Cardiology Flashcards

Question

Echo features of severe Mitral Regurgitation

Answer 1

Jet width of \>0.6cm Systolic pulmonary flow reversal Regurgitant volume \>60ml

Answer 2

MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurse Optimise cardiovascular risk factors: Atorvastatin, anti-platelet, anti-HTN, DM **Specific** **AF**: rate control and **anti**-**coagulate** Reduce afterload: ACE-inhibitor or b-blocker (esp Carvedilol) **Surgical:** Valve replacement or repair If unfit: ?Percutaneous mitral valve leaflet repair for mitral regurgitation Aim to replace the valve before significant LV dilatation and dysfunction Indications for surgery: symptomatic

Answer 3

Quincke's sign: capillary pulsation in nail beds Corrigan's: visible vigorous carotid pulsation De Musset's: head bopping Traube's: pistol-shot femorals (pistol-sound heard over femorals) Durozieze's: systolic murmur over femoral artery with proximal compression, diastolic murmur with distal compression Mueller's: systolic pulsations of uvula Rosenbach's: systolic pulsations of the liver

Answer 4

**Marfan's** Tall, thin, long arms, high-arched palate **Ankylosing spondylitis:** cervical kyphosis

Answer 5

**Pulse:** Collapsing Wide pulse pressure e.g. 180/45 **Precordium** Aortic thrill Apex: displaced (volume overload) **HS:** soft S2, +/- S3 **Murmur** **High-pitched early diastolic murmur** Loudest on lower left sternal edge (parasternal 3rd IC), sitting forward in end-expiration Additional murmurs: Ejection systolic flow murmur **Austin-flint murmur** = **rumbling mid-diastolic murmur** secondary to regurgitant jet fluttering the anterior of mitral valve **Clinical Signs of Severe Aortic Regurgitation** Collapsing pulse Wide pulse pressure Left ventricular failure **Significant negatives:** infective endocarditis, indicators of severity (LVF, wide pulse pressure, collapsing pulse)

Answer 6

Collapsing Pulse Wide pulse pressure Left ventricular failure

Answer 7

**Chronic** Bicuspid aortic valve Rheumatic heart disease Autoimmune: ankylosing spondylitis Connective tissue disease: Marfan's, Ehlers-Danlos **Acute** Infective endocarditis Type A aortic dissection

Answer 8

Mitral stenosis Pulmonary regurgitation, tricuspid stenosis: right-sided

Answer 9

**Severe** Jet width \>65% of outflow tract Regurgitant jet volume Premature closure of mitral valve

Answer 10

**MDT:** GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurse Optimise cardiovascular risk factors: Atorvastatin, anti-platelet, anti-HTN, DM **Specific** **Reduce afterload:** ACE-inhibitor, or b-blockers (carvedilol) OR diuretics **Surgical: valve replacement (before LV dilatation)** Indications: NYHA \>2, LV dysfunction Pulse pressure \>100mmHg ECG changes: T invesion in lateral leads LV enlargement on CXR or EF \<50%

Answer 11

Peripheral inspection: middle-aged female, wafarin bracelet, malar flush **Pulse**: Atrial fibrillation **Precordium** Left parasternal heave: Right ventricular hypertrophy secondary to pulmonary hypertension Apex: Tapping (palpable S1), non-displaced **HS:** Loud S1, +/- Loud S2 if Pulmonary hypertension **Murmur** **Rumbling mid-diastolic murmur** Loudest at the apex, left lateral position, with the bell, radiating to axilla +/- **Graham Steell** (early diastolic) murmur due to pulmonary regurgitation secondary to pulmonary hypertension **Clinical Signs of Severe Mitral Stenosis** Malar flush Long murmur LVF **Significant Negatives:** infective endocarditis, indicators of seveirty, evidence of pulmonary hypertension (raised JVP with large v waves, left parasternal heave, loud P2)

Answer 12

Rheumatic heart disease Other rarer causes: prosthetic valve, congenital

Answer 13

Valve orifice \<1cm2 Pressure gradient \>10mmHg Pulmonary artery systolic pressure \>50mmHg (pulmonary hypertension)

Answer 14

**MDT:** GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurse **Optimise cardiovascular risk factors:** Atorvastatin, anti-platelet, anti-HTN, DM **Specific** **AF:** Rate control with b-blockers, anti-coagulate Diuretics for symptomatic relief **Surgical** Indicated in mod-severe mitral stenosis Percutaneous balloon valvuloplasty CI: atrial mural thrombus Valve replacement

Answer 15

Antibiody cross-reactivity following **_Strep pyogenes_** infection Leading to a **Type II** hypersensitivity reaction (molecular mimicry) **Antibodies cross-react with myosin, muscle glycogen and smooth muscle cells** **Histology: Aschoff bodies and Anitschkow myocytes**

Answer 16

**Evidence of Group A strep infection** **AND** either **2 major criteria** **OR** **1 major + 2 minor criteria**

Answer 17

**PASES** **P**ancarditis **A**rthritis **S**ubcutaneous nodules **E**rythema marginatum **S**ydenham's chorea

Answer 18

**FEPAP** **F**ever **E**SR / CRP raised **P**rolonged PR interval (not if carditis is major) **A**rthralgia (not if arthritis is major) **P**revious rheumatic fever

Answer 19

Bed rest for 2 weeks Benpen for strep throat Naproxen for arthritis Diazepam if chorea not settling

Answer 20

Strep throat infection again Pregnancy OCP

Answer 21

**Mitral: 70%** Aortic: 40% Tricuspid: 10% Pulmonary: 2% Regurgitation ---\> stenosis

Answer 22

resolves within ~3 months **60% of those with carditis will have rheumatic heart disease**

Answer 23

**Pen V 250mg / 12h** For at least **five years** or until age 21 years, whichever is longer. This should be for ten years for RF with carditis but no valvular disease (or well into adulthood, whichever is longer). However, with substantial valvular disease this should be continued longer. In severe valvular damage, or with valve surgery, prophylaxis should be continued for life

Answer 24

General: audible click, bruising from anti-coagulation, warfarin bracelet, anaemia **Scars** * Midline sternotomy: CABG, aortic valve replacement, mitral valve replacement * Left lateral inferior thoracotomy: mitral valve replacement, mitral valvotomy * Neck scars: central line insertion * Groin / femoral / **wrist** scars from angiography * Vein harvesting **Pulse:** **AF** suggestive of mitral replacement due to mitral stenosis Time click with pulse, occurs in time = mitral valve (systole --\> mitral closure) **Precordium** 3 artifical sounds = Starr-Edwards 1 artifical sound = tilting disc or bileaflet No sounds - biological valve Aortic replacement: **lub-click** +/- systolic flow murmur Mitral replacement: **click-dub** +/- diastolic flow murmur **Murmurs** **well-seated valves --\> flow murmurs** Aortic: systolic Mitral: diastolic **Poorly seated valves --\> regurgitation** Aortic: diastolic Mitral: systolic

Answer 25

**3 artifical sounds** **Quiter** click as valve opens **Loud** thud as valve closes **Rumbling** sound as ball rolls in cage

Answer 26

1 artificial sound high-pitched click as valve closes

Answer 27

Thromboembolism: 1-2% per annum despite warfarin Anaemia: haemolysis Bleeding Infective endocarditis Failure Acute: breakage, thrombus, dehiscence Chronic: stenosis or incompetence

Answer 28

IVDU Skin wounds Immunosuppression: Chronic Renal Failure, Diabetes Melitus

Answer 29

**Strep viridans (most common)** **Staph aureus (IVDU)** S.epidermidis S. bovis (needs colonoscopy for colonic neoplasm) HACEK = culture negative IE

Answer 30

**Hands** Clubbing Splinter haemorrhages Janeway lesions Osler nodes **Cardiac** New/changing murmur Mitral regurgitation: 85% Aortic regurgitation: 55% **Other** Fever Roth spots Splenomegaly **Haematuria**

Answer 31

2 major OR 1 major AND **3** **minor** OR **All 5 minor**

Answer 32

**1) Positive blood culture** **Typical** organism in **2 separate** cultures **OR persistently +ve cultures** e.g. 3 \>12 h apart **2) Endocardial involvement** +ve echo vegetation, abscess, dehiscence OR New valvular regurgitation

Answer 33

1. **Predisposition**: IVDU, cardiac lesion 2. **Fever** \>38 3. **Emboli: septic i**nfarcts, splinters, janeway lesions 4. I**mmunological phenomena:** Glomerulonephritis, Osler nodes, Roth spots, RF 5. **+ve blood culture** not meeting major criteria

Answer 34

**Acute severe:** Flucloxacillin OR Vancomycin IV + Gentamicin IV **Subacute:** Benpen + Gentamicin IV

Answer 35

**Thrusting displaced apex beat** is caused by volume overload: an active large stroke volume ventricle eg aortic or mitral regurgitation or left to right shunts. **Sustained apex beat** is caused by pressure overload eg aortic stenosis, gross hypertension. **Tapping apex beat** - mitral stenosis. **Diffuse pulsation asynchronous with apex beat** - left ventricular aneurysm. **Double or triple impulse** may occur in hypertrophic obstructive myopathy. **Impalpable apex beat -** obesity, overinflated chest, pericardial effusion. Also consider dextrocardia.

Answer 36

**On inspection:** Hyperthyroidism: tremor, thin, palmar erythema, sweating, eye signs Mitral stenosis: malar flush Pneumonia: bronchial breath sounds + added sounds **Pulse:** irregularly irregular **Precordium** Mitral stenosis: mid-diastolic murmur Mitral regurgitation: pan-systolic murmur Significant negatives: murmur, evidence of hyperthyroidism, LVF, bruising from warfarin

Answer 37

**Common** IHD Rheumatic herat disease Thyrotoxicosis HTN **Other** Pneumonia PE Post-op Potassium: hypokalaemia Poison: alcohol Painful joints: rheumatoid arthritis

Answer 38

**AF** Remains when exercising the patient Multiple ventricular ectopics As patient exercises, pulse appears regular as there is reduced window for ectopics

Answer 39

Difference ub HR at the wrist and at the apex

Answer 40

Determine the necessity of anticoagulation in AF **C**ongestive heart failure/left ventricular dysfunction (heart failure with reduced ejection fraction, or people with recent decompensated heart failure requiring hospitalization, irrespective of ejection fraction) = 1 **H**ypertension (defined as a resting blood pressure greater than 140 mmHg systolic and/or greater than 90 mmHg diastolic on at least 2 occasions _or current antihypertensive pharmacologic treatment_) = 1 **A₂**ge older than or equal to 75 years = 2 **D**iabetes mellitus (defined as fasting plasma glucose level of 7.0 mmol/L [126 mg/dL] or more or treatment with oral hypoglycaemic drugs and/or insulin) = 1 **S****₂**troke/TIA/thromboembolism = 2 **V**ascular disease (prior myocardial infarction, peripheral arterial disease, or aortic plaque) = 1 **A**ge 65–74 years = 1 **S**ex category (female) = 1 Anticoagulation treatment = **CHA2DS2VASc score of** 2 or above, Consider offering it to men with a CHA2DS2VASc score of 1 **Weigh up with HASBLED**

Answer 41

Identify people at high risk of bleeding who could benefit from increased vigilance and a specific focus on correction of modifiable risk factors * Uncontrolled hypertension * Poor control of INR * Concurrent medication (for example concurrent use of aspirin or a nonsteroidal anti-inflammatory drug) * Harmful alcohol consumption **H**ypertension (uncontrolled, greater than 160 mmHg systolic) **A**bnormal liver function **/ A**bnormal renal function **S**troke (previous history, particularly lacunar) **B**leeding (bleeding history or predisposition) **L**abile international normalized ratios (INRs, therapeutic time in range less than 60%) **E**lderly (aged over 65 years) **D**rugs (antiplatelet agents or nonsteroidal anti-inflammatory drugs) **H**armful alcohol consumption

Answer 42

Admit if they present with severe symptoms or a serious complication of AF. * Identify and manage any underlying causes or triggers of AF. * Treat the arrhythmia : * rate-control treatment (beta-blocker or a rate-limiting calcium-channel blocker) is recommended for most people with AF * Referral for rhythm-control treatment (cardioversion) may be appropriate for people: * With new-onset AF. * Whose AF has a reversible cause (for example a chest infection). * Who have heart failure thought to be primarily caused, or worsened, by AF. * With atrial flutter and is considered suitable for an ablation strategy to restore sinus rhythm. * Rate-control or rhythm-control treatment should be considered for people with AF presenting acutely with non-life threatening haemodynamic instability, depending on the time of onset of arrhythmia. * Assess stroke risk using the CHA2DS2VASc assessment tool. * Assess risks and benefits of anticoagulation , and start treatment if appropriate. * The HAS-BLED assessment tool should be used to assess the risk of a major bleed and to identify and manage modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, and concurrent use of aspirin or a nonsteroidal anti-inflammatory drug. Arrange follow up : * After starting rate-control treatments — to assess their effectiveness and tolerability. * After starting anticoagulation treatment — to assess compliance and adverse effects. Provide advice and information on AF, its treatments, and where to find support groups.

Answer 43

**1st Line** * Offer a rate-control treatment to most people with atrial fibrillation * Offer a beta-blocker (see Choice of beta-blocker) or a rate-limiting calcium-channel blocker (diltiazem [off-label use] or verapamil) * Consider digoxin monotherapy for people with non-paroxysmal AF only if they have a sedentary lifestyle (that is, they do little or no exercise)Follow up within 1 week of starting rate-control treatment to assess tolerance to treatment and to review symptom control, heart rate, and blood pressure. **Refer to a cardiologist for consideration of rhythm-control treatment (cardioversion), people:** * With new-onset AF. * Whose AF has a reversible cause (for example a chest infection). * Who have heart failure thought to be primarily caused, or worsened, by AF. * With atrial flutter who are considered suitable for an ablation strategy to restore sinus rhythm. * For whom a rhythm-control strategy would be more suitable based on clinical judgement. **For people with AF presenting acutely with non-life threatening haemodynamic instability, rate-control or rhythm-control treatment should be considered, depending on the time of onset of arrhythmia.** * If the onset of arrhythmia is within 48 hours, offer rate-control treatment or refer the person to an acute medical unit for consideration of immediate cardioversion (without the need for anticoagulation treatment). * If the onset of arrhythmia is more than 48 hours or uncertain, start rate-control treatment. If referral for consideration for rhythm-control treatment (cardioversion) is thought to be necessary using clinical judgement, cardioversion should be delayed until the person has been maintained on therapeutic anticoagulation for a minimum of 3 weeks. **Rhythm-control treatments used by specialists include:** * Electrical cardioversion. * Pharmacological cardioversion with antiarrhythmic drugs (such as amiodarone or sotalol). * For people having cardioversion for atrial fibrillation (AF) that has persisted for longer than 48 hours, electrical (rather than pharmacological) cardioversion is used

Answer 44

Coagulopathues Compliance issues Risk of falls PUD Pregnancy Patient choice

Answer 45

**Inspection:** groin scars from insertion, Medic alert bracelet **Pulse:** AF **Precordium** Left infraclavicular incisional scar Palpable pacemaker: if large ? defibrillator Murmur ?aortic stenosis **Significant negatives**: AF, LVF, valvuar pathology, complications of pacemaker (infection or erosions)

Answer 46

**Pacing spikes** Physiological ECG trace does not include vertical signals Evidence of ischaemia

Answer 47

Complete AV block Mobitz type II Symptomatic bradycardia e.g. sick sinus syndrome Drug-resistant tacharrhythmias **Biventricular pacing in chronic heart failure**

Answer 48

1st: chamber paced (A, V, or D) 2nd: chamber sensed (A, V, or D) 3rd: Response (**I**nhibited, **T**riggered, **D**ual)

Answer 49

**Single lead:** one lead senses and responds e.g. VVI **Dual lead**: sense and respond in either chamber **Biventricular**: leads to both ventricles +/- right atrium Used for cardiac resynchronisation therapy in HF

Answer 50

Dual lead pacemaker One lead in rigth atrium One in right ventricle

Answer 51

Single lead pacemaker

Answer 52

**Biventricular pacemaker** Right atrium and right venbtricle lead inserted intravenously Left ventricle lead was placed epicardially via mini-sternotomy and tunneled up to the prepectoral pocket

Answer 53

Can be incorporated into any pacemaker

Answer 54

**Insertion** Bleeding Arrhythmia **Post-insertion** Erosion Lead migration Pocket infection Malfunction

Answer 55

**Cardiac output is inadequate** for the body's requirments **despite adequate filling pressures**

Answer 56

Ischaemic heart disease Idiopathic dilatated cardiomyopathy Systemic hypertension Mitral and aortic valve disease

Answer 57

**Signs** Cold peipheries +/- cyanosis AF Cardiomegaly with displaced apex beat S3 + tachycardia = gallop rhythm Wheeze (cardiac asthma) **Bibasal crepitations** **Symptoms** Fatigue Exertional dyspnoea Orthopnoea and paroxysmal nocturnal dyspnoea Nocturnal cough (+forthy pink sputum) Weight loss and muscle wasting

Answer 58

Left ventricular failure Cor pulmonale Tricuspid and pulmonary valve disease

Answer 59

**Signs** **Increased JVP +** jugular venous distension Tender smooth hepatomegaly (may be pulsatile) Pitting oedema Ascites **Symptoms** Anorexia Nausea

Answer 60

**I:** nil shortness of breath **II:**comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea **III:** marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms **IV:** Shortness of breath at rest

Answer 61

**Secreted from ventricles in response to stretch and increased HR** Increased levels are sensitive marker of HF If low, revise diagnosis

Answer 62

**A**lveolar shadowing Kerley **B** lines **C**ardiomegaly Upper lobe **D**iversion **E**ffusions **F**luid in the fissures

Answer 63

Ischaemia Hypertrophy AF / arrhythmias

Answer 64

Focal / global hypokinesia Hypertrophy Valve lesions Ejection fraction reduced (normally 60%) Can be normal HF PEF

Answer 65

MDT: Gp, cardiologist, physio, dietician, specialist nurse Optimise CVS risk factors: statins, Anti-HTN, DM, anti-platelet **Specific** 1st-line treatment for all patients is both an **ACE-inhibitor** and a **beta-blocker** 2nd- line treatment is now either an **aldosterone antagonist, angiotensin II receptor blocker** or a **hydralazine** in combination with a nitrate 3rd -line: If symptoms persist **cardiac resynchronisation therapy** or **digoxin\*** should be considered. A n alternative supported by NICE in 2012 is ivabradine. The criteria for ivabradine include that the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), has a heart rate \> 75/min and a left ventricular fraction \< 35% **Adjuncts** diuretics should be given for fluid overload offer annual influenza vaccine offer one-off\*\* pneumococcal vaccine

Answer 66

ACE inhibitors (SAVE, SOLVD, CONSENSUS) spironolactone (RALES) beta-blockers (CIBIS) hydralazine with nitrates (VHEFT-1)