Cardiology Flashcards
1
Q
What is this?
What does this suggest (with signs)?
A
Median sternotomy -running from the suprasternal notch vertically in the midline to the xiphisternum (subtotal=incision from sternomanubrial junction to 5th/6th IC space)
(Description This is a photograph of the wounds after cardiac surgery The wound in the chest is called a sternotomy because the sternum has been divided The sutures used to close the wounds have been removed leaving classic train track scars Puncture wounds where chest drains have been left and subsequently removed can also been seen)
Anatomy enables access to the underlying structures; most commonly heart, also: pericardium, thoracic aorta, oestophagus, trachea, phrenic and cardiac nerves, thoracic duct, thymus and lymph nodes.
Indications; cardiac (see table), Aortic aneurysm/disection, ?rarely as an alternative approach to resection of lung cancer/oestophagus (the latter with extension), thymectomy (MS)
2
Q
Define: Chronic heart failure
A
Definition: Cardiac output is inadequate for body’s requirements despite adequate filling pressures.
3
Q
LVF
causes/Sx/signs
A
- *Causes**
1: IHD
2: Idiopathic dilated cardiomyopathy
3: Systemic HTN
4: Mitral and aortic valve disease
Symptoms
- Fatigue
- Exertional dyspnoea
- Orthopnoea + PND
- 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
4
Q
RVF
causes/Sx/signs
A
Causes
- LVF
- Cor pulmonale; an alteration in the structure and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory system (pulmonary HTN)
- Tricuspid and pulmonary valve disease
Symptoms
- Anorexia and nausea
Signs
- ↑JVP + jugular venous distension
- Tender smooth hepatomegaly (may be pulsatile)
- Pitting oedema
- Ascites
5
Q
Chronic heart failure classification
A
- *New York Classification**
1. No breathlessness
2. Breathless c¯ moderate exertion
3. Breathless c¯ mild exertion
4. Breathless at rest
6
Q
Investigations for Chronic HF
A
Bloods: FBC, U+E, NT-proBNP, lipids, glucose
NT-proBNP
- Secreted from ventricles in response to ↑ stretch and ↑HR
- ↑ levels is most accurate diagnostic indicator of HF
- NICE recommends that heart failure is not Dx w/o ↑ BNP
- Used to;
- rule out a Dx of HF in pt with acute dyspnoea (if low v.unlikely HF, if raised Ix)
- Prognosis in pt with CHF
- guide Rx in pt with CHF (effective Rx lowers BNP)
CXR: ABCDEF
- Alveolar shadowing
- Kerley B lines
- Cardiomegaly (cardiothoracic ratio >50%)
- Upper lobe Diversion
- Effusions
- Fluid in the fissures
ECG
- Ischaemia
- Hypertrophy
- AF or other arrhythmia
Echo: the key investigation
- Global systolic and diastolic function
- Ejection fraction normally ~60%
- Focal / global hypokinesia
- Hypertrophy
- Valve lesions
7
Q
CHF Management
(gen, spec, surg/other, trials)
A
General
- MDT: GP, cardiologist, physio, dietician, specialist nurses
- Optimise CV risk: statins, anti-HTN, DM, anti-plat
- Monitor: regular f/up and echo
offer annual influenza vaccine
offer one-off** pneumococcal vaccine
Specific
1st: β-B (bisoprolol, carvedilol, and nebivolol) + ACEi + loop diuretic (Bisoprolol/Lisinopril/Frusemide)
2nd: add Spironolactone OR hydralazine in combination with a nitrate
3rd: consider ?ivabradine or digoxin (not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties. Digoxin is strongly indicated if there is coexistent atrial fibrillation)
4th: consider cardiac resynchronisation therapy
Surgery
LVAD
Heart transplant
Trials Showing Drug Benefit in Heart Failure
- β-B: CIBIS-2, MERIT-2
- ACE inhibitors (SAVE, SOLVD, CONSENSUS)
- spironolactone (RALES)
- beta-blockers (CIBIS/MERIT-2)
- hydralazine with nitrates (VHEFT-1)
- ARB = ACEi: ELITE-2
8
Q
Tell me about CABG
A
9
Q
Aortic stenosis Examination (and differentials)
peripheral/pulse/precordium
sig negatives
(differentials)
A
- *Peripheral Inspection**; Often nothing specific
- *Pulse**
- Slow-rising (anacrotic)
- Narrow pulse pressure (<30mmHg)
Precordium
- Pacemaker
- 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
- Clinical Signs of Severe AS
- Quiet / absent A2
- S4
- Narrow pulse pressure
- Decompensation: LVF (may have loud P2 if PHTn due to CCF)
Significant Negatives
- Infective endocarditis
- LVF
- Indicators of severity; quiet/absent A2, S4, narrow pulse pressure, decompensation: LVF
Differential
- Aortic sclerosis: no radiation, normal pulse character
- MR
- HOCM: valsalva ↑s murmur, squatting ↓s murmur (in AS valsalva-decreases systemic venous return->softens AS)
- Right-sided: PS
10
Q
Causes of AS
A
- Age-related senile calcification
- Bicuspid aortic valve
- Rheumatic heart disease
11
Q
Viva AS Hx (clinical Sx of severe AS)
A
Hx: Clinical Symptoms of Severe AS
- Angina: 50% dead in 5yrs
- Syncope: 50% dead in 3yrs
- Dyspnoea: 50% dead in 2yrs
12
Q
AS Ix
A
ECG
- LVH
- Arrhythmias
- *Blood**: FBC, U+E, NT-proBNP, lipids, glucose
- *CXR**
- Calcified AV
- LVH
- Pulmonary oedema
Echo + Doppler
- Severity
- Echo Features of Severe AS (AHA 2006)
- Valve area <1cm2
- Pressure gradient >40mmHg
- Jet velocity >4m/s
- Echo Features of Severe AS (AHA 2006)
- Cause: Bicuspid valve, thick calcified cusps
- LV function
- Other valve function
Cardiac Catheterisation
- Valve gradient
- Assess coronaries (needed if surgery planned)
13
Q
AS Management
A
General
- MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses
- Optimise CV risk: statins, anti-HTN, DM, anti-plat
- Monitor: regular f/up and echo
Surgical: Valve Replacement ± CABG
- Indications
- Symptomatic AS
- Severe asymptomatic AS c¯ ↓ EF (<50%)
- Severe AS undergoing CABG or other valve op
- Mortality: 3-5% depending on pts. EuroSCORE
Other Options
- TAVI: Transcatheter Aortic Valve Implantation
- Balloon valvuloplasty
14
Q
Atrial fibrillation
examination
(general, causes, pulse, precordium, completeion)
and negatives!
A
Peripheral Inspection
-
General
- Warfarin alert bracelet
-
Cause
- ↑T4: tremor, thin, palmar erythema, sweating, eye signs
- MS: mitral flush
Pulse
- Irregularly irregular
Precordium
- MS: MDM
- MR: PSM
- Other murmurs
Completion
- Respiratory examination: pneumonia
- Exercise pt. to bring out any murmur
Significant Negatives
- Murmur
- Evidence of thyrotoxicosis
- LVF
- Bruising from warfarin
15
Q
Causes of AF
common/other
A
Common
- IHD
- Rheumatic heart disease
- Thyrotoxicosis
- Hypertension
Other
- Pneumonia
- PE
- Post-op
- Hypokalaemia
- Alcohol
- RA
16
Q
AF Viva Hx
A
Symptoms: palpitations, dyspnoea, chest pain
- Aware of specific onset
Causes
Warfarin: look @ yellow book
17
Q
Investigation of AF
A
ECG
- Confirm Dx: irregularly irregular, no P waves
- Cause: ischaemia, P-mitrale
Bloods
- FBC: pneumonia, sepsis
- U+E: ↓K
- TFTs: ↓TSH, ↑fT4
- Troponin
- D-dimer: PE
CXR
- Pulmonary oedema
- Calcified mitral valve
- Pneumonia
Echo
- Valve pathology
- LV function
- TOE: left atrial thrombus
18
Q
Differential Dx for Irregularly irregular pulse
…and clinical distinction
A
Differential of Irregularly Irregular Pulse
- AF
- Multiple ventricular ectopics
Clinical Distinction
- Exercise pt.
- AF: pulse stays irregularly irregular
- VE: ↑ HR → regular pulse
- ↓ diastole time closes window for ectopics
19
Q
AF
what is pulse deficit
A
Pulse Deficit
- Difference in HR @ wrist and @ apex
- Rapid ventricular rate → ↓ diastolic filling → ↓CO
20
Q
Management of AF
(not risk strat etc)
A
Acute AF ≤48hrs
- Haemodynamically unstable → cardioversion
- Stable
- Rate control: diltiazem or metoprolol
- Start LMWH
- Cardiovert: DC or medical (flec or amiodarone)
Paroxysmal AF
- Recurrent episodes lasting <7d
- Pill in pocket: flecainide or amiodarone
- Prevention: β-B or sotalol
Persistent AF
- Lasting >7d
- Rhythm control*
- Younger pts., treated precipitants
- ≥3wks anticoagulation c¯ Warfarin first or TOE to exclude mural thrombus
- Cardioversion: DC or medical
- May need maintenance anti-arrhythmic
- Rate control*
1st: β-B or rate-limiting CCB
2nd: add digoxin (not monotherapy) - Permanent AF (*Failed cardioversion / unlikely to succeed) =Rate control
-
Other options:
- Radiofrequency ablation of AV node
- Maze procedure
- Pacing
21
Q
Anticoagulation scoring system
A
CHA2-DS2-VAS Score
- Determines necessity of anticoagulation in AF
- Dabigatran >warfarin (unless metal valve/CI etc)
- Aspirin is no longer recommended for reducing stroke risk in patients with AF
CHA2-DS2
- CCF
- HTN
- Age≥75 (2 points) 65-74 (1 point)
- DM
- Stroke or TIA (2 points)
VS
- Vascular disease
- Sex: female
HAS BLED
- HHypertension, uncontrolled, systolic BP > 160 mmHg 1
- AAbnormal renal function (dialysis or creatinine > 200) Or Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP > 3 times normal=1 for any renal OR liver abnormalities
- SStroke, history of 1
- BBleeding, history of bleeding or tendency to bleed 1
- LLabile INRs (unstable/high INRs, time in therapeutic range < 60%) 1
- EElderly (> 65 years) 1
- DDrugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs) Or Alcohol Use (>8 drinks/week) 1 for drugs OR alcohol
22
Q
AF anticoagulation options
A
NICE recommend that we offer patients a choice of anticoagulation, including warfarin and the direct oral anticoagulants (DOACs). There are complicated rules surrounding which DOAC is licensed for which risk factor - these can be found in the NICE guidelines. Aspirin is no longer recommended for reducing stroke risk in patients with AF
- *Warfarin**
- Contraindications*
- Bleeding diathesis
- Compliance issues: dosing, monitoring
- Risk of falls
- PUD
- Pregnancy
- Pt. choice
Complications
- Bleeding
- Osteoporosis
Advice
- Requires regular monitoring and titration of dose
- Avoid certain foods: e.g. grapefruit
- Care starting new meds
- Wear medic alert bracelet
- Come to hospital if uncontrolled bleeding
DOAC The table below summaries the three DOACs: dabigatran, rivaroxaban and apixaban.
23
Q
MS
examination
(peripheral inspection, pulse, precordium, clinical signs of severe MS sig negatives!)
A
Peripheral inspection
- middle aged female
- warfarin medical alert bracelet
- Malar Flush: CO->back pessure + vasoconstriction
Pulse: AF
Precordium
- LEft parasternal heave: RVH 2ndary to PHT
- Apex: tapping (palpable S1), non-displaced
- Heart sounds:
- Rumbling MDM
- Loudest at Apex…in Left lateral position in end expiration…with the bell
- Radiates to the axilla
- Pre-systolic accentuation if pt in sinus rythm-due to atrial contraction
- ?! possible additional murmus e.g. Graham steel murmur- Pulmonary Regurgitation - EDM (PHT->PR)
clinical signs of severe MS:
- Malar flush
- longer murmur
- LVF
significant negatives
- infective endocarditis
- severity: LVF, malar flush, long murmur
- PHT:
- Malar flush
- raised JVP with large V waves
- Left parasternal heave
- loud P2
24
Q
MS
main differentials (i.e. other diastolic murmurs)
A
AR
R sided: PR, TS
25
Causes of MS
Rheumatic heart disease
rarer: prsthetic valve, congenital
26
MS Ix
**ECG:** P mitrale, AF
**Bloods:** FBC, U+E, NT-proBNP, lipids, lucose
**CxR**
* LA hypertrophy-\> splaying of carina
* calcified mitral valve
* pulmonary oedema
**Echo + Doppler**
* severity
* cusp calcification
* LV function
* other valve function
* TOE: left atrial thrombus if intervention planned
* Features of severe MR:
* Valve orifice \<1cm2
* Pressure gradient \>10mmHg
* Pulmonary artery systolic pressure \>50mmHg
**Cardiac catheterisation:**
Assess coronary arteries (REQUIRED if surgery planned)
27
Management of MS
General/specific/surgical
General:
* MDT: Gp, cardiologist, cardiothoracic surgeon, dietitcian, specialist nurse
* Optimise CV risk: statins, antiHTN, DM, antiplt
* Monitor: reg F/up and echo
Specific:
* consider RF prophylaxis e.g. pen V
* AF:
* Rate control BB
* anticoagulate (4% stroke risk/yr)
* Diuretics provide some symptom relief
Surgical:
* indicated in mod-severe MS (asympto and sympto)
* Percutaneous balloon vavuloplasty:
* Treatment of choice
* suitability depends on valve characteristics
* Pliable, minimally calcified
* CI: left atrial appendage mural thrombus
* surgical valvotomy/commissurotomy: valve repair
* Valve replacement if repair not possible
28
Infective endocarditis
normal valves (RF/organisms), Cardiac disease (RF/organisms)
Normal valves:
* Risk factors:
* IVDU
* Skin wounds
* immunosuppression: CRF, DM
* Organisms:
* S.aureus
* S.epidermidis
Cardiac disease-\> subacute endocarditis
* RF:
* prosthetic valves
* valve disease
* Organisms:
* S viridans
* S bovis (do colonoscopy for colonic neoplasm)
* HACEK (*culture negative IE*)
29
IE
Clinical features
* **Hands:**
* ****clubbing
* splinters
* janeway lesions
* oslers nodes
* **Other:**
* Fever
* Roth spots
* splenomegaly
* haematuria
* **Cardiac:**
* ****new/changing murmur: 85% MR, 55% AR
30
IE Duke criteria
Dx: Duke criteria:
* 2 major
* 1 major + 3 minor
* All 5 minor
MAJOR:
1. +ve blood cultures
* typical organism in 2 seperate cultures
* persistently + cultures e.. 3 \>12hrs apart
2. Endocardial involvement:
* +ve echo: vegetation, abscess, dehiscence
* OR: new valvular regurgitation
MINOR:
1. Predisposition: cardiac lesion, IVDU
2. Fever \>38
3. Emboli: septic infarcts, splinters, janeway lesions
4. Immune: GN, Osler nodes, roth spots, RF
5. + blood cultures not meeting major criteria
31
IE
Emerical Rx
(and prophylaxis?)
**Acute severe:** fuclox/vanc + gent IV
**subacute:** Benpen + gent IV
**proph:** Abx prophylaxis solely to prevent IE not recomended
32
Cardiac causes of clubbing: (3)
* *Infective endocarditis**
* *Congenital cyanotic heart disease**
* Fallot’s Tetralogy
* VSD
* Pulmonary stenosis
* RVH
* Overriding aorta
* Transposition of the Great Vessels
**Atrial myxoma**
* Assoc. c¯ Carney Complex / **LAME S**yndrome
* **L**entigines: spotty skin pigmentation
* **A**trial **M**yxoma
* Endocrine tumours: **P**ituitary
* **S**chwannomas
33
Causes of a collapsing pulse (4)
*Hyperdynamic circulation*
* AR
* Thyrotoxicosis
* Pregnancy
* Anaemia
34
Causes of an absent radial pulse (5)
* Dead
* Trauma
* Thrombosis or Embolism
* Coarctation of the aorta
* Takayasu's arteritis
35
Impalpable apex breat (4)
* _**C**OPD_
* **O**besity
* **P**ericardial effusion
* **D**extrocardia
36
Features of Pulmonary HTN (5)
* ^JVP
* Left parasternal heave
* Loud P2 + PSM (TR)
* Pulsatile hepatomegaly
* Ascites and peipheral oedema
37
Heart sounds (S1-4)
1. S1: mitral valve closure
2. S2: **aortic** valve closure
3. S3: rapid ventricular filling of dilated left ventricle
4. S4 atrial contraction against a stiff ventricle
38
How would you complete your Cardio exam? (1+6)
* History + Drug chart
* (PRODFE)
* **P**V exam
* **R**esp exam
* **O**bservation chart: temp/HR/RR/O2 saturations/BPs
* **D**ip urine
* **F**undoscopy
* 12-lead **E**CG
39
Presentation for Cardio Ex
* On peripheral inspection…
* The pulse…
* On examination of the precordium…
* Significant negatives
* Absence of CCF
* Disease severity
* Evidence of cause
* Differential Dx
* Hx
40
Key Qs in cardio Hx
**Hx**
* Symptoms: dyspnoea, chest pain, palpitations, syncope
* LVF: PND, orthopnoea
* IE: fever, wt. loss, night sweats
* CV Risk: smoking, DM, lipids, HTN, FH
* PMH: rheumatic fever
* DH: antiplatelet agents, statins
41
Key investigations in cardio
ECG/Bloods(4)/Imaging (3)
**ECG**
* Evidence of ischaemia
* Arrhythmia
**Blood**
* FBC: anaemia exacerbates cardiac symptoms
* U+E: renovascular disease
* **_NT-pro_BNP**: heart failure *(N-terminal pro b-type natriuretic peptide )*
* Fasting lipids and glucose: cardiac risk
**Imaging**
* CXR
* Cardiomegaly
* Pulmonary oedema
* Valve calcification
* Echo
* Dx
* Valve function
* LV Function
* Cardiac catheterisation
* Evaluate coronary arteries
42
General management of cardio cases
***General***
* MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses
* Optimise CV risk: statins, anti-HTN, DM, anti-plat
* Monitor: regular f/up and echo
* *Specific**
* *Surgical**
43
Mitral regurg Examination
Peripheral + pulse + precordium + severity + negatives
* *Peripheral Inspection:** Warfarin medic alert bracelet
* *Pulse:** AF
* *Precordium:**
* Left parasternal heave (RVH)
* 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 PSM
* Apex
* Left lateral position in end expiration
* Radiates to the axilla
**Clinical Signs of Severe MR**
* LVF
* AF
**Significant Negatives**
* Infective endocarditis
* Indicators of severity: AF, LVF
44
Differential for MR (PSM)
AS
VSD
(RHS:) TR
45
Causes of MR (4)
* Functional: LV dilatation (e.g. 2 to HTN or idiopathic)
* Annular calcification → contraction
* Rheumatic heart disease
* Mitral valve prolapse
46
47
Mitral regurgitation
Ix (5)
Ix
* **ECG**
* Arrhythmias
* LVH
* P-mitrale
* **Blood**: FBC, U+E, NT-proBNP, lipids, glucose
* **CXR**
* LA and LV hypertrophy
* Mitral valve calcification
* Pulmonary oedema
* **Echo + Doppler**
* Severity
* Echo Features of Severe MR (AHA 2006)
* Jet width \>0.6cm
* Systolic pulmonary flow reversal
* Regurgitant volume \>60ml
* LV function
* Other valve function
**Cardiac Catheterisation**
* Assess coronaries (needed if surgery planned)
48
Management of MR
Gen
Spec
Surg
**General**
* MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses
* Optimise CV risk: statins, anti-HTN, DM, anti-plat
* Monitor: regular f/up and echo
**Specific**
* AF: rate control and anticoagulate
* Emboli: anticoagulate
* ↓ afterload
* ACEi or β-B (esp. carvedilol)
* Diuretics
**Surgical**
* Valve replacement or repair
* Aim to replace the valve before significant LV dilation and dysfunction.
* Indications = Symptomatic
49
Prognosis for MR
* Often asymptomatic for \>10yrs
* Symptomatic: 25% mortality @ 5yrs
50
AR Examination
peripheral inspection: eponymous signs/causes
Pulse
Precordium
?severity
?sig negatives
**Peripheral Inspection**
* Eponymous Signs
* ***Quincke’s***: capillary pulsation in nail beds
* ***Corrigan’s***: visible vigorous carotid pulsation
* ***De Musset’s***: head nodding
* ***Traube’s:*** pistol-shot sound over femorals
* ***Duroziez’s***
* Systolic murmur over the femoral artery c¯proximal compression.
* **D**iastolic murmur c¯ **d**istal compression
* ***Mueller’s***: systolic pulsations of the uvula
* ***Rosenbach’s***: systolic pulsations of the liver
* Cause
* Marfanoid: tall, thin, long arms, high-arched palate
* Ank spond: cervical kyphosis
**Pulse**
* Collapsing pulse
* Wide pulse pressure: e.g. 180/45
**Precordium**
* Aortic thrill
* Apex: displaced (volume overload)
* Heart Sounds
* Soft S2
* ± S3
* Murmur
* High-pitched EDM
* LLSE (3rd left IC parasternal)
* Sitting forward in end-expiration
* Possible Additional Murmurs
* Ejection systolic flow murmur
* Austin-Flint murmur
* Rumbling MDM @ apex 2O regurgitant jet fluttering the anterior mitral valve
**Clinical Signs of Severe AR**
* Collapsing pulse
* Wide pulse pressure
* LVF
**Significant Negatives**
* Infective endocarditis
* Indicators of severity: LVF, wide PP, collapsing pulse
51
Differentials for AR (EDM)
* MS
* (RHS): PR + TS
52
Causes of AR
Chronic/acute
**Chronic**
* Bicuspid aortic valve
* Rheumatic heart disease
* Autoimmune: Ank spond, RA
* Connective tissue: Marfan’s, Ehler’s Danlos
**Acute**
* Infective endocarditis
* Type A aortic dissection
53
Investigations for AR
| (5)
**ECG**
* LVH
* LV strain: lateral T wave inversion
**Blood**
* Standard: FBC, U+E, NT-proBNP, lipids, glucose
* AI disease: ESR, HLA-B27, ANA
**CXR**
* Cardiomegaly
* Pulmonary oedema
Echo + Doppler
* Severity
* Jet width (\>65% of outflow tract = severe)
* Regurgitant jet volume
* Premature closing of the mitral valve
* Cause: bicuspid valve, vegetations, dissection
* LV function
* Other valve function
**Cardiac Catheterisation**
* Assess coronaries (needed if surgery planned)
* Grade severity
54
Management of AR
GEneral/specific/surgical
**General**
* MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses
* Optimise CV risk: statins, anti-HTN, DM, anti-plat
* Monitor: regular f/up and echo
**Specific**
* ↓ afterload
* ACEi or β-B (esp. carvedilol)
* Diuretics
**Surgical: Valve Replacement**
* Aim to replace the valve before significant LV dilation and dysfunction.
* ***Indications***
* Symptomatic: NYHA \>2
* LV dysfunction
* Pulse pressure \>100mmHg
* ECG changes: T inversion in lateral leads
* LV enlargement on CXR or EF \<50%
55
Rheumatic fever
Pathophysiology
* Ab cross-reactivity following ***S. pyogenes*** infection → **T2** hypersensitivity reaction (molecular mimicry).
* Abs cross-react c¯ *myosin*, *muscle glycogen* and *SM* cells
* Path: Aschoff bodies and Anitschkow myocytes.
56
Jones Criteria (revised)
Evidence of GAS infection plus:
* 2 major criteria,
or
* 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 (**CASES**)**
* Pan**c**arditis
* **A**rthritis
* **S**ubcut nodules
* **E**rythema marginatum
* **S**ydenham’s chorea
**Minor criteria**
* Prolonged PR interval (not if carditis is a major)
* Arthralgia (not if arthritis is a major)
* Fever
* ↑ESR or ↑CRP
* Prev rheumatic fever
57
Investigation of rheumatic fever (3)
* Bloods: FBC, ESR, ASOT
* ECG
* Echo
58
Treatment of Rheumatic fever
* Bed rest until CRP normal for 2 wks
* Benpen 0.6-1.2 IM for 10 days
* Analgesia; carditis/arthritis: aspirin/NSAIDs
* Add oral pred if *CCF*, *cardiomegaly*, *3rd degree block*
* Chorea: Haldol or diazepam
59
Prognosis in Rheumatic fever
* Attacks last ~ 3mo
* 60% c¯ carditis develop chronic rheumatic heart disease.
* Recurrence ppted by
* Further strep infection
* Pregnancy
* OCP
* Valve disease: _regurgitation_ → _stenosis_
* Mitral (70%)
* Aortic (40%)
* Tricuspid (10%)
* Pulmonary (2%)
60
Secondary prophylaxis in rheumatic fever
Prevent recurrence
Prev V 250mg/12hr PO for 5-10 Yrs!
61
Valve replacement examination
peripheral exam: gen/skin
Pulse
Precordium: types
sig negatives
**General**
* Audible valve click
* Anticoagulation → bruising
* Warfarin alert bracelet
* Anaemia
**Scars**
* Midline sternotomy: CABG, AVR, MVR
* Left lat. inf. thoracotomy: MVR, mitral valvotomy
* Neck scars from line insertion
* Groin / femoral scars from angiography
* Vein harvesting scar on the medial leg
* May have had CAGB too
**Pulse**
* Variable
* AF suggests mitral valve replacement due to MS
* Time prosthetic clicks c¯ pulse
* Occur **in *time*** = ***mitral*** valve
**_Precordium_**
Two Main Questions
1. When and where is the closing prosthetic sound?
2. Are there any murmurs?
*Starr-Edwards: 3 artificial sounds*
1. Quieter click as valve opens
2. Loud thud as valve closes
3. Rumbling sound as ball rolls in cage
* Tilting disc or bileaflet: 1 artificial sound*
1. High-pitched click as valve closes
* Biological Valve:* Often normal heart sounds
* Aortic*
* Lub-Click
* ± systolic flow murmur
* Abnormal: AR (EDM)
*Mitral*
* Click-Dub
* ± diastolic flow murmur
* Abnormal: MR (PSM)
*Murmurs*
* Well-seated valves may have soft ***flow*** murmurs (pre-closure)
* Aortic: *systolic*
* Mitral: *diastolic*
* Poorly-seated valves → regurgitation (pre opening)
* Aortic: diastolic
* Mitral: systolic
**Significant Negatives**
* Signs of infective endocarditis
* Signs of heart or valve failure
* Anaemia
* Bruising
62
Important Q (1) in Valve replacement history
DH: warfarin dosing + interactions
## Footnote
*see pts yellow warfarin book*
63
Key investigations in valve replacement
bedside/blood/image
* *Bedside**: ECG
* *Blood**
* FBC: anaemia – MAHA, bleeding
* U+E: renovascular disease
* NT-proBNP: heart failure
* Fasting lipids and glucose: cardiac risk
* INR: warfarin
**Imaging**
* CXR: heart failure
* Echo + Doppler
* Valve regurgitation or stenosis
* Peri-valvular leak
* Vegetations
* LV function
* Other valve function
64
Mechanical Valve prosthesis
Types: 3
Features (2)
Use (3)
**Types**
* *Ball and cage:* e.g. Starr-Edwards
* *Tilting disc*: e.g. Bjork-Shiley
* *Bileaflet*: e.g. ***St. Jude***
**Features**
* Longer life-span: **~20yrs**
* Require oral anticoagulation: **Warfarin INR 3-4**
**Use**
* Bileaflet valves are most commonly used
* *Younger* pts. to minimise need for revision.
* Already *on warfarin: e.g. AF*
65
Biological valve prosthesis
Types (2)
Features (2)
Use (3)
**Types**
* ***Porcine*** valves: e.g. Carpentier Edwards
* Discontinued: Bovine pericardium sewn into a metal frame
**Features**
* Less durable cf. mechanical valves: *~10yrs*
* Don’t require long-term oral anticoagulation
* Take ***aspirin***
**Use**
* ***Older*** patients
* ***Women*** of ***child-bearing age***
* ***Bleeding risk***: e.g. peptic ulcer, frequent falls
66
Indications for valve prosthesis
L or R? (1)
Factos? (4)
Mech or Prosth? (3)
**Mainly left-sided valve dysfunction**
* **_AS_** most commonly
**Factors to consider**
* Severity of valve dysfunction
* Severity of heart function
* Co-morbidities
* Pt. choice
**Mechanical or prosthetic**
* Age
* Tolerance of long-term _anticoagulation_ E.g. ***pregnancy, falls***
* Pt. choice
67
Complications of valve prosthesis
Complications of surgery
Complications of valve (5)
* *Complications of surgery**: Operative mortality: 5%
* *Complications of valve**
* Thromboembolism: 1-2% per annum *despite warfarin*
* Anaemia: warfarin and haemolysis
* Bleeding: minor – 7%/yr, major – 3%/yr
* Infective endocarditis
* Early: Staph. epidermidis
* Late: Strep. viridans
* May require 2nd valve replacement
* Mortality: 60%
* NB. avoid erythromycin if on warfarin
* Failure
* Chronic: stenosis or incompetence
* Acute: dehiscence, breakage, thrombus
68
Pacemakers
Examination: Peripheral inspection/pulse/precordium/?negatives
**Peripheral Inspection**
* Groin scars from catheter insertion
* Medic alert bracelet
* *Pulse:** AF
* *Precordium**
* Left infraclavicular incisional scar
* Palpable pacemaker
* Large: may be ***implantable defibrillator***
* ± murmur: esp. AS
**Significant Negatives**
* AF
* LVF
* Valvular pathology
* Complications of pacemaker: infection, erosion
69
Important history questions in pacemakers (2)
* Arrhythmia
* Syncope
* Palpitations
* Dyspnoea
* Cardiac arrest
* Type of pacemaker
70
Investigation of pt with pacemaker
**ECG**
* Pacing spikes
* May be absent if pt. producing adequate intrinsic rhythm
* Evidence of ischaemia
**CXR**
* Visualise pacemaker
* Count leads
* ***Thick leads*** suggests ***implantable defibrillator***
**Echo**
* LV function
* Valve pathology
* Structural abnormalities indicating cause
71
Permanent Pacing Indications
| (5)
* Complete AV block
* Mobitz Type 2
* Symptomatic bradycardia: e.g. sick sinus syndrome
* Drug-resistant tachyarrhythmias
* Biventricular pacing in chronic heart failure
72
Pacemaker letter codes:
Min 3 letters for pacemaker identification
1st letter the chamber **paced** (A=atria, V=ventricles, D=dual chamber).
2nd letter the chamber **sensed** (A=atria, V=ventricles, D=dual chamber, 0=none).
3rd letter the pacemaker response (T=triggered, I=inhibited, D=dual, R=reverse).
4th letter, P=programmable; M=multiprogrammable.
5th letter, P means that in tachycardia the pacemaker will pace the patient. S means that in tachycardia the pace maker shocks the patient. D=dual ability to pace and shock. 0=neither of these.
***VVI*** pacemakers are the most frequently used in the UK.
***DDD*** pacemakers are the only pacemakers that sense and pace both chambers.
73
Pacemaker complications
| (6)
* **Insertion**
* Bleeding
* Arrhythmia
* **Post Insertion**
* Erosion
* Lead migration
* Pocket infection
* Malfunction
