Cardiology Flashcards
What are the stages in the NYHA classification of heart failure?
Class I: no limitation to normal activity
Class II: Mild limitation of ordinary level activity
Class III: Marked limitation of activity
Class IV: symptoms at rest
What investigations would you do for a patient with suspected CCF and what might you find?
ECG: q waves, LBBB, LVH, AF, non specific T wave changes
BNP
CXR: enlarged heart, upper lobe diversion, kerley B lines, pul.oedema
ECHO: systolic/diastolic dysfunction
Coronary angiography: rule out IHD
Exercise testing: for prognosis
Myocardial viability testing (thaliam scanning, cardiac MRI, stress ECHO or PET)
What are the steps in treatment for heart failure with LV systolic dysfunction?
1st line: ACE-i and Beta blocker 2nd line: can consider: - aldosterone antagonist - ARB - hydralazine with nitrate (esp people of African origin)
When is cardiac resynchronisation therapy appropriate?
- patients with LVEF <35% and wide QRS
- Failed optimal medical treatment
Whether they have ICD or CRS with defibrillator or pacemaker depends on duration of QRS, presence of LBBB and NYHA class
Describe the neurohumeral changes that occur in chronic CCF?
Reduced CO -> renal hypoperfusion-> renin release -> converts angiotensinogen to angiotensin II-> causes vasocontriction and salt and water retention and also stimulates aldosterone. Vasoconstriction increases after load putting more pressure on heart.
Atrial natruetic peptides try to counteract this but are inadequate
Acutely the reduced CO -> activation of sympathetic nervous system -> high levels adrenaline and noradrenaline resulting in vasoconstriction, increased afterload, tachycardia which increases myocardial oxygen demand
What are the issues with prosthetic heart valves?
Heart failure or valve dysfunction
Endocarditis
Bleeding from anti-coagulation
Anaemia and jaundice from intravascular haemolysis
If the click is before the carotid pulse is the valve replacment mitral or aortic?
MV replacement- click before pulse
AV replacment- click after pulse
Discuss the advantages and disadvantages of biological and mechanical valves?
Biological:
- Lack of long term anticoagulation (only 3 months)
- HIgher incidence of degeneration and failure requiring re-operation
- Offered to people >70yrs or >60yrs with sig co-morbitiy
- Lifelong annual ECHO
- aortic valves degenerate much quicker than mitral- ? due to higher pressures
Mechanical:
- more durable
- risk of thromboembolism higher in mitral position presumably due to lower flow.
- anti-coagulation
What criteria are used for diagnosis of endocarditis?
Dukes criteria
2 major or 1 major + 3 minor or 5 minor
Major:
Persistantly positive blood cultlures for a typical organism (strep viridans, strep galloyticus, HACEK, staph aureus, enterococcus, staph epidermitis (prosthetic valve))
Positive ECHO for vegetiation or abcess
New regurgitant murmur
Single positive BC for C.Burnetii or serology
Minor:
Fever
IV drug user
Prosthetic heart valve
Vascular phenomonen- emboli, janeway lesions
Immunological phenomona: glomerulonephritis, roth spots, oslers nodes
What criteria are used in rheumatic heart disease
Jones criteria 2 major or 1 major + 2 minor \+ evidence of recent strep infection Major: Carditis Polyarthritis Erythema marginatum Syndenhams chorea Subcutaenous nodules
Minor: Previous rheumatic fever CRP/ESR raised Arthralgia Fever Prolonged PR
+ evidence of recent strep infection
What are the signs of endocarditis?
Due to infection
- fever
- murmur due to progressive valve destruction
- Heart failure
- Hepatosplenomegaly
Due to immune complex formation
- Roth spots
- Oslers nodes
- Proteinuria, haematuria due to GN
Due to embolic phenomena
- Janeway lesions
- Splinter haemorrhages
- Conjunctival haemorrhage
- Mycotic aneurysm
What are the complications of endocarditis?
Direct tissue destruction- Valve failure, aortic root abcess causing heart block and occasionally septic pericarditis
Septic emboli phenomena- lung, brain, splenic abcess and formation of mycotic aneurysms
Renal failure due to sepsis or immune complex GN
What are the indications for surgical intervention in IE?
Uncontrolled infection
Haemodynamic instability due to valve failure
Increasing heart block due to aortic root abcess
What are the signs of a VSD?
Pansystolic murmur best heard at left sternal edge, 4th intercostal space with assoc thrill
If severe signs of RV ovberload with parasternal heave
What is a Maladie de Roger?
Very loud PSM heard at the left sternal edge, indicative of a very small VSD not requiring treatment
What antibiotic prophylaxis should be offered to somebody with a VSD?
None
Counselled that there is some risk of endocarditis after undergoing medical/dental procedures
How might somebody present who has an ASD?
3rd/4th decade with dyspnoea due to pul.htn and AF, palpatations or stroke (paradoxical embolism), RVF (oedema), resp infections
What are the signs of an ASD?
Features of a syndrome- Downs, Holt-Oram syndrome Signs of previous stroke Pulse- maybe AF JVP- normal or raised in RVF Soft ESM loudest in pulmonary area PSM may be heard if TR secondary to RV overload S2 fixed and widely split Signs of RVF
What antibiotics would you use in IE- intial blind therapy?
Native valve: amox +/- gent
Prosthetic: Vanc +rifamp + gent
What would indicate a severe ASD?
RV overload
Pul.htn
AF as result of LA enlargement
What are the types of ASD?
Primum (atrioventricular septal defect)- often assoc with VSD
Secundum (most common)- enlarged foramen ovale, inadequate growth of septum secundum or excessive adsorption of septum primum
What investigations would you perform if you suspected ASD and what would results be?
ECG: AF, 1st degree AV block, LAD in primum defects, RAD in secundum defects
CXR: cardiomegaly, atrial enlargement, pul.arteries
TTE: may need to use bubble contrast
TOE: defines anatomy in more detail
Right and left heart catheterisation- rarely required, toassess pul. pressures and shunt ratio
Cardiac MRI- detailed anatomy
What is the management of ASD?
Most require no intervention
Close surgically or with percutaneous closure devices if:
- paradoxical embolism
- symptomatic
- evidence of significant shunt
- significant pul.htn- only offer closure if shown to be reversible
What is Lutembacher syndrome?
The coexistence of secundum ASD with rheumatic MS
Acquire the syndrome if develop an ASD as a complication of transseptal puncture required to get the valvuloplasty balloon into LA via RA
What is a PDA?
An abnormal connection between aorta and pul.artery
What are the signs of a PDA?
Differential cyanosis and clubbing- toes are cyanosed and clubbed, fingers are normal
Pulse: collapsing with wide pulse pressure
Apex: displaced and thrusting if large PDA
Left parasternal heave due to pul.htn
Palpable P2 (pul.htn)
Loud systolic crescendo murmur that peaks just prior to S2 and is heard best at left chest, more lateral to pul.area.
What are the causes of a PDA?
Congenital Neonatal rubella syndrome Prematurity Born at high altitude Prostaglandin E1 infusion
What would you find on investigation of a PDA?
ECG: biventricular hypertrophy, p.mitrale, AF. When shunt reverses- p.pulmonale
CXR: enlargement of left side of heart, may be able to visualise duct itself if calcified
ECHO: identify ductus and shunt fraction
What is the management of a PDA?
Tiny ducts that are not detected clinically can be managed conservatively.
Any duct which has been infected (endarteritis) should be closed once infection has resolved unless irreversible severe pul.htn
All other ducts should be closed unless evidence of irreversibly severe pul.htn
Achieved with percutaneous deployed duct closure device
What are the symptoms of co-arctation of aorta?
Fatigue particularly in legs Intermittent claudication of legs Symptoms of heart failure Uncontrolled hypertension Endarteritis Chest pain due to atherosclerosis which develops at an accelerated rate
What are the signs of coarctation?
Left lateral thoracotomy scar due to surgical repair
Lower body may be relatively undeveloped compared to upper body. If it is preductal (proximal to left subclavian) then left arm may be smaller than right
Stigmata of endocarditis/endarteritis
Radio-femoral delay
Systolic thrills in the suprasternal notch
Signs of Turners syndrome
Systolic murmur usually louder over thoracic spine
ESM if bicuspid aortic valve
Continous systolic and diastolic murmurs audible though the precordium and back from collateral
What disease are assoc with coarctation?
Biscuspid aortic valve (85%) VSD MV prolapse PDA Aortic dissection Turners syndrome Neurofibromatosis type 1 Marfans syndrome SAH Shones syndrome
What might you find on investigation of coarctation of aorta?
ECG: LVH strain
CXR: rib notching due to formation of intercostal collaterals, 3 shaped descending aorta
TTE- identifys
TOE and cardiac MRI can give more information
What is the management of coarctation of aorta?
Primary percutaneous endovascular stenting
Surgical repair: resection of coarctation and end-end anastomosis if short segment or graft
Medical therapy- treat htn, modify risk factros
What are the indications for intervention/surgery in coarctation of aorta?
All symptomatic patients with a gradient >30mmHg across co-arctation should be offered tx
Asymptomatic patients with htn or signs of LVH
Any patient requiring cardiothoracic surgery for bicuspid aortic valve or aneurysm
What advice should patients with coarcation be given about exercise?
Avoid extreme isometric exercise (strength training) eg weight lifting due to risk of dissection.
Both treated and untreated
Encourage other type of exercise
What are the symptoms of hypertrophic cardiomyopathy?
Heart failure Syncope AF Chest pain Sudden death
What are the signs of hypertrophic obstructive cardiomyopathy?
Infraclavicular scar with underlying device- permanent dual chamber pacemaker to decrease LVOT gradient or ICD if at risk of sudden death
Pulse: jerky, bifid, may get AF
JVP: normal or A wave reflecting increased RA pressures
Apex: heaving in character, may be a double impulse reflecting a palpable atrial contraction
PSM due to MR
ESM at left sternal edge- made longer and louder on standing and shorter on squatting
