Cardiology Flashcards
PR interval
0.12-0.20
PR segment
0.05-0.12
QRS complex
0.08-0.12
QT interval
Less than or equal to 0.45 in males, 0.46 in females
Corrected QT
Bazett’s formula: QT interval/square root of RR in seconds
When to correct for QT
Tachycardia or bradycardia
How to measure heart rate for regular rhythm
1500/number of small boxes from R-R
1 small box: second/s
0.04
5 small boxes (1 big box): second/s
0.2
1 small box: mm
1
5 small boxes (1 big box): mm
5
Normal axis
-30 to 100
Examples of LAD (4)
1) LVH
2) Inferior wall MI
3) Hyperkalemia
4) Normal variant
Examples of RAD (6)
1) RVH
2) Anterolateral wall MI
3) Pulmonary embolism
4) Chronic lung disease
5) ASD, VSD
6) Normal variant in children and thin adults
Leads for eyeballing of axis
1) Lead I
2) aVF
Heart rate in sinus rhythm
60-100bpm
Heart rate in junctional rhythm
40-60bpm
Heart rate in idioventricular rhythm
15-40
Anterior wall: Supplied by
LAD
Anterior wall: Leads
v1-4
Anteroseptal wall: Supplied by
LAD
Anteroseptal wall: Leads
V1-2
Anterolateral wall: Supplied by
LCX
Anterolateral wall: Leads
V4-6
Lateral wall: Supplied by
LCX
Lateral wall: Leads
I, aVL
Inferior wall: Supplied by
RCA
Inferior wall: Leads
II, III, aVF
Vessels that comprise the largest total cross-sectional and surface area of circulation
Capillaries
T/F: Venules have autonomic innervation
T
Correponds to the distensibility of blood vessel
Capacitance/compliance
Artery vs vein: Greater capacitance
Vein
Most important determinant of pulse pressure
Stroke volume
Palpation mtd of BP measurement: Artery used
1) Brachial
2) Radial
Palpation mtd of BP measurement: Inflate the cuff ___ mmHg above the point where loss of pulse is noted
30
Auscultation mtd of BP measurement: Inflate cuff ___ mmHg above systolic pressure
30
Palpation mtd of BP measurement: Rate of decrease in pressure should be
2-3 mmHg/sec
Korotkoff phase: Onset of tapping
Phase 1
Korotkoff phase: Reappearance of tapping sound
Phase 3
Korotkoff phase: Disappearance of sound
Phase 5
Korotkoff phase: 10-15mmHg lower than previous phase during which a murmur may be heard after tap
Phase 2
Korotkoff phase: Muffling of heart sound
Phase 4
Normal BP difference of both arms
Less than 10 mmHg
UE vs LE: Higher BP
LE
BP is __mmHg higher in legs than arms
20
Orthostatic hypotension: Fall in SBP by __mmHg
20
Orthostatic hypotension: Fall in DBP by __mmHg
> 10
Effect of inspiration to SBP
Decrease
Exaggerated fall in SBP with normal respiration
Pulsus paradoxus
mmHg fall in pulsus paradoxus
10mmHg or more
Slow rise in arterial pulse
Pulsus tardus
Pulsus tardus is seen in
Aortic stenosis
Non-cardiac causes of rapid rise in arterial pressure or bounding pulse (3)
1) Thyrotoxicosis
2) Pregnancy
3) Anemia
Cardiac causes of rapid rise in arterial pressure or bounding pulse (3)
1) PDA
2) AR
3) Coarctation of the aorta
Twice beating or double-peaked arterial pulse
Pulsus bisferiens
Condition: Pulsus bisferiens
AR
Single most common cause of heart failure
CAD
***Most common cause of pump failure hence CHF
Myocardial hypertrophy usually sec to htn
Measure of LV function
EF
Heart failure with depressed EF
Systolic failure
Heart failure with preserved EF
Diastolic failure
Treatment for systolic failure
Digoxin
Most common manifestation of left-sided heart failure
Pulmonary congestion and edema
Heart failure cells
Hemosiderin-laden macrophages
Most common cause of right-sided heart failure
Left-sided heart failure
Left vs right sided heart failure, etiology: Pulmonary emboli
Right
Left vs right sided heart failure, etiology: Any disease interfering with pulmonary ventilation
Right
Left vs right sided heart failure, etiology: Cystic fibrosis
Right
Left vs right sided heart failure, etiology: Ischemia
Left
Left vs right sided heart failure, etiology: Systemic htn
Left
Left vs right sided heart failure, etiology: Myocardial disease/cardiomyopathy
Left
Right-sided heart failure caused by pulmonary htn from intrinsic lung dse
Cor pulmonale
Right-sided heart failure results on __ in the liver
Chronic passive congestion
Histologic morphology of liver in right-sided heart failure
Centrilobular congestion and atrophy of central hepatocytes described as nutmeg liver
Functional capacity class: Ordinary physical activity does not cause undue fatigue
I
Functional capacity class: SLIGHT limitation. Ordinary physical activity results in fatigue.
II
Functional capacity class: MARKED limitation. Less than ordinary activity causes fatigue.
III
Functional capacity class: Symptoms present even at rest
IV
Cardinal symptoms of heart failure (2)
1) Fatigue
2) Shortness of breath
Periodic respiration or cyclic respiration
Cheyne-Stokes
Mgt of heart failure with depressed EF (less than 40%)
1) Screen and treat comorbidities
2) Stop smoking and limit alcohol
3) Avoid extremes of temp and heavy physical exertion
4) Diuretics
Most common sustained arrhythmia
Atrial fibrillation
Typical rate of afib
120-160bpm
Treatment for afib (2)
1) Rate controller
2) Anticoagulant
When to begin IV heparin in afib (2 conditions)
1) Duration >12hrs
2) Presence of risk factors for stroke in Afib
Risk factors for stroke in Afib (9)
1) History of stroke or TIA
2) Mitral stenosis
3) Htn
4) DM
5) Age >75
6) CHF
7) LV dysfunction
8) Marked left atrial enlargement (>5.0cm)
9) Spontaneous echo contrast
Membrane channel inhibited by Digoxin
Na/K ATPase pump
Electrolyte imbalances that worsen Digoxin toxicity
1) HypoK
2) Hypomag
Transient or concealed ST elevation in V1-V3 typically provoked with Na channel-blocking drugs
Brugada syndrome
Brugada syndrome: Provoking drugs
1) Ajmaline
2) Procainamide
3) Flecainide
Brugada syndrome: Gene mutation in 20% of patients
scn5a
Brugada syndrome: Most common in
Young males
Brugada syndrome: Responsible for ___ in southeast asian men
SUNDS
Brugada syndrome: Risk of developing
Polymorphic ventricular arrhythmia
Brugada syndrome: Predictors of adverse outcome
1) Spontaneous coved-type ST elevation in the right precordial leads
2) History of syncope
3) Aborted sudden cardiac death
Brugada syndrome: Treatment
Procainamide
***Most common type of heart disease among children
Congenital heart disease
Congenital heart disease develops at which week of gestation
3rd to 8th
Incidence of congenital heart disease
1% of livebirths
Congenital heart disease: L-R shunt (4)
1) ASD
2) VSD
3) PDA
4) AVSD (atrioventricular septal defect)
Most common congenital cardiac anomaly in adults
ASD
Male vs female: ASD
Female
Types of ASD (3)
1) Sinus venosus
2) Ostium primum
3) Ostium secundum
Most common form of ASD
Ostium secundum
Syndrome in which a mutation in tbx5 transcription factor causes ASD and VSD
Holt-Oram syndrome
S2 in ASD
Widely split
ECG change in ASD
rSr’ pattern in the right precordial leads representing enlargement of RV outflow tract
Surgical repair of ASD should not be carried out in
1) Small defects
2) Trivial L-R shunts
3) Severe pulmonary vascular disease without a significant L-R shunt
Location of sinus venosus
High in the atrial septum near the entry of SVC
Sinus venosus ASD is frequently associated with
Anomalous pulmonary venous connection from the right lung to the SVC or right atrium
Location of ostium primum
Adjacent to the AV valves which may be deformed or regurgitant
Location of ostium secundum
Midseptal and involves fossa ovalis
Most common congenital cardiac anomaly overall
VSD
Congenital anomaly frequently associated with VSD
Tetralogy of Fallot
Isolated vs with association: VSD
With association
Single vs multiple: Opening/s in VSD
Single (MC single because MC is membranous; Trabecular or muscular VSD is characteristically “Swiss cheese” in appearance because of multiple openings)
Membranous vs infundibular: Opening in VSD
Membranous
Principal determinant of clinical manifestations, course, and feasibility of surgical repair of a given VSD
Pulmonary vascular bed
Large communication b/w 2 circulations and bidirectional or predominantly right-to-left shunts because of high resistance and obstructive pulmonary htn
Eisenmenger syndrome
Small shunt: Pulmonary-systemic flow ratio
Less than 1.5 to 2:1
Small shunt: Surgery
Surgery not recommended
Medium to large shunt: Pulmonary-systemic flow ratio
> 1.5 or 2:1
Medium to large shunt: Surgery
Operative or transcatheter
Eisenmenger VSD: Management (3)
1) Pulmonary arterial vasodilators
2) Single lung transplantation with intracardiac defect repair
3) Total heart-lung transplantation
Therapeutic phlebotomy: Amount of blood removed
500
Therapeutic phlebotomy: Duration
45 mins
Therapeutic phlebotomy: Replacement of extracted volume
Isovolumetric replacement with isotonic saline
Outcome of R-L shunt (3)
1) Cyanosis
2) Clubbing
3) Erythrocytosis
Cause of erythrocytosis in R-L shunt
Chronic hypoxemia and EPO production
Compensated vs decompensated erythrocytosis: Therapeutic phlebotomy
Decompensated
Caveat of therapeutic phlebotomy
Limits O2 delivery
Isolated vs with association: PDA
Isolated
10% of PDA is associated with (3)
1) Pulmonary or aortic stenosis
2) Coarctation
3) VSD
PDA is associated with what gestational conditions
1) Prematurity (HMD)
2) Congenital rubella infection
Murmur associated with PDA
Machinery
Congenital heart diseases: R-L shunt
5 T’s
1) Tetralogy
2) TOGV
3) Tricuspid atresia
4) Persistent Truncus
5) TAPVR
Most common cause of heart disease in children
RHD
RHD: Etiology
Immunologic hypersensitivity rxn to streptococcal antigens
RHD: Major criteria
1) Chorea
2) Carditis
3) Polyarthritis
4) Subcutaneous nodules
5) Erythema nodosum
RHD: Etiologic agent
GABHS
RHD: Foci of swollen eosinophilic collagen surr by lymphocytes, occ plasma cells, and plump macrophages (granuloma)
Aschoff bodies
RHD: Activated histiocytes/plump macrophages pathognomonic of RHD
Anitschkow’s cells
RHD: Multinucleated giant cells seen in aschoff bodies
Aschoff cells
Most common clinical presentations of ARF (2)
1) Fever
2) Polyarthritis
Clinical features of RF (9)
FEVERSS PE
1) Fever
2) ESR elevation
3) Valvular damage
4) Erythema marginatum
5) Red hot joints (polyarthritis)
6) Subcutaneous nodules
7) St. Vitus dance (Chorea)
8) Polyarthralgia
9) ECG: Prolonged PR interval
Criteria for diagnosis of RF
Jones criteria
Jones criteria
Evidence of GABHS infection +
1) 2 major
2) 1 major + 2 minor
3) 2 minor for recurrence
Hallmark of rheumatic carditis
Valvular damage
RHD: Valve that is almost always affected
Mitral
T/F: Isolated aortic valve involvement is common in RHD
F
Rapid purposeless movements that affect particularly the head with a characteristic darting movement of the tongue
Sydenham’s chorea
Evidence of GABHS infection is required for diagnosis of RF except
When discovered after a long latent period
Acute RF resolves in
3 months without treatment
Chronic RF is cxd persistence of symptoms for
More than 6 months
Polyarthritis in RF: Resolution
Within 2-4 weeks without permanent damage
Polyarthritis in RF: Symmetrical vs asymmetrical
Symmetrical
Polyarthritis in RF: Large vs small joints
Small
Polyarthritis in RF: Rare sequelae
Periarticular fibrosis called Jaccoud joint
Polyarthritis in RF: May be monoarticular with early use of what drug
NSAID
RF: Age of predilection
5-15 y/o
RF: Rare after what age
35 y/o
RF: Symptoms more common in females (2)
1) Mitral stenosis
2) Sydenham’s chorea
RF: Major criteria most common in children
Carditis
RF: Major criteria most common in adults
Polyarthritis
RF: Major criteria that are very rare in adults (3)
1) Erythema nodosum
2) St. Vitus dance
3) Subcutaneous nodules
The ONLY manifestation of ARF with significant potential to cause long-term disability and/or death
Carditis
T/F: Carditis in RF is a PANCARDITIS
T
RF Chorea: Pathophy
Autoantibodies react with brain ganglioside
RF manifestation covered by clothing due to predilection for trunk and proximal aspects of limbs hence frequently missed by parents
Erythema marginatum
Erythema marginatum T/F: Pruritic
F
Erythema marginatum T/F: Painful
F
RF subcutaneous nodules resolve within
1-2 weeks
VSD: Defects in muscular septum
Multiple
VSD: Appearance of muscular defect
Swiss cheese
Components of TOF
PROVe
1) Pulmo stenosis
2) RVH
3) Overriding of aorta
4) VSD
T/F A fraction of VSDs close spontaneously
T
VSD: Timing of spontaneous closure
30-50% in the first 2 years of life
Congenital heart disease: Snowman or figure of 8
TAPVR
PDA: Permanent closure
8 weeks after birth
PDA: Inversely related to (2)
1) Gestational age
2) Birth weight
PDA: Attached to which portion of aorta
Descending
Classical rash of congenital rubella
Blueberry muffin rash
PDA: Mgt
Prostaglandin synthase inhibitors
1) Indomethacin
2) Ibuprofen
PDA: Drug associated with premature closure
Ibuprofen
Congenital heart disease: Boot-shaped heart
TOF
Most common cyanotic congenital anomaly
TOF
TOF: Prognosis is dependent on
Degree of pulmonary stenosis
TOF: Paroxysmal hypercyanotic attacks
Tet spells
TOF: Tet spells are due to
R-L flow across VSD due to overload from pulmo stenosis
TOF: Pharmacologic management
b-blocker
TOF: Physiologic management
Squatting or knee to chest position
TOF: Surgical management
Blalock-Tausig shunt
TOF: Best timing for Blalock-Tausig shunt
1st month
Most common aorticopulmonary anastomosis
Blalock-Tausig shunt
Anomalous in TOGV
Aorticopulmonary septum
TOGV: Risk factor
Diabetic mother
Congenital defect and associated cardiac disease: Down
ASD, VSD, AV septal defect (endocardial cushion defect)
Congenital defect and associated cardiac disease: Congenital rubella
PDA, pulmonary artery stenosis
Congenital defect and associated cardiac disease: Turner
Preductal coarctation of aorta
Congenital defect and associated cardiac disease: Marfan
Aortic insufficiency and dissection (late complication)
Congenital defect and associated cardiac disease: Infant of diabetic mother
TOGV
“Tree bark” aorta is seen in
Syphilitic heart disease
Most common PRIMARY cardiac tumor
Myxoma
90% of cardiac myxomas occur in
Atria, mostly left atrium
“Ball valve” obstruction of the left atrium
Cardiac myxoma
Most frequent primary cardiac tumor in children
Rhabdomyomas
Most common heart tumor
Metastasis
Most common tumours that metastasize to the heart
Melanoma, lymphoma
