left heart failure?

A
  • Orthopnoea
  • PND
  • Pulmonary oedema
  • Fatigue
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9
Q

What are the causes of left heart failure?

A
  • Iscahemia
  • HTN
  • CM
  • VHD
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10
Q

What are the precipitants of heart failure?

A

I - Ischaemia

I - infection

A - arrhythmia

A - anaemia

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11
Q

What is the NYHA classification?

A

I - normal (no limitation on physical activity)

II - mild (comfortable at rest but SOB on physical activity)

III - moderate (comfortable at rest but SOB on mild activity)

IV - severe (SOB at rest)

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12
Q

What are the signs of right heart failure?

A
  • Peripheral oedema
  • Elevated JVP
  • Ascites
  • Tender hepatomegaly
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13
Q

What are the symptoms of right heart failure?

A

F - Fatigue

A - Ankle swelling

C - Cerebral (faints)

I - Increased urinary freq

A - Anorexia

L - Liver congestion

P - Palpitations

A - Ascites

N - Nausea

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14
Q

What are the causes of aortic stenosis?

A
  • Senile calcification
  • Congenital bicuspid valve
  • Rheumatic fever
  • Severe hypercholesterolaemia
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15
Q

What are the causes of aortic regurgitation?

A
  • Rheumatic fever + subacute IE
  • Bicuspid valve
  • RA
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16
Q

What are the causes of mitral stenosis?

A
  • Rheumatic heart disease
  • Congenital
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17
Q

What are the symptoms of mitral regurgitation?

A
  • Palpitations
  • SOBOE
  • Fatigue/weakness
  • Orthopnoea (pulmonary oedema)
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18
Q

What are the signs of mitral regurgitation?

A
  • Pan-systolic murmur best heard at apex, radiating to the axilla
  • LVD
  • S1 soft, S3 present
  • LV failure
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19
Q

What are markers of severity of mitral regurgitation?

A
  • S3
  • LVF
  • diffuse displaced apex beat
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20
Q

What are the symptoms of aortic regurgitation?

A
  • Palpitations
  • Dizziness
  • Symptoms of LVF (dyspnoea)
  • Angina
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21
Q

What are the signs of aortic regurgitation?

A
  • Early diastolic rumbling murmur (Austin-flint)
  • Collapsing water-hammer pulse, ‘head-nodding’
  • Nail bed pulsation
  • Wide pulse pressure
  • LVH
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22
Q

What are the symptoms of mitral stenosis?

A
  • Progressive SOBOE
  • Pulmonary congestion (Orthopnoea, PND, Cough/haemoptysis)
  • Later –> RV failure
  • Palpitations due to paroxysmal AF
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23
Q

What are the signs of mitral stenosis?

A
  • Mid-diastolic murmur heard loudest at the apex
  • Mitral flush
  • Low volume pulse +/- AF
  • Low pulse pressure
  • Tapping apex beat
  • L parasternal heave
  • Diastolic thrill
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24
Q

What are the causes of dilated cardiomyopathy?

A
  • Idiopathic (50%)
  • Genetic (25%)
  • Alcohol
  • Inflammatory (SLE, SS)
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25
What are the signs and symptoms of dilated cardiomyopathy?
- Signs of CCF - Syncope - Sudden cardiac death (esp. in young children whilst playing sports) - New onset murmur (regurgitant type) - AF - Diffuse apex beat
26
What are the investigations for dilated cardiomyopathy?
1. Bedside: ECG - non-specific changes 2. Bloods: FBE, UEC, LFTs 3. Imaging - CXR - global/ball shaped heart - Echo - dilatation of L/R/both ventricles - Angiogram - to rule out CAD
27
What is the management of dilated cardiomyopathy?
1. Managing heart failure symptoms: - ACEi/ARBs - B-Blockers - Spironolactone 2. Managing arrhythmias/SCD: - PPM/ICD (if EJ heart transplant (but quite rare & long waiting period)
28
What are the causes of HOCM?
- Familial/genetic - Acquired due to chronic HTN - Idiopathic
29
How would you rate control a patient with AF?
- Metoprolol/dilitaizem (1st line) - Digoxin - Anti-coagulation if necessary
30
How would you rhythm control a patient with AF?
- Medical: Amiodarone - Electrical: DC cardioversion - Anti-coagulation if necessary
31
After how many times do you need to have AF to have 'recurrent AF'?
2
32
What characterises paroxysmal AF?
Self-terminating episode within 7 days
33
What characterises persistent AF?
Not self-terminating within 7 days
34
What characterises long-standing persistent AF?
Having AF for more than 1 year
35
What characterises permanent AF?
More than 1 year in which rhythm control interventions are not pursued or are unsuccessful
36
What are the causes of cardiac arrest?
H - Hypovolaemia H - Hypothermia H - Hypokalaemia/metabolic H - Hypoxia T - Toxin T - Tamponade T - Thrombosis T - Tension pneumothorax
37
What is the management of a patient in cardiac arrest with a shockable rhythm?
- DRSABCD - Oxygen - Waveform capnography - IV/IO access - Adrenaline 1mg after 2nd shock (then every 2nd cycle) - Amiodarone 300 mg after 3rd shock Post-Resuscitation - Re-evaluate DRSABCD - 12 lead ECG - Treat cause - Re-evaluate oxygenation and ventilation - Temperature control if cold
38
What is the management of a patient in cardiac arrest with a non-shockable rhythm?
- DRSABCD - Oxygen - Waveform capnography - IV/IO access - Adrenaline 1mg immediately (then every 2nd cycle) Post-Resuscitation - Re-evaluate DRSABCD - 12 lead ECG - Treat cause - Re-evaluate oxygenation and ventilation - Temperature control if cold
39
How do you calculate the CHADS2VASc score for a patient with AF?
- CCF = 1 - HTN = 1 - Age 65 - 74 = 1 - Diabetes = 1 - Stroke (previous) = 2 - Vascular disease = 1 - Age 75+ = add 1 - Sex (female) = 1 If 0 = aspirin If 1 = aspirin/warfarin If 2 = warfarin
40
What is the prophylactic management of angina?
Beta blockers (atenolol/metoprolol) +/- CCB (amlodipine/nifedipine)
41
What are the investigations for ACS?
- Bedside: ECG - Labs/bloods: FBE, UEC, LFT, cardiac enzymes (troponins/CK), INR + group and hold, blood glucose, fasting lipid levels - CXR - Special tests: angiography (not really in the acute setting unless therapeutic), stress testing, echocardiogram Note: troponin is a marker for necrosis/tissue death not ischaemia
42
What is the acute management of ACS/chest pain?
- Morphine - Oxygen - N - GTN (as required/patch) - Aspirin (300mg) chewed/dissolved before swallowing
43
What is the management of STEMI?
* MONASH + C: * M - Morphine * O - Oxygen (if hypoxic) * N - GTN (as required/patch) * A - Aspirin 300 mg chewed/dissolved before swallowing * S - Statin + stent (PCI) * H - Heparin (prior to PCI) * C - Clopidogrel
44
Where do you expect ST elevation for: - Inferior MI - Lateral MI - Anteroseptal MI
* Inferior MI: 2, 3 avF * Lateral MI: I, avL, V5, V6 * Anteroseptal: V1-4
45
Bare metal stent vs drug eluting stent for PCI
46
PCI vs CABG
PCI - day procedure, less invasive CABG * Indications: * triple vessel disease * left main disease * diabetic patient * No need for repeated re-vascularisation * Internal thoracic vessel/radial artery/saphenous vein
47
What are the discharge medications for ACS?
* SAAB+C: * Statin * ACE-i * Aspirin * Beta-blocker * Clopidogrel
48
3 days after discharging Mr A, who had a STEMI & undergone PCI, he was brought in to the ED with severe dyspnoea. On auscultation, you hear a diastolic murmur. What would you be concerned about? A.Pericarditis B.Aortic stenosis C.HOCM D.Mitral valve prolapse E.Another STEMI
D. Mitral valve prolapse
49
What are the post-MI complications?
_Early_ - Cardiogenic shock - Reinfarction - Arrhythmias (VT/VF) _Late (few weeks after)_ - Congestive heart failure
50
What is the pathology timeline post-AMI?
51
Does CK or troponin peak first, if so when and when does the other peak?
CK peaks first, but drops after 2-3 days Troponin peaks later (may be normal first, but MUST do trops every 6 hours) & remains elevated for up to 6 weeks
52
What are the causes of infective endocarditis?
53
What is the risk stratification for infective endocarditis?
**High risk**: prosthetic valve, previous IE, congenital heart defects, cardiac transplant with valve disease **Moderate risk**: other congenital cardiac defects, acquired valvular dysfunction, HOCM **Low risk/opportunistic**: IVDU, indwelling catheter, poor dentition, mucosal injury
54
What are the HACEK organisms for infective endocarditis and what makes them special :D
* Haemophillus species * Aggregatibacter species * Cardiobacterium hominis * Ekinella corrodens * Kingella species * They are all culture negative!
55
What is Duke's Criteria for infective endocarditis?
Major: * +ve blood culture (2 out of 3 sets) * Echo: +ve vegetation/valve involvement (TOE) Minor: * Fever \> 38oc * Immunlogical phenomena * Vascular phenomena * Predisposing conditions (IVDU, abnormal heart valves) * +ve blood cultures but not enough to meet major criteria
56
How must the blood cultures be taken if infective endocarditis is suspected?
Blood cultures must be taken from 3 different sites and must be 1 hour apart
57
How much of each major and minor criteria for Duke's criteria is required to diagnose infective endocarditis?
2 major criteria OR 1 major + 1 minor criteria OR 5 major criteria
58
What are the investigations for infective endocarditis?
Labs: * FBE + blood cultures * UECs + LFTs (checking for function + baseline) * Cardiac enzymes Imaging: Echocardiogram (TOE/TTE)
59
What is the management for infective endocarditis (empirical and specific)?
* Empirical: BenPen + Flucloxacillin + Gentamicin * Specific: * Staph aureus: flucloxacillin * MRSA: vancomycin * S. viridans: BenPen + gentamicin * HACEK: ceftriaxone * BenPen targets gram -ve * Flucloxacillin targets gram +ve * Gentamicin targets gram -ve (pseudomonas, proteus, serratia) & gram +ve staph
60
What are the immunological phenomena of infective endocarditis?
* Osler's nodes * GN * Arthritis * Roth's spots
61
What are the vascular (embolic) phenomena of infective endocarditis?
* Petechiae * Splinter haemorrhages * Janeway lesions * Focal neurological signs * Headaches * Splenomegaly * Microscopic haematuria + flank pain +/- active sediments
62
What are the causes of pericarditis/myocarditis?
63
What are the differences in presentation between pericarditis and myocarditis?
64
What is the management of pericarditis/myocarditis?
65
What are the investigations for cardiac tamponade?
1. Bedside: ECG (electrical alternans + small voltages) 2. Labs: 1. FBE, UEC, LFTs 2. Troponins/CK/CKMB 3. ESR/CRP 3. Imaging: 1. CXR 2. **Echocardiogram\*\* (TOE)**
66
What are the investigations for aortic dissection?
1. Bedside: ECG 2. Labs: 1. FBE, UEC, LFTs 2. CK/troponins, myoglobin, D-dimer, LDH 3. Blood group and hold 3. Imaging: 1. CXR 2. CT 3. Echocardiogram (TTE/TOE)
67
What is the management of aortic dissection?
1. DRSABCD (ensure pt is haemodynamically stable) 2. Vitals monitoring 3. Analgesics 4. Stanford A * Immediate surgical correction - cardiopulmonary bypass + excise intimal tear and replace with synthetic graft 5. Stanford B * Control BP (keep it within normal limits) * Endovascular interventions (percutaneous stenting/fenestration technology)
68
What is the clinical presentation of aortic aneurysm?
* Usually asymptomatic but can present with: * Vague back pain * Hypotension * Pulsatile EXPANSILE abdominal mass
69
What are the differences between true and pseudoaneurysms?
True aneurysms: involve all 3 walls Pseudoaneurysms: not all layers/covered by fascia
70
What are the investigations for aortic aneurysm?
1. Bedside: Abdo U/S (beware if aortic dilation is 1.5x more - aneurysm) 2. Labs: 1. FBE, UEC, LFTs 2. ESR/CRP 3. Group and hold 4. Blood cultures (if suspect mycotic) 3. Imaging: 1. CT 2. MRI 3. Aortography
71
What is the management of aortic aneurysm?
* If \< 5.5cm in diameter * Keep for observation * Follow up * If \> 5.5cm in diameter * Immediate surgical management * Dacron graft * Bentall procedure (replace damaged section + aortic valve) * David procedure (replace damaged section + reimplant aortic valve) * Medical * Labetalol + GTN * CCB
72
What are the dynamic maneouvers for murmurs?
73
What are the differences between a tissue valve (allograft/xenograft) and a mechanical valve?
* Tissue valve (allograft/xenograft) * Better in older patients * Lasts for 5 years * No need anti-coags * Mechanical valve * Better in younger patients * Last longer * Need to be on anti-coags for life
74
What is the management for HOCM?
1. Medication: * Beta-blockers * CCBs 2. Surgical/intervention: * Alcohol ablation * Holter monitoring + ICD (dual) * Biventricular PPM * Septal myomectomy
75
What is the definition of restrictive cardiomyopathy?
Impaired ventricular filling, dilation of atria and thrombus formation. Usually ideopathic.
76
What is restrictive cardiomyopathy associated with?
* Amyloidosis * Sarcoidosis * Loeffler's endocarditis\* * Endocardial fibrosis\* * \* = associated with eosinophillia
77
What are the signs and symptoms of restrictive cardiomyopathy?
* Dyspnoea, fatigue and embolic symptoms\* * Elevated JVP * High jugular pressure with diastolic collapse (Friedrich's sign) * Elevation of venous pressure with inspiration (Kussmaul's sign) * S4 ("a stiff wall") * Signs of heart failure
78
What is Friedeich's sign and what is it a sign of?
Friedreich's sign is high jugular pressure with diastolic collapse and a sign of restrictive cardiomyopathy. Early diastolic filling not inhibited but filling becomes impaired in the last two0thirds of diastole when the explanding ventricle hits the rigid pericardium à pressure rises to higher-than-normal level.
79
What is Kussmaul's sign and what is it a sign of?
Kussmaul's sign is elevation of venous pressure with inspiration, occurring in restrictive cardiomyopathy.
80
What are the investigations for restrictive cardiomyopathy?
1. Bedside: ECG (low voltages, non specific ST-T changes) 2. Labs: FBE, UEC, LFT 3. Imaging: CXR (pulmonary venous congestion), Echocardiogram (myocardial thickening, normal EF, impaired filling) 4. Others * Cardiac catheterisation/haemodynamic studies (differentiate from constrictive pericarditis) * Endomyocardial biopsy (useful --\> diagnosis of amyloidosis = apple-green bifringent crystals)
81
What is the magnagement of restrictive cardiomyopathy?
* No specific treatment for restrictive cardiomyopathy * Usually just treat the symptoms * Primary amyloidosis = melphalan + prednisilone (may improve survival) * Other choice: heart transplant (but may reoccur)

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