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PACES Hawthorne > Cardiology > Flashcards

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)

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2
Q

Define: Chronic heart failure

A

Definition: Cardiac output is inadequate for body’s requirements despite adequate filling pressures.

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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
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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
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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
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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
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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
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8
Q

Tell me about CABG

A
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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
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10
Q

Causes of AS

A
  • Age-related senile calcification
  • Bicuspid aortic valve
  • Rheumatic heart disease
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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
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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
  • Cause: Bicuspid valve, thick calcified cusps
  • LV function
  • Other valve function

Cardiac Catheterisation

  • Valve gradient
  • Assess coronaries (needed if surgery planned)
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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
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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
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15
Q

Causes of AF

common/other

A

Common

  • IHD
  • Rheumatic heart disease
  • Thyrotoxicosis
  • Hypertension

Other

  • Pneumonia
  • PE
  • Post-op
  • Hypokalaemia
  • Alcohol
  • RA
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16
Q

AF Viva Hx

A

Symptoms: palpitations, dyspnoea, chest pain

  • Aware of specific onset

Causes
Warfarin: look @ yellow book

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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
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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
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19
Q

AF

what is pulse deficit

A

Pulse Deficit

  • Difference in HR @ wrist and @ apex
  • Rapid ventricular rate → ↓ diastolic filling → ↓CO
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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

  1. Recurrent episodes lasting <7d
  2. Pill in pocket: flecainide or amiodarone
  3. 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
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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
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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.

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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
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24
Q

MS

main differentials (i.e. other diastolic murmurs)

A

AR

R sided: PR, TS

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25
Q

Causes of MS

A

Rheumatic heart disease

rarer: prsthetic valve, congenital

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26
Q

MS Ix

A

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)

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27
Q

Management of MS

General/specific/surgical

A

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
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28
Q

Infective endocarditis

normal valves (RF/organisms), Cardiac disease (RF/organisms)

A

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)
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29
Q

IE

Clinical features

A
  • Hands:
    • ​clubbing
    • splinters
    • janeway lesions
    • oslers nodes
  • Other:
    • ​Fever
    • Roth spots
    • splenomegaly
    • haematuria
  • Cardiac:
    • ​new/changing murmur: 85% MR, 55% AR
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30
Q

IE Duke criteria

A

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
    • blood cultures not meeting major criteria
31
Q

IE

Emerical Rx

(and prophylaxis?)

A

Acute severe: fuclox/vanc + gent IV

subacute: Benpen + gent IV

proph: Abx prophylaxis solely to prevent IE not recomended

32
Q

Cardiac causes of clubbing: (3)

A
  • *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 Syndrome
    • Lentigines: spotty skin pigmentation
    • Atrial Myxoma
    • Endocrine tumours: Pituitary
    • Schwannomas
33
Q

Causes of a collapsing pulse (4)

A

Hyperdynamic circulation

  • AR
  • Thyrotoxicosis
  • Pregnancy
  • Anaemia
34
Q

Causes of an absent radial pulse (5)

A
  • Dead
  • Trauma
  • Thrombosis or Embolism
  • Coarctation of the aorta
  • Takayasu’s arteritis
35
Q

Impalpable apex breat (4)

A
  • COPD
  • Obesity
  • Pericardial effusion
  • D​extrocardia
36
Q

Features of Pulmonary HTN (5)

A
  • ^JVP
  • Left parasternal heave
  • Loud P2 + PSM (TR)
  • Pulsatile hepatomegaly
  • Ascites and peipheral oedema
37
Q

Heart sounds (S1-4)

A
  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
Q

How would you complete your Cardio exam? (1+6)

A
  • History + Drug chart
  • (PRODFE)
    • PV exam
    • Resp exam
    • Observation chart: temp/HR/RR/O2 saturations/BPs
    • Dip urine
    • Fundoscopy
    • 12-lead ECG
39
Q

Presentation for Cardio Ex

A
  • On peripheral inspection…
  • The pulse…
  • On examination of the precordium…
  • Significant negatives
    • Absence of CCF
    • Disease severity
    • Evidence of cause
  • Differential Dx
  • Hx
40
Q

Key Qs in cardio Hx

A

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
Q

Key investigations in cardio

ECG/Bloods(4)/Imaging (3)

A

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
Q

General management of cardio cases

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
  • *Specific**
  • *Surgical**
43
Q

Mitral regurg Examination

Peripheral + pulse + precordium + severity + negatives

A
  • *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
Q

Differential for MR (PSM)

A

AS

VSD

(RHS:) TR

45
Q

Causes of MR (4)

A
  • Functional: LV dilatation (e.g. 2 to HTN or idiopathic)
  • Annular calcification → contraction
  • Rheumatic heart disease
  • Mitral valve prolapse
47
Q

Mitral regurgitation

Ix (5)

A

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
Q

Management of MR

Gen

Spec

Surg

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

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
Q

Prognosis for MR

A
  • Often asymptomatic for >10yrs
  • Symptomatic: 25% mortality @ 5yrs
50
Q

AR Examination

peripheral inspection: eponymous signs/causes

Pulse

Precordium

?severity

?sig negatives

A

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.
      • Diastolic murmur c¯ distal 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
Q

Differentials for AR (EDM)

A
  • MS
  • (RHS): PR + TS
52
Q

Causes of AR

Chronic/acute

A

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
Q

Investigations for AR

(5)

A

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
Q

Management of AR

GEneral/specific/surgical

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

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
Q

Rheumatic fever

Pathophysiology

A
  • 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
Q

Jones Criteria (revised)

Evidence of GAS infection plus:

  • 2 major criteria,

or

  • 1 major + 2 minor
A

Evidence of GAS infection

  • +ve throat culture
  • Rapid strep Ag test
  • ↑ ASOT or DNase B titre
  • Recent scarlet fever

Major Criteria (CASES)

  • Pancarditis
  • Arthritis
  • Subcut nodules
  • Erythema marginatum
  • Sydenham’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
Q

Investigation of rheumatic fever (3)

A
  • Bloods: FBC, ESR, ASOT
  • ECG
  • Echo
58
Q

Treatment of Rheumatic fever

A
  • 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
Q

Prognosis in Rheumatic fever

A
  • 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
Q

Secondary prophylaxis in rheumatic fever

A

Prevent recurrence

Prev V 250mg/12hr PO for 5-10 Yrs!

61
Q

Valve replacement examination

peripheral exam: gen/skin

Pulse

Precordium: types

sig negatives

A

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
Q

Important Q (1) in Valve replacement history

A

DH: warfarin dosing + interactions

see pts yellow warfarin book

63
Q

Key investigations in valve replacement

bedside/blood/image

A
  • *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
Q

Mechanical Valve prosthesis

Types: 3

Features (2)

Use (3)

A

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
Q

Biological valve prosthesis

Types (2)

Features (2)

Use (3)

A

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
Q

Indications for valve prosthesis

L or R? (1)

Factos? (4)

Mech or Prosth? (3)

A

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
Q

Complications of valve prosthesis

Complications of surgery

Complications of valve (5)

A
  • *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
Q

Pacemakers

Examination: Peripheral inspection/pulse/precordium/?negatives

A

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
Q

Important history questions in pacemakers (2)

A
  • Arrhythmia
    • Syncope
    • Palpitations
    • Dyspnoea
    • Cardiac arrest
  • Type of pacemaker
70
Q

Investigation of pt with pacemaker

A

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
Q

Permanent Pacing Indications

(5)

A
  • Complete AV block
  • Mobitz Type 2
  • Symptomatic bradycardia: e.g. sick sinus syndrome
  • Drug-resistant tachyarrhythmias
  • Biventricular pacing in chronic heart failure
72
Q

Pacemaker letter codes:

Min 3 letters for pacemaker identification

A

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
Q

Pacemaker complications

(6)

A
  • Insertion
    • Bleeding
    • Arrhythmia
  • Post Insertion
    • Erosion
    • Lead migration
    • Pocket infection
    • Malfunction

PACES Hawthorne (18 decks)

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