Cardiology Flashcards
State the arterial supply to the lateral leads
Circumflex
Name the leads that correlate to the lateral area of the heart
I
aVL
V5
V6
State the arterial supply to the inferior leads
right coronary artery
State the arterial supply to the anteroseptal leads
LAD
Name the leads that correlate to the inferior area of the heart
II
III
aVF
Name the leads that correlate to the anteroseptal area of the heart
VI
V2
V3
V4
What is the initial management of ACS?
o2 if <94% 12 lead ECG IV access sublingual GTN spray aspirin 300mg diamorphine IV + metaclopramide IV
?ticagrelor, clopidogrel or prasugrel
Glycoprotein IIb/IIIa inhibitors
What investigations would you do in ACS?
Bedside: ECG
Bloods: FBC U+E LFTs glucose lipids troponin I
Imaging: portable CXR
What are the indications for thrombolysis or PCI in STEMI?
<12hrs pain
\+ any of ST elevation >1mm in 2 limb leads ST elevation >2mm in 2 chest leads posterior infarct new onset LBBB
What are the absolute contraindications for thrombolysis?
stroke <6m CNS neoplasia recent trauma or surgery GI bleed <1m bleeding disorder aortic dissection
What are the relative contraindications for thrombolysis?
warfarin
pregnancy
advanced liver disease
infective endocarditis
State the complications of thrombolysis
bleeding hypotension ICH reperfusion arrhythmias systemic embolisation of thrombus allergic reaction
What drug is used for thrombolysis in STEMI?
reteplase
What are the complications of a STEMI?
S udden death P ericarditis R upture papillary muscles E mbolism A rrhythmias D ressler's syndrome
What drugs should a patient be prescribed post MI?
Aspirin ACEi Beta blocker Clopidogrel/prasugrel (STEMI)/ticegralor (NSTEMI) Statin
In terms of work and driving, what should a patient be advised post MI?
off work for 1 month
need to inform DVLA - no driving for 1 month
How can you distinguish between NSTEMI and unstable angina?
troponin I 12hrs after onset
+ve for NSTEMI
-ve for unstable angina
How is an NSTEMI treated?
MONA
LMWH - fondaparinux
Beta blocker or calcium chanel blocker
nitrates
When should PCI be considered in a patient with NSTEMI?
rise in troponin I recurrent angina/ischaemic ECG changes despite therapy heart failure develops poor LV function haemodynamically unstable PCI <6m previous CABG
Name some narrow complex tachycardias
regular: sinus tachy accessory pathway atrial tachy junctional tachy - - AVNRT/AVRT multifocal atrial tachycardia
irregular:
AF
How do you manage a regular narrow complex tachycardia?
ABC
O2
IV access
vagal manoeuvres
adenosine 6mg IV bolus
monitor ECG
How does adenosine work?
inhibition SAN and AVN
Leads to AV block
What are the vagal manouevres?
carotid sinus massage
Valsalva - hold breath and bear down
If adenosine fails, and the patient is haemodynamically compromised in regular SVT, what next?
Senior help!!!
Amiodarone 300mg IV
DC cardioversion
If adenosine fails, and the patient is haemodynamically stable in regular SVT, what next?
senior help!!!
B blocker
digoxin
What could cause a broad complex tachycardia?
VT - most common! until proven otherwise
SVT with BBB
SVT with aberrancy
WPW antidromic
If the patient is unstable, how should a VT be managed?
senior help!
sedation
DC cardioversion
amiodarone
If the patient is stable, how should a VT be managed?
amiodarone 300mg IV
If SVT, give adenosine
What is the most common organism to cause endocarditis?
Streptococcus viridans
Staph aureus in IVDU
Staphylococcus epidermidis in valve surgery <2m ago
What are the key features of infective endocarditis?
fever
new heart murmur
What murmurs are seen in infective endocarditis?
aortic regurg
mitral regurg
What are the systemic signs of infective endocarditis?
oslers nodes
janeway lesions
clubbing
splinter haemorrhages
What are the major criteria for diagnosis of IE?
+ve blood culture - typical organism on 2 separate cultures
evidence of endocardial involvement - +ve echo (vegetation, abscess, prosthetic valve damage) or new valvular regurgitation
What are the minor criteria for diagnosis of IE?
predisposition - IVDU, prosthetic valve fever >38 vascular signs \+ve blood culture \+ve echo
What predisposes to IE?
prosthetic heart valves congenital defect valvular disease prev endocarditis prev rheumatic fever
What investigations if IE is suspected?
Bedside: ECG urinalysis
Bloods: FBC U+E LFT CRP
Micro: blood cultures X3
Imaging: CXR, Echo
Why is urinalysis done if IE is suspected?
glomerulonephritis can develop secondary to immune vasculitis
Treatment for IE
ABC
microbiologist + cardiologist
empirical abx - benzylpenicillin + gentamicin
How can you tell a posterior MI on an ECG?
reciprocal changes in V1-V3
ask for leads V7-V9
Which artery supplies the posterior aspect of the heart?
circumflex
What parts of the heart does the right coronary artery supply?
right atrium
right ventricle
SA Node
AV Node
What parts of the heart does the left anterior descending supply?
left ventricle
right ventricle
interventricular septum
What parts of the heart does the circumflex supply?
left atrium
left ventricle
What parts of the heart does the left marginal artery supply?
left ventricle
What parts of the heart does the right marginal artery supply?
right ventricle
apex
Which antiplatelet should be given to which groups of patients in the long term management of ACS
STEMI - aspirin + prasugrel
NSTEMI - aspirin + ticagrelor
other - aspirin + clopidogrel
List some complications of an MI
Myocardium: cardiac arrest - VF cardiogenic shock chronic heart failure LV aneurysm
Electrics:
VT
AV block
Pericardium:
Pericarditis
Dressler’s syndrome
Valves:
mitral regurgitation
What is an LVAD?
What does it do?
Left Ventricular Assist Device
tube that pulls blood from the left ventricle into a pump. which sends blood into the aorta
Battery pack outside body
used in people with heart failure as long term therapy or bridge to transplant
What is a CRT-D?
What does it do?
Cardiac resynchronisation therapy - defibrillator
resynchronizes the contractions of the heart’s ventricles by sending tiny electrical impulses to the heart muscle, which can help the heart pump blood throughout the body more efficiently. Used in heart failure
Also cardioverter-defibrillator, to quickly terminate an abnormally fast, life-threatening heart rhythm
What is BNP used to measure?
BNP increases with right or left systolic or diastolic heart failure.
It is an independent predictor of high left ventricular end-diastolic pressure.
BNP levels decrease after effective treatment of heart failure.
When is BNP released?
in response to stretch of the ventricles
released in direct proportion to ventricular volume expansion and pressure overload
State the CHA2DS2-VASc score
C Congestive heart failure 1
H Hypertension (or treated hypertension) 1
A2 Age >= 75 years 2 Age 65-74 years 1
D Diabetes 1
S2 Prior Stroke or TIA 2
V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1
S Sex (female) 1
What counts as a vascular disease in CHA2DS2-VASc ?
ACS, PVD, MI, stent
What is the appropriate course of action in someone with a CHA2DS2-VASc score of 0?
no anticoagulation
What is the appropriate course of action in someone with a CHA2DS2-VASc score of 1?
Male - consider anticoagulation
Female - no anticoagulation
What is the appropriate course of action in someone with a CHA2DS2-VASc score of 2 or more?
Offer anticoagulation
What is the purpose of the HAS BLED score?
formalise this risk assessment of the risk of bleeding on anticoagulation medication
State the components of the HASBLED score
H Hypertension, uncontrolled, systolic BP > 160 mmHg 1
A Abnormal renal function (dialysis or creatinine > 200) 1 for any renal abnormalities
Or
Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP > 3 times normal 1 for any liver abnormalities
S Stroke, history of 1
B Bleeding, history of bleeding or tendency to bleed 1
L Labile INRs (unstable/high INRs, time in therapeutic range < 60%) 1
E Elderly (> 65 years) 1
D Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) 1 for drugs
Or
Alcohol Use (>8 drinks/week) 1 for alcohol
What can the HASBLED score tell you?
> =3 = high risk of bleeding
eg. intracranial haemorrhage, hospitalisation, haemoglobin decrease >2 g/L, and/or transfusion.
Where can AF conduct through?
AVN
accessory pathways
State some causes of AF
HTN ischaemia cardiomyopathy hyperthyroidism mitral stenosis obstructive sleep apnoea CCF
State some drugs used for rate control in AF
bisoprolol
verapamil
State some drugs used for rhythm control in AF
flecainide
sotalol
amiodarone
When is flecainide contraindicated?
ischaemic heart disease
structural heart disease
valvular heart disease
In what groups of patients are NOACs not licensed for use?
prosthetic valves
mitral stenosis
When are NOACs indicated for prevention of stroke and systemic embolism in AF?
non-valvular disease
\+ one or more of: prior stroke or transient ischaemic attack age 75 years or older hypertension diabetes mellitus heart failure
Name some NOACs
dabigatran
rivaroxiban
apixaban
What is the mechanism of action of the NOACs?
dabigatran + rivaroxaban = direct factor Xa inhibitors
apixaban = direct thrombin inhibitor
What length is a broad complex tachycardia?
> 120ms, >3 small squares
What is seen in VT on ECG?
positive QRS concordance LAD AV dissociation or AV block fusion beats capture beats
What is a fusion beat?
= normal QRS + VT = unusual complex
What is a capture beat?
= normal QRS between abnormal beats
Which cardiac arrest rhythms are shockable?
VF
pulseless VT
Which cardiac arrest rhythms are non-shockable?
pulseless electrcal activty
asystole
What are the reversible causes of cardiac arrest?
hypoxia
hypovolaemia
hypo/hyperkalaemia
hypothermia
thrombosis
tamponade
toxins
tension pneumothorax
What is VT?
Why is it considered an emergency?
broad-complex tachycardia originating from a ventricular ectopic focus.
has potential to precipitate ventricular fibrillation
What causes monomorphic VT?
myocardial infarction
What causes polymorphic VT eg torsades de pointes?
prolongation of QT interval
Give some causes of QT interval prolongation
sotalol amiodarone TCA fluoxetine hypocalcaemia
What is bifascicular block?
both the right bundle branch AND one of the left bundle branch fascicles is not conducting.
How is bifascicular block seen on ECG?
combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
What is trifascicular block?
combination of RBBB with left anterior or posterior hemiblock
AND
1st degree heart block
What murmur is most likely to occur in and IVDU with IE?
Tricuspid regurg
What murmur is most likely to occur with IE?
mitral or aortic regurgitation
When is valve replacement considered in IE?
If the infection is not clearing despite optimal Abx
heart failure starts to develop
What is the difference between AVRT and AVNRT?
AVRT - accessory pathway between ventricles and atria
AVNRT - accessory pathway between AVN and atria
alpha = slow, beta = fast. causes loop
Give lifestyle interventions used in management of hypertension
smoking cessation, weight reduction, reduction of excessive intake of alcohol and caffeine, reduction of dietary salt, reduction of total and saturated fat, increasing exercise, increasing fruit and vegetable intake.
What investigations are carried out in suspected HTN?
clinicn BP >140/90
confirmed using ambulatory blood pressure monitoring or home blood pressure monitoring
What are some causes of secondary HTN?
phaeochromocytoma renal disease pre-eclampsia renal artery stenosis Conn's hyper/hypothyroid coarctation aorta
Describe systolic heart failure
inability of the ventricles to contract to give sufficient cardiac output
Describe diastolic heart failure
inability of the ventricles to relax and fill to provide sufficient cardiac output
What can the ejection fraction tell us in heart failure?
<40% = systolic
> 50% = diastolic
What are the causes of systolic heart failure
IHD
dilated cardiomyopathy
MI
What are the causes of diastolic heart failure
constrictive periccarditits
tamponade
restrictive or hypertrophic cardiomyopathy
HTN
What are the causes of high output heart failure?
anaemia
pregnancy
hyperthyroidism
What are the symptoms of left heart failure?
breathlessness, reduced exercise tolerance, PND, orthopnoea, fatigue, nocturnal cough, wheeze, nocturia, weight loss.
What are the signs of left heart failure?
cool peripheries, muscle wastage, crepitations on auscultation, S3 gallop, pleural effusion, displaced apex beat due to LV dilatation, Low BP, narrow pulse pressure due to low stroke volume, tachycardia,
What are the symptoms of right heart failure?
peripheral pitting oedema
ascites
nausea
anorexia
What are the signs of right heart failure?
Neck vein distension, S3 gallop, raised JVP, hepatomegaly, hepatojugular reflex, RV heave
How should a person with suspected heart failure be investigated if they have had a previous MI?
Bedside: ECG
Bloods: U+E, eGFR, FBC, TFT, LFT, HbA1c, and fasting lipids.
Imaging: echo within 2 weeks, CXR
Refer: specialist
How should a person with suspected heart failure be investigated if they have not had a previous MI?
Bedside: ECG
Bloods: BNP!!! U+E, eGFR, FBC, TFT, LFT, HbA1c, and fasting lipids.
Imaging: CXR, echo
How does the management of heart failure change depending on BNP level?
If the BNP level is above 400 pg/mL refer for specialist assessment and echocardiography to be seen within 2 weeks.
If the BNP level is between 100-400 pg/mL, refer for specialist assessment and echocardiography to be seen within 6 weeks.
If BNP levels are less than 100 pg/mL a diagnosis of heart failure is unlikely. Consider referral if a clinical suspicion of heart failure persists and conditions are present which may cause a false negative result.
What can cause a false negative BNP result?
Obesity Diuretics ACE inhibitors Beta-blockers Angiotensin 2 receptor blockers Aldosterone antagonists
What can cause a increase the levels of BNP?
Age over 70 years.
Female gender.
Left ventricular hypertrophy, myocardial ischaemia, or tachycardia.
Hypoxia.
Pulmonary hypertension.
Pulmonary embolism.
Chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73m2).
Sepsis.
Chronic obstructive pulmonary disease (COPD).
Diabetes mellitus.
Liver cirrhosis.
What is BNP?
BNP is a biologically active peptide and has vasodilator and natriuretic properties released from the cardiac ventricles in response to stretching of the chamber.
The release of BNP appears to be in direct proportion to ventricular volume expansion and pressure overload. BNP increases with right or left systolic or diastolic heart failure. It is an independent predictor of high left ventricular end-diastolic pressure. BNP levels decrease after effective treatment of heart failure.
Describe the New York Heart Association classification of class I heart failure
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
Describe the New York Heart Association classification of class II heart failure
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
Describe the New York Heart Association classification of class III heart failure
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
Describe the New York Heart Association classification of class IV heart failure
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
What is the management of heart failure?
first-line = ACE-inhibitor + beta-blocker
second-line = aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
third line = cardiac resynchronisation therapy or digoxin
diuretics should be given for fluid overload
offer annual influenza vaccine
offer one-off** pneumococcal vaccine
cardiac rehabilitation
Which beta blockers are suitable to use in heart failure?
bisoprolol, carvedilol, and nebivolol.
Which drugs can worsen pre-existing heart failure?
NSAIDs,
beta-blockers,
calcium-channel blockers`.
What are the symptoms of pericarditis
chest pain - improves on sitting forwards, worse on inspiration
SOB
non-productive cough
flu like
What are the signs of pericarditis
pericardial friction rub
tachycardia
tachypnoea
fever
What can cause pericarditis
idiopathic coxsackie b Dressler's syndome uraemia systemic - RA, SLE TB
How should suspected pericarditis be investigated?
bedside: ECG
bloods: FBC, U+E, troponin I , autoantibodies
Mirco - blood cultures, viral serology
Imaging: CXR, echo
What are the signs on ECG of pericarditis
widespread ST elevation
PR depression
T wave inversion/depresssion
What is a complication of pericarditis
pericardial effusion
How is pericarditis treated
analgesia
treat cause
What is the sign of pericardial effusion on CXR
water bottle heart
what is the sign of pericardial effusion on ECG
electical alternans
What is constrictive pericarditis
heart encased in rigid pericardium
Pericarditis can lead to constrictive pericarditis. What is a major cause of constrictive pericarditis
TB
What are the symptoms of constrictive pericarditis
dyspnoea
oedema
What are the signs of constrictive pericarditis
right heart failure: elevated JVP, ascites, oedema, hepatomegaly
Kussmaul’s sign
pericardial knock
third heart sound
What is Kassmaul’s sign
JVP rising paradoxically with inspiration`
What is seen on CXR in constrictive pericarditis
pericardial calcification
How is the JVP changed in cardiac tamponade
absent Y descent
tamponade = TAMpaX
What are the signs of cardiac tamponade
dyspnoea tachycardia hypotension muffled heart sounds raised JVP pulsus paradoxus
What is pulsus paradoxus
abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration
What is Beck’s triad?
cardiac tamponade:
falling BP
rising JVP
muffled heart sounds
What investigations should be done in cardiac tamponade
Bedside: ECG
Imaging: CXR, echo
What is the management of cardiac tamponade
urgent drainage!
Define AF
irregular atrial electrical activity causing disorganised atrial depolarisations and ineffective contractions
due to the AVN receiving more impulses than it can conduct, the ventricular rate is irregular
Define paroxysmal AF
lasting less than 7d, self terminating
Define persistent AF
lasting >7days, terminates with cardioversion
Define permanent AF
fails to terminate
What investigations should be carried out in suspected AF?
ECG
FBC, U+E, troponin, TFT,
echo
What are the main aims of treatment in AF
rate/rhythm control
stroke prevention
Describe situations where rate or rhythm control are more suitable in the treatment of AF
rate - first line.
rhythm - if easily reversible cause, HF, new onset AF
When can digoxin be used in the treatment of AF
as rate control in patients with HF or who are mianly sedentary
due to it being less effective at controlling the heart rate during exercise
State Virchow’s triad
hypercoaguability
stasis
vessel wall injury
State what Well’s score is used for
to determine the likelihood of a DVT
State the factors involved in calculating a well’s score
Active cancer (treatment ongoing, within 6 months, or palliative) 1 Previously documented DVT 1
Paralysis, paresis or recent plaster immobilisation of the lower extremities 1
Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia 1
Entire leg swollen 1
Calf swelling at least 3 cm larger than asymptomatic side 1
Pitting oedema confined to the symptomatic leg 1
Localised tenderness along the distribution of the deep venous system 1
Collateral superficial veins (non-varicose) 1
An alternative diagnosis is at least as likely as DVT -2
How does management of DVT chnage depending on the outcome of the Well;s score
<2 = perform a D-dimer test
ifit is positive arrange:
a proximal leg vein ultrasound scan within 4 hours
(if a proximal leg vein ultrasound scan cannot be carried out within 4 hours low-molecular weight heparin should be administered whilst waiting)
> =2 = a proximal leg vein ultrasound scan should be carried out within 4 hours
if the result is negative, a D-dimer test
(if a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and low-molecular weight heparin administered whilst waiting)
How is a DVT treated?
enoxaparin 1.5mg/kg/24h or fondaparinux
warfarin for 3 months if provoked, 6m if unprovoked, lifelong if recurrent
stop LMWH when INR is 2-3 for 24hrs
How should patients with an unprovoked DVT be investigated
a physical examination (guided by the patient’s full history) and
a chest X-ray and
blood tests (full blood count, serum calcium and liver function tests) and urinalysis.
CT CAP if >40y
thrombophilia screening if family history
What are the signs of heart failure on CXR
Alveolar oedema Kerley B lines Cardiomegaly Dilated prominent upper lobe vessels pleural Effusion
What are the symptoms of aortic stenosis?
syncope
angina
dyspnoea
dizziness
What are the causes of aortic stenosis
degenerative calcification
bicuspid valve
rheumatic fever
What are the signs of aortic stenosis
slow rising pulse wide pulse pressure heaving apex beat ejection click soft S2 ejection systolic murmur radiating to carotids
How is aortic stenosis investigated?
ECG
FBC, U+E, cholesterol, glucose
CXR, echo, doppler echo
What are the signs of aortic stenosis on ECG
p mitrale
LAD
LBBB
What are the signs of aortic stenosis on CXR
LVH
calcified aortic valve
Who is aortic valve replacement offered to in aortic stenosis
those who are symptomatic
asymptomatic, but valvular pressure gradient >40mmHg + LV dysfunction
Who is ballon valvuloplasty offered to in aortic stenosis
those who need a replacement but are unfit for valve replacement
What is an important differential for aortic stenosis
hypertrophic cardiomyopathy
What is the appropriate management for asymptomatic aortic stenosis
monitoring every 6 months
stress test and echo
in patients unfit for any surgical treatment, how should aortic stenosis be treated
tx of HTN or HF
What are the causes of aortic regurgitation
valve insufficiency - IE, rheumatic fever, SLE
aortic root dilation - aortic dissection, HTN, ankylosing spondylitis, marfan’s, ehlers-danlos
What are the symptoms of AR
dyspnoea
PND
orthopnoea
What are the signs of aortic regurgitations
collapsing pulse wide pulse pressure hyperdynamic apex beat early diastolic murmur S3 Quinke's de Musset's corrigan's pistol shot femorals
What is Quinke’s sign
visible pulsation in nail beds due to AR
What is de Musset’s sign
head bobbing in time with pulse in AR
What is corrigan’s sign
visible carotid pulsations in AR
What investigations should be carried out in AR
ECG
FBC
blood cultures
CXR, echo
What is seen on CXR in AR
cardiomegaly
aortic dissection
pulmonary oedema
What is seen on ECG in AR
LAD
increased R wave amplitude in aVL, I, V4-6
Where is the AR mumur heard best
leaning forwards in expiration at lower left sternal edge
What is the treatment for AR
conservative - ACEi - to decrease symptoms.review every 6m with echo
surgical - replacement or balloon valvuloplasty
What are the indications for surgery in aortic regurgitation
incrreasing symotoms
enlarging heart
ECG deterioration
IE refractory to medical therapy
what are the causes of mitral stenosis
rheumatic fever
what causes rheumatic fever
2-6 weeks post Streptococcus pyogenes infection
molecular mimicary means there is immune targeting of the heart tissue
what are the symptoms of mitral stenosis
exertional dyspnoea
PND
orthopnoea
palpitations
Why does mitral stenosis cause RHF
increased pressure in the left atrium leads to venous congestions and pulmonary hypertension
right heart failure
Why does mitral stenosis cause AF
stretch of myocytes
irritation
AF!
What are the signs of mitral stenosis
low volume pulse AF mitral facies tapping non-displaced apex beat opening snap mid-late diastolic murmur
Right ventricular heave
raised JVP
bibasal crackles
peripheral oedema
Where is the murmur in mitral stenosis best heard
in mitral area lying on left during expiration with bell
What investigations should be carried out in mitral stenosis
ECG
CXR
echo
What is seen on CXR in mitral stenosis
left atrial enlargement
double right heart border
elevation of left bronchus
What is the treatment for mitral stenosis
conservative: diuretics, rate control and anticoagulation in AF, yearly follow up with echo
surgical: Percutaneous mitral commissurotomy (PMC) or mechanical valve replacement
When is surgery indicated for mitral stenosis
severe
pulmonary hypertension
What are the causes of mitral regurgitation
primary = damage to valve
IE, rheumatic fever, papillary muscles damaged in MI
secondary = due to left ventricular dilation, valve incompetency results.
idiopathic cardiomyopathy or coronary heart disease, left heart failure
What are the symptoms of mitral regurgitation
dyspnoea
fatigue
What are the signs of mitral regurgitation
AF displaced hyperdynamic apex beat soft S1 split S2 pansystolic murmur
What investigations should be carried out in mitral regurgitation
ECG
CXR
echo
What are the signs of mitral regurgitation on CXR
left atrial and ventricular enlargement
pulmonary oedema
What is the treatment for mitral regurgitation?
conservative: rate control and anticoagulation for AF, diuretics and ACEi for pulmonary oedema
surgical: valve replacement or repair
When is surgery indicated in mitral regurgitation
signs of left ventricular dysfunction, symptoms bad
where is mitral regurgitation murmur radiate to?
the axilla
What are some risk factors for ischaemic heart disease
Increasing age
Male gender
Family history
Smoking Diabetes mellitus Hypertension Hypercholesterolaemia Obesity
State the pathophysiology of IHD
initial endothelial dysfunction
fatty infiltration of the subendothelial space by low-density lipoprotein (LDL) particles
monocytes migrate from the blood and differentiate into macrophages.
macrophages then phagocytose oxidized LDL, slowly turning into large ‘foam cells’.
smooth muscle proliferation and migration from the tunica media into the intima
formation of a fibrous capsule covering the fatty plaque.
Describe the pathophysiology of angina
the plaque forms a physical blockage in the lumen of the coronary artery.
This may cause reduced blood flow and hence oxygen flow to the myocardium, particularly at times of increased demand
What are the potential systemic consequences of infective endocarditis
Cerebrovascular accident (CVA) from embolism
Finger/toe gangrene caused by embolism ± vasculitis.
• Renal or splenic abscess or infarction.
• Mesenteric embolism (ischaemic bowel and an acute abdomen).
• Joint infection.
• Bone infection
• Acute renal failure: this may occur from immune complex disease, haemodynamic upset (acute heart failure), damage during cardiac surgery and nephrotoxic antibiotics. Close monitoring of renal function throughout the illness is mandatory
When would surgery be indicated in infective endocarditis
Severe valvular destruction causing heart failure.
• Abscess formation.
• Failure to eradicate infection despite prolonged antibiotic therapy.
• Prosthetic valve endocarditis.
Describe the pathophysiology of infective endocarditis
damaged valve endothelium
thrombosis (fibrin and platelets aggregate)
bacterial adhesion to form biofilm = vegetation
Where could the bacterial source be in IE
open wound
mouth - poor dentition
gut - more likely if colorectal cancer or UC
IVDU
Describe the characteristic signs of WPW on ECG
short PR interval
slurring QRS
delta wave
Why is there shortening of the PR interval and a delta wave in WPW
atrioventricular reentrant pathway means that excitation passes from the atria to the ventricles more quickly than through the AVN
this means the PR interval is shortened
the excitation travels slowly through the myocardium, which is why the slurred upstroke (delta wave) occurs
What is used to treat an SVT in the long term?
B blocker or digoxin as prophylaxis
radiofrequency ablation to cure
What are the differences between a monomorphic VT and a polymorphic VT
mono
caused by structural problem
does not often convert to VF
uniform QRS complexes
poly
caused by metabolic or electrophysiological lengthening of QT interval
quickly converts to VF
less regular and chaotic QRS complexes
What is the treatment for polymorphic VT
stop drugs that prolong QT interval
correct metabolic abnormalities
IV magnesium sulfate 2mg over 10mins
What class as adverse features in tavhycardia
shock
syncope
myocardial ischaemia
heart failure
What are the possoble signs of ACS on CXR
pulmonary oedema
cardiomegaly
What are the signs of heart failure on CXR
alveolar oedema Kerley B lines Cardiomegaly upper lobe diversion pleural effusion
What is the role of palliative care in severe heart failure?
40% die within in a year of diagnosis
need to educate, advande care plan
prescibe meds for pain and symptoms relief - opiates and O2 help
How can you distinguish between tricuspid and mitral regurgitation
mitral - pansystolic radiating to axilla
tricuspid - pansystolic heard best in inspiration at the lower sternal edge
What is mitral valve prolapse?
mitral valave leaftlets bulge into left strium during ventricular systole
What can cause mitral valve prolapse
ASD
patent ductus srteriosis
cardiomyopathy
Marfan’s
What are the signs of mitral valve prolapse
mid systolic click
late systolic murmur
To which patients with mitral valve prolapse should prophylactic antibiotics be given to?
A systolic click and murmur on examination.
Myxomatous degeneration and mitral regurgitation on echocardiography.
‘High-risk’ features, such as LV dilatation, left atrial enlargement, leaflet thickening, redundant chordae,
Age over 50, hypertension or obesity.
Moderate-to-severe mitral regurgitation.
Mitral regurgitation during exercise but not at rest.
Echocardiographic findings of mitral leaflet thickness >5 mm, posterior leaflet prolapse or increased LV dimensions.
Atrial fibrillation.
Reduced LV systolic function.
Left atrial enlargement.
What are the key questions to ask a patient with HTN
changes in vision kidney problems - haematuria? sweating/palpitations? - phaeochromocytoma weight gain? - Cushing's diabetic? CV disease smoking, alcohol medications
What signs are present in HTN
LVH
retinopathy
palpable kidneys - renal disease
signs of Cushing’s or hyperthyroid
What are the causes of HTN
primary essential
secondary: Cushing's renal Conn's phaeochromocytoma coarctation of the aorta drugs: steroids, COCP, NSAIDs
What is a normal BP
<140/90
Define the korotkov sounds
sounds heard when auscultating manual blood pressure reading between systolic and diastolic pressure
What are the 5 kortokov sounds
1 = tapping 2 = soft swishing 3 = crisp 4 = blowing 5 = silence
What are eh features of ohypertensive retinopathy
arteriolar narroqing
etinal haemorrhages
papilloedema
cotton wool spots
What are the key investigations in HTN
24 hour ambulatory BP, urine dipstick, ECG
FBC, U+E, glucose, lipid profile,
urine catecholamines, urine free cortisol
USS kidneys
What is the difference between arteriosclerosis and atherosclerosis
Arteriosclerosis is the stiffening or hardening of the artery walls.
Atherosclerosis is the narrowing of the artery because of plaque build-up. It is a type of arteriosclerosis
When should antihypertensive medication be considered?
if Stage 2
or
if < 80 years of age AND target organ damage, established cardiovascular disease, renal disease, diabetes 10-year cardiovascular risk equivalent to 20% or greater
Define Stage 1 HTN
Clinic BP >= 140/90 mmHg
ABPM daytime average or HBPM average BP >= 135/85 mmHg
Define stage 2 HTN
Clinic BP >= 160/100 mmHg
ABPM daytime average or HBPM average BP >= 150/95 mmHg
If the clinic reading of BP is >140/90, what is the next step
ABPM or HBPM
What are the complications of untreated HTN
stroke AF MI PVD CKD HF retinopathy AAA vascular dementia
What are the stages in management of HTN
Step 1 treatment
< 55-years-old: ACE inhibitor
>= 55-years-old or of Afro-Caribbean origin: calcium channel blocker
Step 2 treatment
ACE inhibitor + calcium channel blocker (A + C)
Step 3 treatment
add a thiazide diuretic (D)
chlorthalidone or indapamide
Step 4 treatment
consider further diuretic treatment
if potassium < 4.5 mmol/l add spironolactone 25mg od
if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
What is resistant HTN
clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses
What is teh blood pressure target in HTN
<140/90 if <80y
<150/90 if >80y
What are ACEi used for?
HTN
kidney protection in diabetes
post MI
HF
What is the mechanism of action of ACEi
Inhibit the conversion angiotensin I to angiotensin II therefore causing vasodilation
and preventing aldosterone release
reduces BP
What are teh common adverse effects of ACEi
dry cough
angioedema
hyperkalaemia
Why might ACEi be contraindicated
hypersensitivity to ACEi
What is bisoprolol used for
HF
angina
What are some contraindications for beta blockers
Asthma; - risk of bronchspasm cardiogenic shock; hypotension; marked bradycardia; second or third-degree AV block; severe peripheral arterial disease; uncontrolled heart failure
What are some things to be careful of in treatment with loop diuretics?
Elderly - particularly susceptible to the side-effects.
Potassium loss - In hepatic failure, hypokalaemia caused by diuretics can precipitate encephalopathy, particularly in alcoholic cirrhosis.
Urinary retention - If there is an enlarged prostate, urinary retention can occur
What info should be given to patients about loop diuretics
may cause dizziness, electrolyte abnormalities, tummy upset
need to have blood tests to monitor electrolyte levels
best taken in morning - so that not weeing during night! you may find you need to go to the toilet a couple of times within a few hours of taking the tablet.
What kind of drug is simvastatin
inhibitor of HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis
lowers cholesterol
When should statins be taken? Why?
before bed
most cholesterol is made at night
What are the side effects of statins
myalgia
rarely - myositis, rhabdomyolysis
liver impairment
What monitoring should take place in statin therapy
checking LFTs at baseline, 3 months and 12 months.
baseline CK and lipid profile
What can cause bradycardia
physiological (e.g. during sleep, in athletes)
cardiac causes (e.g. atrioventricular block or sinus node disease)
non-cardiac causes (e.g. vasovagal, hypothermia, hypothyroidism, hyperkalaemia)
drugs (e.g. beta-blockade, diltiazem, digoxin, amiodarone) in therapeutic use or overdose.
What defines bradycardia
HR <60BPM
Describe the management of bradycardias
A-E assessment
if signs of adverse features, give atropine 500mcg IV
if unsuccessful, arrange senior help and transvenous pacing
if no adverse features, assess for risk of asystole
if risk of asystole, ger senior help and arrange transvenous pacing
What are the adverse features of bradycardias
shock - hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
heart failure
syncope
myocardial ischaemia
What is the mechanism of action of atropine
o antagonises acetylcholine at postganglionic nerve endings
o increases sinus rate and sinoatrial and AV conduction.
What makes a patient at risk of asystole in bradycardia
previous asystole
Mobitz II heart block
complete heart block
ventricular pause >3s
What are some interim measures that you can do whilst waiting for transvenous pacing in bradycardia
further atropine up to 3mg
transcutaenous pacing
adrenaline
What is a PDA
patent ductus arteriosus
between descending aorta and pulmonary trunk
What are the signs of PDA
continuous machinery murmur
left supraclavicular palpable thrill
wide pulse pressure
collpasing pulse
What are the signs of ASD
ejection systolic murmur
What are the signs of coarctation of the aorta
radiofemoral delay
HTN
midsystolic murmur
What are the INR targets for pts taking warfarin
venous thromboembolism: target INR = 2.5, if recurrent 3.5
atrial fibrillation, target INR = 2.5
mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.
Describe the pathophysiology of aortic dissection
tear in tunica intima
high pressure in artery forces blood between tunica intima and tunica media to form a fulse lumen
What is the difference between Type A and B aortic dissections
A = ascending B = descending dital to subclavian
What are some causes of aortic dissection
HTN
CT disease - Ehler’s-danlos or Marfan’s
aneurysms
What are the symptoms and signs of aortic dissection
chest pain - tearing, radiating to back
weak pulses
hypotension
AR
What is the long term management of acute heart failure
Daily weights, aim reduction of 0.5kg/day
Repeat CXR.
• Change to oral furosemide or bumetanide.
• If on large doses of loop diuretic, consider the addition of a thiazide (eg bendroflumethiazide or metolazone 2.5–5mg daily po).
• ace-i if lvef <40%. If ace-i contraindicated, consider hydralazine and nitrate (may also be more effective in African-Caribbeans).
• Also consider β-blocker and spironolactone (if lvef <35%).
• Is the patient suitable for biventricular pacing or cardiac transplantation?
• Optimize management of AF if present; consider anticoagulation.
