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Finals Bible: Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

ECG signs of firs degree block, second degree and third degree heart block

A

1 = PR interval > 0.2 seconds

  1. 1 = Increasing delays until dropped
  2. 2 = Intermittent drops, in a ratio

3 = Complete dissociation

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2
Q

ECG signs of RVH vs LVH?

A

RVH = Tall R wave in V1, deep S in V6
e.g. cor pulmonale

LVH is Deep S in V1, tall R in V6
e.g. HTN, aortic stenosis and co-arctation

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3
Q

Causes of long QT?

A

TIMME

Toxins e.g. macrolides / amiodarone
Ischaemia
Myocarditis
Mitral valve prolapse
Electrolyte = Low K/Ca/Mg
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4
Q

Short QT causes?

A

Digoxin, BB, phenytoin

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5
Q

What is a trifasicular block and when do you see it?

A

1st degree heart block with LAD and RBBB

Commonly presents as falls in the elderly

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6
Q

What is p pulmonale and p mitrale?

A

Pulmonale = Peaked p wave in RAH e.g. Pulmonary HTN or tricuspid stenosis

P mitrale = Broad bifid p wave in LAH = mitral stenosis

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7
Q

ECG changes in VT?

A

No p waves or T waves. Regular broad QRS

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8
Q

ECG changes in Brugada syndrome?

A

RBBB and coved ST elevation in V1-V3

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9
Q

Digoxin ECG changes?

A

Reverse tick = down sloping ST segment and T-wave inversion

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10
Q

ECG changes in hyperkalaemia vs hypokalaemia?

A

Hyper = Tall tented t waves, wide QRS and absent/flat p-waves

Hypo = Small T waves, ST depression. Prolonged QT and prominent U waves

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11
Q

Causes of bradycardia?

A

DIVISION

Drugs e.g. CCB, BB, amiodarone

Ischaemia

Vagal hypotonia e.g. athletes

Infection e.g. infective endocarditis

Sick sinus syndrome = damage to the SAN / AVN or conducting tissue

Infiltration e.g. sarcoidosis

O’s = hypothyroid, hypokalaemia

N = neuro = raised ICP

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12
Q

Investigations of bradycardia?

A

ECG, bloods (cardiac enzymes), event monitor and exercise testing

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13
Q

Management of bradycardia?

A

Unstable = Atropine 0.5mg IV bolus, repeat 3mg max

If refractory can use pacing if:

  • Complete heart block, systole, mobitz type 2 or ventricular pause > 3 seconds
  • transvenous pacing = lead into RV, only for a few days. Mechanical tricuspid is CI

Stable:
Mild = treat underlying cause + theophylline 200mg PO BD

Severe = Treat and temporary dual chamber pacing

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14
Q

Definition of narrow complex tachycardia?

A

Rate >100BPM, QRS <120ms

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15
Q

2 types of narrow complex tachycardias?

A

AV independent:

  • Sinus tachy
  • Atrial tachycardia = different focus takes over from SA node
  • atrial fibrillation
  • flutter = macro re-entry rhythm, atria rhythm of 300 (ventricles can’t conduct 300 so P:QRS is usually 2:1)

AV node dependent:

  • AVNRT = within node so activates atria and ventricles simultaneously

-AVRT = large accessory pathway e.g. WPW bundle of Kent :
+ Can be orthodromic = down AV node and back round up accessory pathway into atria. p follows each QRS, delayed RP interval

+ can be antidromic = conducted down accessory pathway, and re-enters atria via retrograde flow = broad QRS

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16
Q

Management of unstable narrow complex tachycardia?

A 
ABC
DC cardio version x 3
Amiodarone 300mg IV over 10 minutes
Repeat shock
Amiodarone 900mg over 24 hours
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17
Q

management of stable narrow complex tachycardia?

A

Irregular = treat as AF:

  • Rate with BB/CCB + digoxin
  • anticoagulate
  • onset <48 hours = cardioversion

Regular:
- Vagal manouvres
- Adenosine 6mg IV bolus, then 12 then 12. (Use verapamil in asthmatics) If it is AV dependent the adenosine will stop the arrhythmia as it cause AV block.
If it doesn’t work means independent = Flutter, AF or ST

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18
Q

Management of atrial tachycardia and atrial flutter?

A 
AT:
1st line = Diltiazem or Verapamil
2nd line = amiodarone
3rd line = Flecainide
Refractory = ablation

AF:
Unstable = DC cardiovert

Stable = BB e.g. metoprolol 5mg bolus, repeating up to 3 times
- Amiodarone if refractory
Then cardiovert if refractory (electrical or medical with ibutilide)

For ongoing can ablate the tricuspid isthmus if symptomatic, or asymptomatic give Metoprolol

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19
Q

What drugs should you avoid in WPW?

A

Verapamil and digoxin

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20
Q

Definition of brand complex tachycardia?

A

> 100 BPM, QRS > 120ms

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21
Q

Classification of broad complex tachycardia?

A

Most are ventricular:

  • monomorphic = single form QRS
  • Polymorphic
  • Fascicular = Arise from LV with re-entrant into Purkinje’s = Sensitive to verapamil
  • RV outflow tract tachy = Due to cAMP activity = uniquely sensitive to adenosine
  • Torsades des pointes = type of polymorphic

Some are SVT’s with aberrant conduction

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22
Q

Ventricular tachycardia causes?

A

MILDE

Myocarditis
Infarction
Long QT: TIMME
Dilated cardiomyopathy 
Electrolytes low K/Mg/Ca
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23
Q

Management of unstable VT?

A 
ABC
DC cardioversion x 3
Amiodarone 300mg IV over 10-20 minutes
Repeat shock
Amiodarone 900mg over 24 hours
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24
Q

Management of torsades des pointes?

A

In line with ACLS guidelines for unstable VT.
+ usually due to low potassium / magnesium so aggressively replenish

magnesium sulphate 1-2g IV single dose
KCL max 60mM

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25
Q

Management of stable broad complex tachycardia?

A

Correct electrolyte balance
Anti-arrhythmics:
- Amiodarone 150mg bolus then 1mg/min for 6 hours then 0.5mg/min for 18 hours
- 2nd line = lidocaine

Ongoing:

Implanatble cardioverter defibrillator if = Cardiomyopathy, previous VT/VF or congenital arrhythmia problem e.g. Long QT
Anti-arrhythmics e.g. Metoprolol 50mg PO BD

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26
Q

What is atrial fibrillation?

A

Supraventricular tachyarrhythmia, with an irregularly irregular rhythm.

Abnormal atria promoting electrical re-entry

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27
Q

How do we classify atrial fibrillation?

A

First diagnosed = new diagnosis regardless of duration

Paroxysmal = self terminating, usually within 2 days

Persistent = longer than 7 days, including episodes cardioverted post 7 days

Long standing = continuous > 1 year, have adopted rhythm control

Permanent = No rhythm control

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28
Q

Causes of atrial fibrillation?

A

Cardiac = HTN, LV failure, ischaemic heart disease

Non-cardiac = thyrotoxicosis, pulmonary e.g. PE, drugs and alcohol

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29
Q

Management of unstable AF?

A

Unstable = DC cardiovert, if >48 hours must do a TOE to exclude atrial thrombus

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30
Q

Management of Acute AF?

A

If >65 or Hx of IHD = RATE control:

without heart failure - metoprolol 5mg bolus, repeat up to 3 times then regular metoprolol 50mg PO BD
If asthmatic use diltiazem

Heart failure = use digoxin 0.5mg PO OD

If <65, symptomatic, first presentation, lone AF / secondary to corrected precipitant = RHYTHM:
- <48 hours = immediate cardioversion
+ DC cardioversion with amiodarone therapy 4 weeks prior and 12 months after
+ Flecainide single dose 200mg
+ If evidence of structural heart disease use amiodarone

> 48 hours = establish INR of 2-3 for 3 weeks prior to cardioversion

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31
Q

Anticoagulation in AF?

A

CHADS score>2
Apixiban if non-valvular
Heparin / warfarin if valvular or kidney disease

Continue 3-4 weeks following cardioversion

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32
Q

Paroxysmal AF management?

A

Flecainide 200mg pill in the pocket
Rate control with BB (digoxin of heart failure)
Anticoagulate

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33
Q

Management of high INR on warfarin?

A

Major bleeding = stop warfarin, Vitamin K 5mg IV and prothrombin complex

INR >5, minor bleeding = stop warfarin, 5mg of IV vitamin K (repeat if INR still high after 24 hours), restart when INR < 5

INR >8 no bleeding = Stop warfarin, oral vitamin K, restart warfarin when <5

INR 5-8 no bleeding = Withhold 1-2 doses
Reduce subsequent dosing

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34
Q

How does NSTEMI differ from unstable angina?

A

NSTEMI has sufficiently severe ischaemia to cause myocardial damage, and therefore release cardiac biomarkers

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35
Q

RF’s for ACS?

A

Modifiable = HTN, DM, lipids, obesity and smoking

Non-modifiable = Male, increasing age and FHx MI >50

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36
Q

Clinical features of unstable angina?

A

Rest angina that is new onset (<2 months)

Crescendo pattern in occurence

Radiation to jaw/arm/neck

SOB

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37
Q

Investigations in unstable angina / NSTEMI?

A

ECG = ST depression and T-wave inversion

Trop normal in UA
FBC and clotting, lipid profile

CXR

Angiography gold standard, use based on GRACE mortality score

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38
Q

Acute management of unstable angina / NSTEMI?

A 
Acutely = 
Diamorphine 5mg IV every 30 minutes
Oxygen if sats <90%
GTN 0.3-0.6mg tablets sublingual, max 3
Antiplatelet = aspirin 300mg  and clopidogrel 300mg PO for 1 year

Anti-coagulate = fondaparinux 2.5mg SC if not having an angiography within 24 hours and no bleeding risk

Next do a GRACE-6 month mortality score:
- low risk (>3%) = conservative only
- Intermediate / high risk (>3%) do a coronary angiography within 96 hours. Significant findings = PCI
If not = prophylaxis and rehab.

High risk also requires addition go GPIIb/IIIa inhibitor e.g. tirofiban for 3 days

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39
Q

Long term management of UA / NSTEMI/ STEMI?

A

Conservative = cardiac rehabilitation. Diet, RF’s controlled, exercise

Medical is just like 'A-SBA'
 =
A spirin for life 75mg, clopidogrel 75mg for one year. 
S tatin - Atorvastatin 80mg PO OD
B B - Propranolol 40mg PO BD
A CEI - Perindopril 10mg PO OD

STEMI = return to work 2 months, no sex or driving for 1.

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40
Q

ECG changes in a STEMI:

first changes seen, how vessels relate to leads, and criteria for thrombolysis based on ECG findings?

A

Hyper acute T waves often first sign seen

Inferior = 2, 3, aVF = RCA
Anterior = V2-4 = LAD
Lateral = V5, V6 and 1 = Left circumflex

Criteria for thrombolysis / PCI:

  • ST elevation >2mm in 2 or more consecutive anterior leads
  • ST elevation >1mm in 2 consecutive inferior leads
  • New onset LBBB
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41
Q

At what times do we need to take troponin?

A

need a 3 hour and 12 hour

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42
Q

Acute management of STEMI?

A

Acutely = continuous ECG, IV access and bloods.
Diamorphine 5mg IV every 30 minutes
Oxygen if sats <90%
GTN tablets 0.3-0.6 mg sublingual, max 3
Antiplatelet = aspirin 300mg and clopidogrel 300mg PO for 1 year
Anti-coagulate = fondaparinux 2.5mg SC

If access within 120 minutes and PC <12 hours = PCI = angioplasty and stenting
- consider if >12 hours

If access > 120 minutes = thrombolysis = Streptokinase 1.5 million units IV over 1 hour

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43
Q

Thrombloysis contraindications

A

AGAINST

Aortic dissection
GI bleed <1 month
Allergic reaction
Iatrogenic e.g. recent surgery
Neuro = ischaemic stroke <6 months ago 
Severe HTN (200/120)
Trauma
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44
Q

How is PCI done and complications?

A

Gain radial artery access, guide wire passed through to coronary and across stenosis. Balloon is the dilated and stented

Can have metal stent or drug-eluting (Reduces restenosis rate)

Home same day, no driving 1 week

Complications = Re-stenoiss, arrhythmias, coronary dissection / rupture, PCI induced MI

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45
Q

CABG procedure and indications?

A

Sternotomy , although can do more minimally invasive scars.
Off pump done on beating heart. Graft attached to aorta and then distally to stenosis
Internal left thoracic best for graft as maintains latency, although most use great saphenous.

Indications:
Severe refractory angina
Left main stem stenosis or triple vessel disease
Unsuccessful PCI

No driving for 4 weeks

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46
Q

MI side effects?

A

Short term:

RCA causes heart block 1/2 due to ischaemia of AV node

LAD = complete heart block as infarcts bundle branches in septum

VF = most common cause of death post-MI

Cardiac tamponade = due to thin wall following necrosis
Pupillary muscle rupture = gives acute mitral regurgitation
Dresslers syndrome

Long term:

Arrhythmias
Heart failure
Depression

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47
Q

Angina pectoris classification?

A

Stable and unstable
Decubitus = brought on lying down
Prinzmetals = younger demographic, during rest, absence of positive exercise test
Syndrome X = angina pain and ST elevation on exercise tolerance BUT no evidence of atherosclerosis on angio

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48
Q

Stable angina management?

A

MDT approach

Conservative = lifestyle advice

Medical:
Sublingual GTN 0.3-0.6mg PRN
Aspirin 75mg PO OD
Atorvastatin 80mg PO OD

1st line = monotherapy BB propranolol 40mg PO BD
OR
Raste limiting CCB - Verapamil

2nd line = BB with long acting dihydropyridines CCB e.g. Nifedipine as can’t give BB with rate limiting CCB.

3rd line = ivabradine monotherapy

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49
Q

Definition of heart failure?

A

Insufficient cardiac output to sufficiently supply the tissues of the body

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50
Q

How to classify heart failure by the symptoms?

A

New York heart association classification:

1 = no limitation of activity
2 = slight limitation of activity
3 = marked limitation of activity although comfortable at rest
4 = Inability to carry out physical activity without discomfort
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51
Q

What is frank starlings law?

A

Hesrts contractility and therefore SV is directly proportional to diastolic return

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52
Q

How does cardiac dysfunction precipitate change in the heart?

A

Any reduction in systolic function (loss of isotropy) / loss of diastolic function (poor ventricular compliance) = reduced CO

Reduced CO = neuroendocrine activation e.g. arterial vasoconstriction / increased blood volume = increased pre-load

Increased pre-load = ventricular wall stress = ventricular remodelling

These raised ventricular pressure = backlog

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53
Q

Causes of LVF?

A

Systolic dysfunction = myocardial damage e.g. IHD / cocaine / sarcoid
Dilated cardiomyopathy
Long standing HTN

Diastolic dysfunction =
Long standing HTN
Aortic stenosis
Restrictive cardiomyopathy

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54
Q

Causes of RVF?

A

LVF
ASD/VSD
Cor pulmonale
Pulmonary / tricuspid disease

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55
Q

Symptoms of LVF?

A

Exertional dyspnoea
Orthopnoea
Fatigue
Cough and wheeze secondary to pulmonary oedema

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56
Q

Signs of LVF?

A

Cold and cyanosed
Bibasal crackles
Gallup rhythm = S3. Causes by rapid ventricular filling.
Cardiomegaly and displaced apex

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57
Q

RVF symptoms?

A

Fatigue
Abdo discomfort
Nausea

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58
Q

Signs of RVF?

A 
Raised JVP
Hepato-splenomegaly
Pitting oedema
Ascites
Pleural effusion
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59
Q

Framingham diagnostic criteria for heart failure?

A

Need 2 major criteria or 1 major and 2 minor

MAJOR = HN-COWPAT:

Hepatojugular reflex
Neck vein distension
Cardiomegaly
Orthopnea / PND
Weight loss >4.5kg in 5 days
Pulmonary rales
Acute pulmonary oedema
Third heart sound
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60
Q

Investigations in heart failure?

A

Any one with symptoms = do a BNP <100 / NT-pro-BNP <300 rules out heart failure

If high perform a transthoracic echo (NICE recommend within 48 hours)

ECG

61
Q

CXR findings in heart failure?

A

ABCDE

Alveolar oedema
(Kerley) B lines
Cardiomegaly
Dilated upper lobe vessels
Effusion if RVF
62
Q

Management of heart failure ?

A

Treat any underlying cause
Conservative = stop smoking, diet, weight loss, annual influenza vaccine + ono off pneumococcal

Medical:
Statins and aspirin
Loop diuretic if congested
1st line for all patients = Captopril 10mg PO TDS (up to 50mg TDS)
Bisoprolol 1.25mg PO OD (up to 10mg) 
Spironolactone 25mg PO OD
63
Q

What are second line treatments for heart failure?

A

ARB
If you can tolerate an ACEI can try an ARNI = Angiotensin receptor neprilysin inhibitor = entresto (valsartan + sacubitril)

Surgical:
If refractory after 3 months of medical treatment
LVEF <35% and no LBBB = ICD
LVEF <35% and LBBB = CRT with biventricular pacemaker

64
Q

What medicines shouldn’t you use in heart failure?

A

CCB’s non-dihydropyridines

65
Q

What is the grades of HTN and numbers?

A 
normal < 120/80
Pre-HTN >120/80
Stage 1 >140/90
Stage 2 > 160/100
Severe > 180/110
66
Q

When do we treat HTN?

A 
If it is stage 1 we treat when the patient is less than 80 plus one of:
End organ damage
CVS / renal disease
DM
10 year CVS risk >20%

If stage 2 we treat after average home reading 150/95

67
Q

Investigations for HTN?

A

2 separate BP’s at GP
Ambulatory monitoring to confirm the diagnosis

Investigate for organ damage e.g. ECG, urinalysis, fundoscopy

68
Q

Causes of HTN?

A 
Diet e.g. salt, coffee
COCP or HRT
Kidneys = RAS, glomerulonephritis
Endocrine = Cushings, Conns, Phaeo
Preganancy
69
Q

Management of HTN?

A

Conservative = diet, relaxation therapy, smoking cessation.

Medical:

1st line <55 = ACEI/ARB
1st line >55 / black = CCB

2nd line = ACEI/ARB + CCB

3rd line = ACEI/ARB + CCB + Thiazide

4th line = specialist referral

A+C+D plus a further diuretic K-sparing

70
Q

Examples and doses of your anti-HTN drugs?

A

ACEI = Lisinopril 10mg PO OD

ARB = Candesartan 4mg PO OD

CCB = Amlodipine 2.5mg PO OD

Thiazide = hydrochlorothiazide 12.5mg PO OD

Spiro same dose

71
Q

What anti-HTN should you always use first line in diabetics?

A

ACEI

72
Q

Blood pressure targets for diabetics and normal?

A

Diabetics if end organ = 130/80
Without end organ = 140/80

Normal <80 years = <140/90

Normal >80 = <150/90

73
Q

Signs and management of severe/malignant HTN?

A

Papilloedema. 180/110, severe headaches, SOB

Admit
Controlled reduction over 2 days
1st line BB = labetalol 20mg IV every 10 minutes

74
Q

Causes of aortic stenosis?

A 
>65 = calcification
<65 = bicuspid valve

Can also get things like rheumatic fusion and LV hypertrophy

75
Q

Clinical features of aortic stenosis?

A

Triad = Angina, exertion dyspnoea and syncope

Ejection systolic murmur loudest at
RSE, 2nd ICS
Radiates to carotids
Slow rising pulse and narrow pulse pressure

76
Q

Investigations for suspected aortic stenosis?

A

TTE

ECG can see deep S in V1 and tall R in V6, due to LVH

77
Q

Aortic stenosis management?

A

Treat any co-morbidities

Asymptomatic;
Valve replacement if EF <50%, or aortic valve gradient >40mmHg
non-surgical = 6 monthly follow up

Symptomatic:
Low surgical risk = surgical replacement
High risk surgery = Transcatheter aortic valve replacement
- New valve mounted on stent and deployed via a catheter entering heart via femoral or apical incision
Long term anti-coagulation and IE prophylaxis

78
Q

In aortic stenosis valve replacement who gets prosthetic who gets metallic?

A

Young = mechanic + anticoagulation as last longer
- INR 3.0

Older = bioprosthetic

79
Q

What is aortic regurgitation?

A

Diastolic leakage of blood from the aorta into the left ventricle

80
Q

Common causes of aortic regurgitation?

A

Acutely = infective endocarditis

Chronic = Bicuspid aortic valve
Rheumatic disease

81
Q

Clinical features, signs and murmur of aortic regurgitation?

A

LVF, arrhythmias and angina

Collapsing pulse = Corrigans
De mussets = head bobbing
Quinckes = pulsating nail beds

Murmur = Early diastolic murmur at left sternal edge

82
Q

What is an Austin-flint murmur?

A

Severe aortic regurgitation gives you a mid-diastolic low pitched rumbling

83
Q

Management of aortic regurgitation?

A

Mild/moderate = treat underlying cause

Severe:

Asymptomatic with EF >50 = Nifedipine. 
Asymptomatic decompensated (EDD >70mm) = valve replacement / TAVR

Symptomatic = Valve replacement / TAVR

84
Q

Mitral regurgitation definition?

A

Retrograde flow of blood from the LV into the LA via the mitral valve during systole

85
Q

Causes of mitral regurgitation?

A

Acute = IE, post-MI papillary muscle rupture

chronic = Mitral valve prolapse, annular calcification

86
Q

clinical features of mitral regurgitation?

A

Angina, exertion dyspnoea
Pulmonary congestion = LHF

Displaced apex, quiet S1

high pitched blowing pan-systolic murmur.
Radiates to the axilla

87
Q

Management of mitral regurgitation ?

A

Acute = emergency surgery
Valvuloplasty or annuloplasty

Asymptomatic chronic:
EF >60 = ACEI and BB
EF <60, or LV-ESD >45mm = Surgery

Symptomatic chronic = surgery and medical

88
Q

Mitral stenosis causes?

A

Rheumatic fever

89
Q

Mitral stenosis features?

A

Left sided failure signs

Middle aged female
Malar flush 
AF
Tapping, non-displaced apex
Right ventricular heave
90
Q

What murmur is mitral stenosis?

A

mid-diastolic murmur with opening snap

91
Q

What is Barlow syndrome?

A

mitral valve prolapse into the LA during systole

92
Q

What is the management of mitral stenosis?

A

If severe symptomatic = surgery

93
Q

Causes of Barlow syndrome? Clinical features?

A

MI, connective tissue disease e.g. Marfans

Slim young female, mid-late systolic clicks
Late systolic murmur

94
Q

Tricuspid regurgitation causes?

A

Primary defects are rare e.g. Ebsteins anomaly

Secondary = RVF, IE, rheumatic disease

95
Q

Clinical features of tricuspid regurgitation? (same for T stenosis)

A

RHF signs
Of advanced = hepatomegaly
Fluid retention with peripheral oedema

Pan-systolic murmur lodest at LLSE

96
Q

Management?

A

LFT’s to check for any liver disease

Treat underlying cause
Tricuspid replacement or annuloplasty

97
Q

What is ebsteins anomaly?

A

Downward displacement of the tricuspid valve

98
Q

Causes of tricuspid stenosis?

A

Late complication of rheumatic disease

99
Q

Pulmonary stenosis murmur?

A

Systolic ejection, loudest at left USE

100
Q

Causes of plumonary stenosis?

A

Majority are congenital = Turners, Noonans, ToF and Williams

101
Q

What is infective endocarditis?

A

Colonisation / invasion of the heart valves. Causes platelets and thrombin to adhere causing prothrombotic milieu

102
Q

Which side valves are affected most in IE?

Organisms?

A

Left sided in 95%

S. Viridians = Affects abnormal valves, most prevalent

S. Aureus = IVDU, classically right sided, although still left side affected more

S. Epidermidis in prosthetic valves

103
Q

Clinical features of IE?

A

Triad = persistent fever, emboli and changing/new murmur

Abdo = splenomegaly, microscopic haematuria

Cardiac = new murmur

Hands = Janeways and oslo’s
Splinter haemorrhages
Petichiae
Clubbing

104
Q

DUKES criteria?

A

need two major, 1 major + 3 minor, or 5 minor:

Major:
+ve blood culture (typical MO, two separate cultures)
Evidence of cardiac involvement = new murmur OR +ve echo signs

Minor:
Predisposing heart condition / IVDU
Fever >38
Vascular phenomenon e.g. laneway lesions
Immunological phenomenon e.g. haematuria
MO +ve but not meeting major
Echo consistent with IE but not major
105
Q

IE investigations?

A 
3 cultures 12 hours apart
FBC = anaemic
ESR and cRP raised
Urinalysis
ECHO
106
Q

Management of IE?

A

Initial = broad spectrum antibiotics:
Native valve = amoxicillin + gentamicin
Prosthetic = Vancomycin + gentamicin + rifampicin

Staph = Native flucloxacillin 4 weeks,
prosthetic = Flucloxacillin + Gentamicin + rifampicin 6 weeks

Strep = BenPen 6 weeks

107
Q

What is rheumatic fever?

A

Immunological response to GAS (pyogenes)

108
Q

Jones criteria for rheumatic fever?

A

Evidence of GAS + 2 major / 1 major and 2 minor

Evidence of GAS = +ve throat culture or +ve rapid antigen test

Major = PACES
Pancarditis
Arthritis
Chorea
Erythema marginatum
Subcut nodules
Minor
Fever
ESR raised
Polyarthralgia
Prolonged PR on ECG
109
Q

Investigations for rheumatic fever?

A

Bloods = ESR and CRP, cultures, GAS antigen test

ECG

Echo

110
Q

Management of rheumatic fever?

A

Confirmed = Amoxicillin 875mg PO BD for 10 days

111
Q

Complications / prognosis of rheumatic fever?

A

Attack will last about 3 months

50% get chronic rheumatic fever

Typically affecting mitral valve, generally do a repair over replacement as younger patients

112
Q

What is acute pericarditis and its features?

A

Inflammation of the pericardium. <4-6 weeks

Chest pain sharp and well localised, relieved by leaning forward
Worse lying flat

Fever

Pericardial rub

113
Q

Causes of acute pericarditis?

A 
Viral e.g. Coxsackie B
Systemic e.g. SLE
Bacterial e.g. S. Aureus
TB
Post-MI = Dresslers
114
Q

Investigations and management of pericarditis?

A

ECG = saddle shaped ST segement, with PR depression

Echo shows effusion

Management:
Treat any underlying disorder
Pericardiocentesis under ECG and echo monitoring

If purulent = Vancomycin and gentamicin

115
Q

What is constrictive pericarditis?

A

Pericarditis that impedes normal diastolic filling. Can be a complication of acute pericarditis, or complete drainage previously

116
Q

Clinical picture of constrictive pericarditis?

Management?

A

Congestiv heart failure = Left and right sided signs
Kussmauls breathing = raised JVP on inspiration

CXR = small heart and pericardial calcification

Echo = thickened pericardium

Management = pericardial excision

117
Q

What is a pericardial effusion?

A

Accumulation of fluid in pericardial sac. Can result from any condition that causes pericarditis

118
Q

Clinical features of pericardial effusion/

A

CHF

Tamponade

119
Q

What is tamponade?

A

When accumulation of pericardial fluid cause a rise in the intra-pericardial pressure = poor ventricular filling and low CO

Becks triad = Falling BP, rising JVP and muffled heart sounds
Pulsus paradoxus

120
Q

Management of pericardia effusion?

A

Pericardiocentesis

121
Q

Management of tamponade?

A

Emergency
20ml syringe and 18G cannula
45-degree angle just left of xiphisternum aiming for the tip of left scapula
Aspirate and continuously watch ECG

122
Q

What’s myocarditis and its causes?

A

Group od disorders characterised by myocardial inflammation in the absence of ischaemia

Causes = Viral e.g. influenza, coxsackie

Protozoa e.g. Chagas disease (most common cause of heart failure worldwide

Systemic = SLE

123
Q

Clinical features of myocarditis?

A

Prodromal flu 2-3 weeks prior
Chest pain
Dyspnoea, orthopnoea, fatigue

124
Q

Myocarditis investigations and management?

A 
Bloods = mildly elevated trop
ECG = non-specific ST changes
CXR = bilateral pulmonary infiltrates due to CHF

management = supportive
Steroids if Autoimmune
Benznidazole if Chagas

125
Q

What is hypertrophic obstructive cardiomyopathy?

A

Genetic disorder characterised by asymmetrical LVH with no identifiable cause

Mutation in the B-myosin heavy chain

126
Q

Clinical features of HOCM?

A 
FHx of sudden cardiac death,
Young male
Syncope on exertion and angina
Systolic ejection murmur due to outflow obstruction = MR
Accentuated by standing / exercise
Lessened by lying supine / squatting
127
Q

Investigations for HOCM?

A 
ECG = LVH, deep q-waves and progressive t-wave inversion
ECHO = MR, asymmetrical septal hypertrophy

CXR = cardiomegaly

128
Q

HOCM management?

A

Restrain from high intensity sport!!!

Symptomatic = BB, low anticoagulation threshold
Amiodarone if arrhythmias

Genetic counselling

129
Q

What is a cardiac myxoma?

A

Rare benign cardiac tumour, 90% in the left atrium attached to the septum

130
Q

Clinical features of cardiac myxoma?

Management?

A

Mitral valve obstruction = left sided heart failure

Mid diastolic murmur of mitral stenosis

Atriotomy = may need valvular repair or CABG

131
Q

What is a cardiomyopathy?

A

Disease of myocardium associated with mechanical or electrical dysfunction that exhibits ventricular hypertrophy or dilation

132
Q

Causes of dilated cardiomyopathy?

A

C-DILATE:

Cardiac = IHD, rheumatic, HTN

Dystrophy e.g. Duchennes

Infection = Myocarditis e.g. Coxsackie

Late pregnancy

Autoimmune e.g. SLE

Toxins e.g. alcohol or doxorubicin

Endocrine = thyrotoxicosis

133
Q

Features and investigations of dilated cardiomyopathy.

Management?

A

Features = LVF and RVF, arrhythmias

Investigations:
CXR = cardiomegaly, pulmonary oedema
Echo = globally dilated, reduced EF

Management = No alcohol, and treat as for heart failure e.g. BB, ACEI and diuretic

134
Q

Restrictive cardiomyopathy causes?

A

IIEE

Idiopathic e.g post radiotherapy

Infiltrations e.g. amyloidosis

Eosinophilic endomyocardial disease

Endomyocardial fibrosis

135
Q

Clinical features, investigations and management of restrictive cardiomyopathy?

A

Congestive heart failure + kussmauls

CXR = cardiomegaly and pulmonary oedema
Echo = increased LV wall thickness, systolic function normal

Management = treat the cause

136
Q

what is Marfans?

A

Autosomal dominant disorder characterised by loss of elastic tissue due to mutation in fibrillar 1 gene

137
Q

Clinical features of marfans

A 
Tall
High arched palate
Arachnodactyly
Pectus excavtaum
Scoliosis
Hypermobile

Cardiac = Aortic aneurysms / dissections.
Aortic root dilation = aortic regurgitation
Mitral valve prolapse

eyes = lens dislocation, glaucoma, retinal detachment

138
Q

Investigations of Marfans?

A

Echo = root dilation / dissection = AR or MR

Slit lamp

CXR = pneumothorax

blood screening

139
Q

Management of Marfans?

A

Referral to cardio and ophthalmology

Medical = BB’s, ACEI’s

Aortic root dilation > 5cm = elective surgery with a modified Davids re-implantation with replacement of the root sparing the aortic valve.

Scoliosis = orthopaedic bracing

Retinal tears = laser photocoagulation

140
Q

What is Ehlers Danlos?

A

Genetic disorder affecting connective tissue, particularly collagen. 6 types

141
Q

Clinical features of Ehlers Danlos?

A

Often asymptomatic
Recurrent joint dislocation / subluxation
Skin = silky, semi-transparent, elastic and bruises easily

Cardiac = mitral valve prolapse

142
Q

Investigations of Ehlers Danlos?

A

Clinical diagnosis, can use genetic testing

143
Q

Management of Ehlers Danlos?

A

Asymptomatic = conservative. Avoid contact sport

Pain management and watch out for depression
Physio / OT

144
Q

What is aortic dissection?

A

Medical emergency resulting from tear in aortic wall intimate, causing blood flow and false lumen composed of inner and outer layers of lumen

145
Q

Aortic dissection causes?

A

Inherited e.g. ED or marfans
HTN
Bicuspid aortic valve
Turners / noonans

146
Q

Clinical features of aortic dissection

A

Severe chest pain, classically radiates through to the back
Tearing in nature
Aortic regurgitation
HTN

147
Q

Stanford classification of aortic dissection?

A

A = ascending aorta (66% of cases)

B = Descending aorta distal to left subclavian

148
Q

Aortic dissection management?

A

A = surgical management =open surgery

B = bed rest and IV labetalol

Finals Bible: Medicine (6 decks)

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