Cardiology Flashcards

Question

STEMI ECG

Answer 1

``` STEMI Sequence  Normal  ST elevation + hyperacute (tall) T waves  Q waves: full-thickness infarct  Normalisation of ST segments  T wave inversion  (New onset LBBB also = STEMI) ```

Answer 2

ST depression | T wave inversion

Answer 3

No Q waves

Answer 4

2 3 avf vessel RCA

Answer 5

1 avl V4-V6 vessel LCx

Answer 6

V2-V4 vessel LAD

Answer 7

V2-V6 vessel LMCA

Answer 8

V1-V3 reciprocal changes vessel RCA

Answer 9

Troponin T and I look at 3 and 12 hours peak 24 hours returns to baseline 5-14 days

Answer 10

cardiomegaly pulmonary oedema widened mediastinum - aortic rupture

Answer 11

STEMI/LBB - typical symptoms + ST elevation / LBB NSTEMI - typical symptoms + no ST elevation + +ve troponin UA - typical symptoms + no ST elevation + -ve troponin

Answer 12

PCI or thrombolysis

Answer 13

medical + elective angioplasty +- PCI/CABG

Answer 14

Death Passing PRAED st. Death- VF, LVF, CVA Pump failure Pericarditis - mild fever pericardial friction rub relieved by sitting forward, ECG saddle shaped ST elevation, give ibuprofen Rupture - myomalacia cordis, cardiac tamponade giving beck's triad (drop BP, rise JVP, muffled heart sounds) and pulsus paradoxus. Papillary muscle = Mitral regurg. septum = heart failure Arrhythmias Aneurysm- ventricular Embolism from LV mural thrombus Dressler's syndrome - autoantibodies against myocyte sarcolemma read through notes following this flashcard more info

Answer 15

drop in systolic BP >10mmHg on inspiration

Answer 16

``` MONAC Morphine- 5-10mg IV Metoclopramide - 10mg IV Oxygen - 2-4L sats 94-98% Nitroglycerin - 2 puffs Aspirin 300mg PO then 75mg/day Clopidogrel - 300mg po then 75mg/day ``` 12 lead ECG LMWH eg enoxaparin IV then subcut Admit to CCU Primary PCI or thrombolysis

Answer 17

PCI if <12 hours Thrombolysis if >24 hours from pain onset If not suitable for either then give fondaparinux

Answer 18

angioplasty and stenting + GP IIA/IIIA antagonist eg clopidogrel, tirofiban - give this if patient is delayed PCI, diabetes, complex

Answer 19

bleeding emboli arrhythmia

Answer 20

ST elevation >1mm in 2+ limb leads or >2mm in 2+ chest leads New LBBB Posterior MI - DEEP ST depression in V1-V3 and tall R waves

Answer 21

AGAINST ``` Aortic dissection GI bleeding Allergic reaction previously Iatrogenic- recent surgery Neuro- cerebral neoplasm Severe HTN Trauma - including CPR ```

Answer 22

Alteplase (tissue plasminogen activator ) streptokinase tenecteplase

Answer 23

bleeding stroke arrhythmia allergic reaction

Answer 24

ACEi- start within 24 hours B blocker Aspirin (+- clopidogrel) statin and cardiac rehabilitation programme lifestyle advice

Answer 25

``` stop smoking diet- oily fish, decrease sat fats exercise 30min/day work== return in 2 months sex == avoid 1 month driving== avoid 1 month ```

Answer 26

MONAC fondaparinux 12 lead ECG GRACE score High risk - persistent recurrent ischaemia, ST depression, DM, positive troponin Low risk- No pain , flat or inverted T waves, normal ECG, negative troponin

Answer 27

used to assess ACS risk

Answer 28

GP2a/3a antagonist- tirofiban angiography +- PCI within 96 hours clopidogrel 75mg/day for one year

Answer 29

may discharge after 12 hours if troponin negative follow up outpatient tests - angiography - perfusion scan - stress echo

Answer 30

atherosclerosis leading to ischaemia

Answer 31

``` mostly atheroma anaemia aortic stenosis tachyarrhythmias arteritits ```

Answer 32

central chest tightness brought on by exertion and relieved by rest may radiate to arms/jaw precipitants - emotion, cold weather, heavy meals

Answer 33

Stable - induced by effort Unstable - occurs at rest, minimal exertion Decubitus - induced by lying down Variant - at rest due to coronary spasm, gives ST elevation during attack, treat with CCB and long acting nitrate Syndrome X - angina pain and ST elevation on exercise test no evidence of coronary atherosclerosis

Answer 34

Aortic stenosis Aortic aneurysm GORD chostrochondritis

Answer 35

``` Angiography (gold standard) Bloods - FBC UE lipids glucose ESR TFTs ECG - usually normal Exercise ECG Stress echo Perfusion scan CT coronary calcium score ```

Answer 36

Lifestyle Medical Interventional Surgical

Answer 37

secondary prevention - aspirin - ACEi - Statin - Antihypertensive ``` Anti anginals - GTN spray/sublingual + B blocker + CCB + Both (Amlodipine) ``` + ivabradine +nicorandil

Answer 38

What -PCI When - poor response to medical treatment - not suitable for CABG Complications - restenosis - MI - Death clopidogrel reduces risk of restenosis best to use drug eluting stent as well

Answer 39

What - CABG When - LMCA disease - Triple vessel disease - Refractory angina - Unsuccessful PCI Complications - stroke - MI - Pericardial tamponade - Post perfusion syndrome - Post op AF - Graft stenosis

Answer 40

CO is inadequate for the body's requirements despite adequate filling pressures

Answer 41

``` Initial reduction in CO== compensation starling effect dilates heart to enhance contractility remodelling == hypertrophy RAAS activation ANP/BNP release Sympathetic activation ``` Progressive decline in CO == decompensation progressive dilation gives impaired contractility and valve regurgitation hypertrophy leads to relative myocardial ischaemia RAAS activation leads to Na+ retention and fluid retention == increased venous pressure and oedema sympathetic excess - increased afterload and decreased CO

Answer 42

Low output cardiac failure is when CO drops and it can't increase with exertion ``` 1. Pump failure: Systolic failure → impaired contraction  Ischaemia/MI (commonest cause)  Dilated cardiomyopathy  Hypertension  Myocarditis ``` Diastolic failure → impaired filling  Pericardial effusion / tamponade / constriction  Cardiomyopathy: restrictive, hypertrophic Arrhythmias  Bradycardia, heart block  Tachycardias  Anti-arrhythmics (e.g. beta-blocker, verapamil) ``` 2. Excessive pre-load  AR,MR  Fluid overload t 3. Excessive afterload  AS  HTN  HOCM hypertrophic cardiomyopathy ```

Answer 43

This is when body has increased needs which the heart can't meet, initially gives RVF then LVF. Anaemia, Arteriovenous malformation Thyrotoxicosis, Thiamine deficiency (beri Beri) Pregnancy, Pagets

Answer 44

Causes: - LVF - Cor pulmonale - Tricuspid and pulmonary valve disease Symptoms: - Anorexia - Nausea ``` Signs:  ↑JVP + jugular venous distension  Tender smooth hepatomegaly (may be pulsatile)  Pitting oedema  Ascites ```

Answer 45

``` Causes  1st: IHD  2nd: idiopathic dilated cardiomyopathy  3rd: Systemic HTN  4th: Mitral and aortic valve disease  Specific cardiomyopathies ``` Symptoms  Fatigue  Exertional dyspnoea  Orthopnoea + PND paroxysmal nocturnal dyspnoea  Nocturnal cough (± pink, frothy sputum)  Wt. loss and muscle wasting ``` Signs  Cold peripheries ± cyanosis  Often in AF  Cardiomegaly ̄c displaced apex  S3 + tachycardia = gallop rhythm  Wheeze (cardiac asthma)  Bibasal creps ```

Answer 46

For CCF diagnosis need 2 major or 1 major + 2 minor Major: - Paroxysmal nocturnal dyspnoea - Neck vein distension - Cardiomegaly - Acute pulmonary oedema - Increase CVP

Answer 47

Bloods- FBC UE BNP TFTs glucose lipids CXR - ABCDE (Alveolar shadowing bats wings, B kerley lines, Cardiomegaly, Dilated upper veins, Effusions) ECG- Ischaemia, hypertrophy, AF Echocardiogram - Hypertrophy, valve lesions, Intracardiac shunts, Reduced ejection fraction, hypokinesia

Answer 48

Actions:  ↑ GFR and ↓ renal Na reabsorption  ↓ preload by relaxing smooth muscle Marker:  ↑ BNP (>100) better than any other variable and clinical judgement in diagnosing heart failure  BNP correlates ̄c LV dysfunction  i.e. ↑ most in decompensated heart failure  ↑ BNP = ↑ mortality  BNP <100 excludes heart failure (96% NPV)  BNP also ↑ in RHF: cor pulmonale, PE

Answer 49

1. No limitation of activity 2. Comfortable @ rest, dyspnoea on ordinary activity 3. Marked limitation of ordinary activity 4. Dyspnoea @ rest, all activity → discomfort

Answer 50

1st line: ACEi/ARB + B Blocker + Loop Diuretic with B blockers start low and go slow 2nd line: K+ saving diuretic - spironolactone (watch for hyperkalaemia especially if on ACEi as well) ACEi + ARB Vasodilators (hydralazine + ISDN) 3rd line: Digoxin ICD

Answer 51

BP may be very low Renal function Plasma K if on spironolactone and ACEi Daily weight

Answer 52

1. Sit patient up 2. Oxygen 15L non rebreath mask target 94-98% 3. IV access and monitor ECG (bloods and treat any arrhythmias 4. Diamorphine 2.5-5mg IV (pain and is pulmonary venodilator) + metoclopramide 10mg IV 5. Furosemide 40-80mg IV 6. GTN 2 puffs or 2 buccal tablets (unless SBP<90) 7. If SBP>100 start nitrate infusion 8. if worsening consider CPAP dialysis If SBP drops below 100 treat as cardiogenic shock and give inotropes

Answer 53

Cardiogenic  MI  Arrhythmia  Fluid overload: renal, iatrogenic Non-cardiogenic  ARDS: sepsis, post-op, trauma  Upper airway obstruction  Neurogenic: head injury

Answer 54

Dyspnoea Orthopnoea pink frothy sputum

Answer 55

``` Distressed, sweaty, cyanosed Tachycardia Tachypnoea Raised JVP S3 gallop rhythm Bibasal crepitations Pleural effusions Wheeze ```

Answer 56

Asthma COPD Pneumonia PE

Answer 57

decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume. the failure of CO is due to pump failure

Answer 58

1. Oxygen 15L nonrebreath mask 94-98% 2. IV access and monitor ECG 3. Diamorphine 2.5-5mg IV + metoclopramide 4. Correct any arrhythmias, electrolyte disturbances, acid-base abnormalities 5. CXR, Echo, CT thorax 6. Monitor CVP, BP, ABG, ECG, Urine 7. Consider need for inotropes dobutamine 8. Treat underlying cause

Answer 59

MI HEART ```  MI  Hyperkalaemia (inc. electrolytes)  Endocarditis (valve destruction)  Aortic Dissection  Rhythm disturbance  Tamponade ``` + obstructive causes - Tension pneumothorax - Massive PE

Answer 60

Unwell, pale, sweaty, cyanosed, distressed cold clammy peripheries, ↑RR ± ↑HR Pulmonary oedema

Answer 61

```  Trauma  Lung/breast Ca  Pericarditis  MI  Bacteria (e.g. TB) ```

Answer 62

 Beck’s triad: ↓BP, ↑JVP, muffled heart sounds  Kussmaul’s sign: ↑JVP on inspiration  Pulsus paradoxus (pulse fades on inspiration)

Answer 63

Echo - diagnostic | CXR - globular heart

Answer 64

ABCDE | Pericardiocentesis using echo guidance is best

Answer 65

```  Stage 1: Clinic BP > 140/90  Stage 2: Clinic BP > 160/100  Severe: Clinic BP > 180/110  Malignant: BP > 180/110 + papilloedema and/or retinal haemorrhage  Isolated SHT: SBP ≥140, DBP <90 ```

Answer 66

PREDICTION ``` Primary/Essential 95% Renal - RAS, glomerulonephritis, PKD Endocrine - Hyperthyroid, cushing's, phaeochromocytoma, acromegaly, conn's Drugs- cocaine, cocp, NSAIDS ICP raised Coarctation of aorta Toxaemia of pregnancy Increased viscocity Overload with fluid Neurogenic ```

Answer 67

``` Increased HR thyrotoxicosis Radio-femoral delay = Coarctation of aorta Renal bruits = Renal artery stenosis Palpable kidneys = PKD Paroxysmal symptoms = phaeochromocytoma ```

Answer 68

CANER Cardiac  IHD  LVH → CCF  AR,MR Aortic  Aneurysm  Dissection Neuro  CVA: ischaemic, haemorrhagic  Encephalopathy (malignant HTN) Eyes - hypertensive retinopathy Keith-Wagener Classification: 1. Tortuosity and silver wiring 2. AV nipping 3. Flame haemorrhages and cotton wool spots 4. Papilloedema grades 3 and 4 signify malignant hypertension Renal - proteinuria - CKD

Answer 69

24 HR ABPM Urine - haematuria Albumin:creatinine ratio Bloods - FBC, UE eGFR glucose fasting lipids 12 lead ECG - LVH, old infarct Calculate 10 year CV risk Q score important to do ABPM first before starting treatment so you can confirm diagnosis

Answer 70

<80yrs, stage 1 HTN (>140/90) and one of:  Target organ damage (e.g. LVH, retinopathy)  10yr CV risk ≥20%  Established CVD  DM  Renal disease  Anyone with stage 2 HTN (>160/100)  Severe / malignant HTN (specialist referral)  Consider specialist opinion if <40yrs with stage 1 HTN and no end organ damage.

Answer 71

 Under 80yrs: <140/90 (<130/80 in DM) |  Over 80yrs: <150/90

Answer 72

1. <55 = A > 55 or black = C 2. A+C 3. A+C+D 4. A+C+D + consider further diuretic eg spironolactone + consider a blocker or B blocker + seek expert opinion A: ACEi or ARB  e.g. lisinopril 10mg OD (↑ to 30-40mg)  e.g. candesartan 8mg OD (max 32mg OD) C: CCB: e.g. nifedipine MR30-60mg OD D: Thiazide-like diuretic: e.g. chlortalidone 25-50mg OD In step 2, use ARB over ACEi in blacks. Avoid thiazides + β-B if possible (↑ risk of DM). Only consider β-B if young and ACEi/ARB not tolerated.

Answer 73

 Controlled ↓ in BP over days to avoid stroke  Atenolol or long-acting CCB PO  Encephalopathy/CCF: fruse + nitroprusside / labetalol IV  Aim to ↓ BP to 110 diastolic over ~4h  Nitroprusside requires intra-arterial BP monitoring

Answer 74

 Senile calcification (60yrs +): commonest  Congenital: Bicuspid valve (40-60yrs), William’s syn.  Rheumatic fever

Answer 75

```  Triad: angina, dyspnoea, syncope (esp. ̄c exercise)  LVF: PND, orthopnoea, frothy sputum  Arrhythmias  Systemic emboli if endocarditis  Sudden death ```

Answer 76

 Slow rising pulse ̄c narrow PP  Aortic thrill  Apex: Forceful, non-displaced (pressure overload) Heart Sounds  Quiet A2  Early syst. ejection click if pliable (young) valve  S4 (forceful A contraction vs. hypertrophied V) ``` Murmur  ESM  Right 2nd ICS  Sitting forward in end-expiration  Radiates to carotids ```

Answer 77

```  Coronary artery disease  MR  Aortic sclerosis  Valve thickening: no pressure gradient  Turbulence → murmur  ESM ̄c no radiation and normal pulse ``` HOCM  ESM murmur which ↑ in intensity ̄c valsalva (AS↓)

Answer 78

Bloods: ECG:  LVH  LV strain: tall R, ST depression, T inversion in V4-V6  LBBB or complete AV block (septal calcification)  May need pacing ``` CXR  Calcified AV (esp. on lateral films)  LVH  Evidence of failure  Post-stenotic aortic dilatation ``` Echo + Doppler: diagnostic  Thickened, calcified, immobile valve cusps Cardiac Catheterisation + Angiography  Can assess valve gradient and LV function  Assess coronaries in all pts. planned for surgery Exercise Stress Test  Contraindicated if symptomatic AS  May be useful to assess ex capacity in asympto pts.

Answer 79

 Optimise RFs: statins, anti-hypertensives, DM  Monitor: regular f/up ̄c echo  Angina: β-B  Heart failure: ACEi and diuretics

Answer 80

``` Poor prog. if symptomatic  Angina/syncope: 2-3yrs  LVF: 1-2yrs Indications for valve replacement  Severe symptomatic AS  Severe asymptomatic AS ̄c ↓ EF (<50%)  Severe AS undergoing CABG or other valve op Valve types  Mechanical valves last longer but need anticoagulation: young pts.  Bioprosthetic don’t require anticoagulation but fail sooner (10-15yrs) ```

Answer 81

Acute: Infective endocarditis Type A aortic dissection ``` Chronic: Congenital - bicuspid aortic valve Rheumatic heart disease Connective tissue disease: Marfan's , Ehler's danlos Autoimmune: ankylosing spondylitis RA ```

Answer 82

 LVF: Exertional dyspnoea, PND, orthopnoea  Arrhythmias (esp. AF) → palpitations  Forceful heart beats  Angina

Answer 83

 Collapsing pulse (Corrigan’s pulse)  Wide PP  Apex: displaced (volume overload) Heart Sounds  Soft / absent S2  ± S3 ``` Murmur  Early DM decrescendo  UR Sternal Edge + 3rd left IC parasternal  Sitting forward in end-expiration  ± ejection systolic flow murmur  ± Austin-Flint murmur ``` Underlying cause  High-arched palate  Spondyloarthropathy  Embolic phenomena

Answer 84

Bloods: FBC, U+E, lipids, glucose ECG: LVH (R6+S1 > 35mm) CXR  Cardiomegaly  Dilated ascending aorta  Pulmonary oedema Echo  Aortic valve structure and morphology (e.g. bicuspid)  Evidence of infective endocarditis (e.g. vegetations) Cardiac Catheterisation  Coronary artery disease  Assess severity, LV function, root size

Answer 85

Medical basically just manage the risk factors HTN, DM etc and have regular follow up Surgical Aortic valve replacement reserved for severe cases with HF symptoms

Answer 86

Rheumatic fever Prosthetic valve Congenital

Answer 87

 Valve narrowing → ↑ left atrial pressure → loud S1 and atrial hypertrophy → AF  → pulmonary oedema and PHT → loud P2, PR  → RVH → left parasternal heave  →TR→largevwaves  → RHF → ↑JVP , oedema, ascites

Answer 88

``` Dyspnoea Fatigue Chest pains AF == palpitations and emboli haemoptysis == rupture of bronchial veins due to dilated rleft atrium ```

Answer 89

Symptoms manifest when orifice <2cm2 (norm 4-6)  AF, low volume pulse  Malar flush (↓CO → backpressure + vasoconstriction) JVP may be raised late on  Prominent a waves: PTH  Large v waves: TR  Absent a waves: AF  Left parasternal heave (RVH secondary to PHT)  Apex: Tapping (palpable S1), non-displaced Heart sounds  Loud S1  Loud P2 (if PHT)  Early diastolic opening snap ``` Murmur  Rumbling MDM  Apex  Left lateral position in end expiration  Radiates to the axilla  ± Graham Steell murmur (EDM 2O to PR) ```

Answer 90

Hypertrophy

Answer 91

Palpable murmur

Answer 92

 Pulmonary HTN  Emboli: TIA, CVA, PVD, ischaemic colitis  Hoarseness: rec laryngeal N. palsy = Ortner’s Syn  Dysphagia (oesophageal compression)  Bronchial obstruction

Answer 93

Bloods: FBC, U+E, LFTs, glucose, lipids ECG  AF  P mitrale (if in sinus)  RVH ̄c strain: ST depression and T wave inversion in V1-V2 CXR  LA enlargement  Pulmonary oedema: ABCDE  Mitral valve calcification Echo and doppler Severe MS (AHA 2006 Criteria)  Valve orifice <1cm2  Pressure gradient >10mmHg  Pulmonary artery systolic pressure >50mmHg Use TOE to look for left atrial thrombus if intervention considered. Cardiac Catheterisation  Assess coronary arteries

Answer 94

Medical monitor risk factors and treat them prophylaxis for rheumatic fever Treat AF Surgical  Indicated in mod–severe MS (asympto and symptomatic) ``` Percutaneous balloon valvuloplasty  Rx of choice  Suitability depends on valve characteristics  Pliable, minimally calcified  CI if left atrial mural thrombus ```  Surgical valvotomy / commissurotomy: valve repair  Valve replacement if repair not possible

Answer 95

 Mitral valve prolapse  LV dilatation: AR, AS, HTN  Annular calcification → contraction (elderly)  Post-MI: papillary muscle dysfunction/rupture  Rheumatic fever  Connective tissue: Marfan’s, Ehlers-Danlos

Answer 96

Dyspnoea fatigue AF == palpitations and emboli Pulmonary congestion == Hypertenison and oedema

Answer 97

 AF  Left parasternal heave (LVH) Apex: displaced  Volume overload as ventricle has to pump forward SV and regurgitant volume  → eccentric hypertrophy Heart Sounds  Soft S1  S2 not heard separately from murmur  Loud P2 (if PTH) ``` Murmur  Blowing PanSystolicMurmur  Apex  Left lateral position in end expiration  Radiates to the axilla ```

Answer 98

Bloods: FBC, U+E, glucose, lipids ECG  AF  P mitrale (unless in AF)  LVH CXR  LA and LV hypertrophy  Mitral valve calcification  Pulmonary oedema Echo - Doppler echo to assess severity - TOE to assess severity and suitability of repair Cardiac Catheterisation  Confirm Dx  Assess CAD

Answer 99

Medical Control risk factors Control AF Drugs to reduce afterload ``` Surgical  Valve replacement or repair Indications  Severe symptomatic MR  Severe asympto MR ̄c diastolic dysfunction: ↓EF ```

Answer 100

Most common valve problem | Gives mitral regurgitation

Answer 101

```  Primary: myxomatous degeneration  Often young women  MI  Marfan’s, ED  Turner’s ```

Answer 102

``` Symptoms  Usually asymptomatic  Autonomic dysfunction: Atypical chest pain, palpitations, anxiety, panic attack  MR: SOB, fatigue ``` Signs:  Mid-systolic click ± late-systolic murmur

Answer 103

Functional RV dilation Rheumatic fever Infective endocarditis especially IVDU Carcinoid syndrome

Answer 104

Fatigue hepatic pain on exertion Ascites Oedema

Answer 105

 ↑JVP ̄c giant V waves  RV heave Murmur:  PanSystolicMurmur  LowerLeftSternalEdge in inspiration (Carvallo’s sign)  Pulsatile hepatomegaly  Jaundice

Answer 106

Rheumatic fever with comorbid mitral valve and aortic valve disease

Answer 107

Fatigue Ascites oedema

Answer 108

``` Increased JVP Opening snap Murmur: - End diastolic murmur - Lower left sternal edge in inspiration ```

Answer 109

Any cause of pulmonary hypertension | If PR is secondary to Mitral stenosis = Graham Steel murmur

Answer 110

Murmur Decrescendo early diastolic murmur heard at left upper sternal edge

Answer 111

``` Usually congenital Turner's syndrome Tetralogy of fallot rheumatic fever carcinoid syndrome ```

Answer 112

Dyspnoea fatigue ascites oedema

Answer 113

``` JVP changes RV heave Murmur - crescendo decrescendo systolic murmur - ULSE radiates to left shoulder ```

Answer 114

Cardiac valves develop vegetations composed of bacteria and platelet-fibrin thrombus

Answer 115

``` Prosthetic valves Degenerating valvulopathy Congenital abnormality Rheumatic fever Post-op wounds IVDU== especially tricuspid valve Immunocompromised including DM ```

Answer 116

Bacterial infection +ve S.aureus -ve Haemophilus Non-infective SLE

Answer 117

Sepsis - fever - rigors - Anaemia - Clubbing Embolic phenomena - Janeway lesions - abscesses in brain, heart, kidney, spleen Cardiac - New murmur MR most common - atrio-ventricular block - LV failure Immune complex deposition - Haematuria due to glomerulonephritis - Vasculitis - Roth spots - Splinter haemorrhages - Osler's nodes Roth spots are boat shaped retinal haemorrhages with pale centre

Answer 118

Use Duke criteria Diagnose if 2 major, 1 Maj + 3 min , all 5 minor Major 1. +ve blood culture  Typical organism in 2 separate cultures, or  Persistently +ve cultures, e.g. 3, >12h apart 2. Endocardium involved  +ve echo (vegetation, abscess, valve dehiscence) or  New valvular regurgitation Minor 1. Predisposition: cardiac lesion, IVDU 2. Fever >38 3. Emboli: septic infarcts, splinters, Janeway lesions 4. Immune phenomenon: GN, Osler nodes, Roth spots, RF 5. +ve blood culture not meeting major criteria

Answer 119

``` Bloods  N.chromic, N.cytic anaemia  ↑ESR, ↑CRP  +ve IgG RF (immune phenomenon)  Cultures x 3, >12h apart  Serology for unusual organisms ``` Urine: Micro haematuria ECG: AV block Echo  TTE detects vegetations > 2mm  TOE is more sensitive (90-100% vs. 50-60%)

Answer 120

Empiric = Acute sever -- flucloxacillin and gentamicin IV = Subacute -- Benzylpenicillin + gentamicin IV Then once bacteria is elucidated treatment is accordingly

Answer 121

 Streps: benpen + gent IV  Enterococci: amoxicillin + gent IV  Staphs: fluclox ± rifampicin IV  Fungi: flucytosine IV + fluconazole PO.  Amphotericin if flucytosine resistance or Aspergillus.

Answer 122

30% with staphs

Answer 123

Group A beta haemolytic strep. pyogenes

Answer 124

5-15 years rare in west common in developing world Only 2% of population susceptible

Answer 125

Antibody cross reactivity following strep pyogenes infection gives T2 hypersensitivity reaction due to molecular mimicry Abs attack Myosin protein in cell wall Cross react and creates damage Pathology gives Aschoff bodies and Anitschkow myocytes

Answer 126

use the revised Jones criteria evidence of Group A strep infection + 2 major criteria or evidence of GAS infection + 1 major + 2 minor ``` Evidence of GAS infection  +ve throat culture  Rapid strep Ag test  ↑ ASOT or DNase B titre  Recent scarlet fever ``` ``` Major Criteria  Pancarditis  Arthritis  Subcutaneous nodules  Erythema marginatum  Sydenham’s chorea ``` ``` Minor criteria  Fever  ↑ESR or ↑CRP  Arthralgia (not if arthritis is major)  Prolonged PR interval (not if carditis is a major)  Prev rheumatic fever ```

Answer 127

``` Pancarditis (60%)  Pericarditis: chest pain, friction rub  Myocarditis: sinus tachy, AV block, HF, ↑CK, T inversion  Endocarditis: murmurs  MR, AR, Carey Coombs’ (MDM) ``` Arthritis (75%)  Migratory polyarthritis of large joints (esp. knees) ``` Subcutaneous nodules (2-20%)  Small mobile, painless nodules on extensor surfaces (esp. elbows) ``` ``` Erythema marginatum (2-10%)  Red, raised edges ̄c central clearing.  Trunk, thighs and arms. ``` Sydenham’s Chorea (10%)  Occurs late  Grimacing, clumsy, hypotonia (stops in sleep)

Answer 128

Bloods  Strep Ag test or ASOT  FBC, ESR/CRP ECG Echo

Answer 129

``` Bed rest until CRP normalises BENPEN IM 10 days Analgesia ASPIRIN add oral prednisolone if CCF of chorea symptoms give HALDOL or DIAZEPAM ```

Answer 130

Attacks last around 3 months 60% with carditis will develop chronic rheumatic heart disease Mitral valve disease is very common complication Secondary prophylaxis helps prevent recurrence take peniciliin po for a while depending on initial severity

Answer 131

Causes  Viral: coxsackie, flu, EBV, HIV  Bacterial: pneumonia, rheumatic fever, TB, staphs  Fungi  MI, Dressler’s  Drugs: penicillin, isoniazid, procainamide, hydralazine  Other: uraemia, RA, SLE, sarcoid, radiotherapy

Answer 132

Clinical Features ``` Central / retrosternal chest pain  Sharp  Pleuritic  Worse lying down  Relieved by sitting forward  Radiates to left shoulder ```  Pericardial friction rub.  Fever  Signs of effusion / tamponade

Answer 133

ECG - saddle shaped ST elevation - PR depression Bloods - FBC - troponin may be raised - cultures - virology

Answer 134

Analgesia ibuprofen Treat cause Consider steroids and immunosuppression

Answer 135

Heart becomes encased in rigid pericardium often unknown cause often follows acute pericarditis

Answer 136

``` Clinical features  RHF ̄c ↑JVP (prominent x and y descents)  Kussmaul’s sign: ↑JVP ̄c inspiration  Quiet heart sounds  S3  Hepatosplenomegaly  Ascites, oedema ```

Answer 137

CXR - small heart and pericardial calcification Echo Cardiac catheterisation

Answer 138

A third heart sound occurs early in diastole. In young people and athletes it is a normal phenomenon. In older individuals it indicates the presence of congestive heart failure. The third heart sound is caused by a sudden deceleration of blood flow into the left ventricle from the left atrium

Answer 139

Forceful atria contraction in late diastole to force blood into ventricle which wont expand any further

Answer 140

surgical excision of the heart from it's restricting chamber

Answer 141

Any cause of pericarditis

Answer 142

 Dyspnoea  ↑JVP (prominent x descent)  Bronchial breathing @ left base  Ewart’s sign: large effusion compressing left lower lobe  Signs of cardiac tamponade may be present.

Answer 143

 CXR: enlarged, globular heart ECG  Low-voltage QRS complexes  Alternating QRS amplitude (electrical alterans) Echo: echo-free zone around heart

Answer 144

Treat cause | Pericardiocentesis may be diagnostic and therapeutic use it for culture and cytology

Answer 145

 Accumulation of pericardial fluid → ↑ intra-pericardial pressure → poor ventricular filling → ↓ CO

Answer 146

``` any cause of pericarditis aortic dissection bacterial endocarditis warfarin trauma ```

Answer 147

 Beck’s Triad: ↓ BP, ↑ JVP, quiet heart sounds  Pulsus paradoxus: pulse fades on inspiration  Kussmaul’s sign = JVP rise on inspiration

Answer 148

ECG - low voltage QRS - electrical alterans CXR - Large globular heart Echo - diagnostic - echo free zone around the heart

Answer 149

 Urgent pericardiocentesis  20ml syringe + long 18G cannula  45degrees, just left of xiphisternum, aiming for tip of left scapula.  Aspirate continuously and watch ECG.  Treat cause  Send fluid for cytology, ZN stain and culture

Answer 150

Idiopathic - 50% Viral - cocksackie flu HIV Bacterial - staph aureus syphilis Drugs - Herceptin Phenytoin

Answer 151

Flu like prodrome-- sore throat myalgia dyspnoea fatigue chest pain Arrhythmias == palpitations

Answer 152

Soft S1 | S4 gallop as atria contract to hard ventricles

Answer 153

ECG  ST-elevation or depression  T wave inversion  Transient AV block Bloods: +ve trop, ↑CK

Answer 154

Left ventricular outflow tract obstruction due to asymmetrical septal hypertrophy Autosomal dominant inheritance B - myosin heavy chain mutation commonest Ask questions about family history of sudden death

Answer 155

Angina Dyspnoea Palpitations: AF, WPW, VT Exertional syncope or sudden death

Answer 156

Jerky pulse Double apex beat S4 sound Harsh early systolic murmur

Answer 157

ECG | -LVH

Answer 158

Medical  -ve inotropes: 1st – β-B, 2nd –verapamil  Amiodarone: arrhythmias  Anticoagulate if AF or emboli Non-medical  Septal myomectomy (surgical or chemical) if severe symptoms Consider ICD

Answer 159

Rare benign cardiac tumour May be familial eg due to part of Carney Complex - cardiac myxoma - skin pigmentation - cushing's 90% found in Left atrium

Answer 160

``` Clubbing fever weight loss signs similar to MS (MDM, systemic emboli and AF) but vary with posture ``` Diagnosed with echo Treatment with excision

Answer 161

``` miSSHAPEN Sarcoid Systemic sclerosis Haemochromatosis Amyloidosis Primary - endoymyocardial fibrosis Eosinophilia Neoplasia == carcinoid ==> TR + PS ```

Answer 162

``` Clinical features  RHF ̄c ↑JVP (prominent x and y descents)  Kussmaul’s sign: ↑JVP ̄c inspiration  Quiet heart sounds  S3  Hepatosplenomegaly  Ascites, oedema ``` this is the same as restrictive pericarditis

Answer 163

``` DILATE Dystrophy Infection Late pregnancy -- peri/post partum Autoimmune -- SLE Toxins - alcohol , doxorubicin Endocrine -- thryotoxicosis ```

Answer 164

LVF RVF Arrhythmias

Answer 165

```  JVP ↑↑  Displaced apex  S3 gallop  ↓BP  MR/TR ```

Answer 166

 CXR: cardiomegaly, pulmonary oedema  ECG: T inversion, poor progression  Echo: globally dilated, hypokinetic heart + ↓EF  Catheter + biopsy: myocardial fibre disarray

Answer 167

 Bed rest  Medical: diuretics, ACEi, digoxin, anticoagulation  Non-medical: biventricular pacing, ICD  Surgical: heart Tx

Answer 168

No problems at birth Most will eventually develop stenosis +- regurg Predisposes to infective endocarditis

Answer 169

Hole connects the atria Secundum defects are commonest Often asymptomatic until adulthood LV compliance eventually gets worse so more blood in atria and gives L==> R shunt

Answer 170

Symptoms: - dyspnoea - pulmonary HTN - arrhythmia - Chest pain ``` Signs:  AF  ↑JVP  Pulmonary ESM  PHT→TRorPR ```

Answer 171

``` Paradoxical emboli (ie from venous origin) Eisenmenger syndrome ```

Answer 172

ECG: CXR: -pulmonary plethora, increased pulmonary perfusion due to the shunt Echo: -diagnostic

Answer 173

Transcatheter closure this is recommended if there is a lot of blood flowing from pulmonary to systemic (eisenmenger) 1.5:1 ratio due to cyanosis problems it needs management.

Answer 174

Congenital narrowing of the aorta usually just distal to the origin of the L subclavian artery M>F

Answer 175

Bicuspid aortic valve | Turner's syndrome

Answer 176

Radio - femoral delay Weak femoral pulse Hypertension Systolic murmur -- bruit best heard over left shoulder

Answer 177

CXR: - inferior rib notching ECG CT angiogram

Answer 178

Balloon dilatation and stenting

Answer 179

Hole connecting the ventricles

Answer 180

Congenital Acquired post MI

Answer 181

Either severe heart failure in childhood Or incidental finding in adulthood depending on severity

Answer 182

 Small holes which are haemodynamically less significant → louder murmurs  Harsh, pansystolic murmur @ left sternal edge  Systolic thrill  Left parasternal heave  Larger holes → PHT

Answer 183

infective endocarditis pulmonary hypertension eisenmenger's syndrome

Answer 184

ECG  Small: normal  Large: LVH + RVH CXR  Small: mild pulmonary plethora  Large: cardiomegaly + marked pulmonary plethora

Answer 185

surgical closure if symptomatic VSD from large hole

Answer 186

VSD Pulmonary stenosis Right ventricular hypertrophy Overriding aorta The commonest congenital cyanotic heart disease occurs following abnormal separation of truncus arteriosus into aorta and pulmonary arteries Associated with DiGeorge syndrome CATCH-22 gene

Answer 187

 Infants: hypercyanotic episodes, squatting, clubbing Adult  Often asympto  Unoperated: cyanosis, EarlySystolicMurmur of PS  Repaired: dyspnoea, palpitations, RVF

Answer 188

ECG: RVH + RBBB CXR: Coeur en sabot Echo: anatomy + degree of stenosis

Answer 189

surgically usually before age of 1 closure of VSD correction of pulmonary stenosis

Answer 190

Autosomal dominant M=F 1/5000

Answer 191

Mutation in FBN1 gene chromosome 5 - encodes fibrillin 1 glycoprotein fibrillin 1 is an essential component of elastin Histology gives cystic medial necrosis

Answer 192

Cardiac  Aortic aneurysm and dissection  Aortic root dilatation → regurgitation  MV prolapse ± regurgitation Ocular  Lens dislocation: superotemporal ``` MSK  High-arched palate  Arachnodactyly abnormal long and slender digits  Arm-span > height  Pectus excavatum  Scoliosis  Pes planus  Joint hypermobility ```

Answer 193

Ruptured aneurysms Spontaneous pneumothorax Diaphragmatic hernias Hernias

Answer 194

MEN-2B Homocystinuria Ehlers-danlos

Answer 195

 Slit-lamp examination: ectopia lentis CXR  Widened mediastinum  Scoliosis  Pneumothorax ECG  Arrhythmias: premature atrial and ventricular ectopics Echo  Aortic root dilatation → AR  MVP and MR  MRI: dural ectasia (dilation of neural canal)  Genetic testing: FBN-1 mutation

Answer 196

 Refer to ortho, cardio and ophtho  Life-style alteration: ↓ cardiointensive sports  Beta-blockers slow dilatation of the aortic root  Regular cardiac echo  Surgery when aortic root ≥5cm wide

Answer 197

Rare heterogeneous group of collagen disorders 6 subtypes type 1&2 are commonest and autosomal dominant

Answer 198

 Hyperelastic skin  Hypermobile joints  Cardiac: MitralValveProlapse , AR, MR and aneurysms  Fragile blood vessels → easy bruising, GI bleeds  Poor healing

Answer 199

Cutis laxa - loose skin and hypermobile joints pseudoxanthoma elasticum - skin laxity Marfan's syndrome