Cardiology Flashcards
what Leads represent the anterior surface of the heart?
V2-V6
what leads represent the posterior surface of the heart?
V1-V3
but reciprocal
what Leads represent the inferior surface of the heart?
II, III, aVF
what leads represent the anterolateral surface of the heart?
I, aVL, V5+ V6
what leads represent the anteroseptal surface of the heart?
V2-V4
what vessel supplies the inferior aspect of the heart?
Right Coronary Artery
what vessel supplies the anterior aspect of the heart?
Left main stem
which splits into LAD + Left Cx
what vessel supplies the posterior aspect of the heart?
right coronary artery
what vessel supplies the anterolateral aspect of the heart?
Left circumflex
what vessel supplies the anteroseptal aspect of the heart? (V2-V4)
Left anterior descending
ECG showing PR interval > 200ms (0.20 s)
what diagnosis?
first degree heart block
ECG shows progressive lengthening of the PR interval
diagnosis?
2nd degree heart block
mobitz type I
wenckebach
ECG shows complete dissociation of P waves and QRS complexes
3rd degree heart block
ECG shows two p waves per QRS complex
w normal consistent PR intervals
2nd degree heart block
(2:1 block)
ECG shows constant PR interval, wide QRS complexes, occasional non-conducted p waves
2nd degree heart block
mobitz type II
(block usually in bundle branches of Purkinje fibres)
Right BBB
features on ECG?
MarroW
Rabbit ears in V1, W in V6
Wide QRS complexes
Causes of RBBB?
Infarct - Inferior MI
Normal Variant
Congenital - ASD, VSD, Fallot’s
Hypertrophy - RVH (PE, Cor Pulmonale)
Left BBB
features on ECG?
WilliaM
W in V1, rabbit ears in V6
wide QRS
T wave inversion in lateral leads
Causes of LBBB?
Fibrosis
LVH - AS, HTN
Infarct - Inf MI
Coronary Heart Disease
Bifasicular Block
involves?
RBBB + LAFB
Trifascicular Block
involves?
RBBB +
LAFB (left anterior fascicular block)
+ 1st degree heart block
What is Beck’s triad?
Hypotension
Raised JVP
muffled heart sounds
Complication of MI due to left ventricular free wall rupture?
Cardiac tamponade
Signs of Cardiac Tamponade
Becks Triad:
low BP, raised JVP, muffled heart sounds
Pulsus paradoxus
What is pulsus paradoxus?
An abnormally large decrease in stroke volume and Systolic Blood pressure and pulse wave amplitude during inspiration.
fall in > 10mmHg
Complication of MI
-> Papillary muscle rupture
what signs?
Pan systolic murmur
due to mitral regurgitation
What is the mx of STEMI?
after confirmation by 12 lead ECG
- O2 2-4L aim for SpO2 94-98%
- IV access
Bloods for FBC, U+E, glucose, lipids, Troponin
- Aspirin 300mg and Clopidogrel 300mg
- Morphine 5-10mg IV and Metoclopramide 10mg IV
- GTN spray 2 puffs + BB atenolol
- LMWH enoxaparin
- Monitor with cardiac monitoring + regular obs
- Primary PCI or thrombolysis
what is stable angina?
chest pain induced by effort
what is unstable angina?
chest pain that occurs at rest/ on minimal exertion
what is angina decubitus?
chest pain induced by lying down
what is Syndrome X?
angina pain + ST elevation on exercise test
but no evidence of coronary atherosclerosis
probably microvascular disease
what is Prinzmetal’s angina?
chest pain at rest
due to coronary spasm
ST elevation during attack: resolves as pain subsides
Angina
management for secondary prevention of cardiovascular events?
Aspirin 75mg
ACEi
Statins: simvastatin 40mg
Antihypertensives
anti anginals tx?
GTN spray
+ BB Atenolol (or CCB Verapamil)
signs of RVF
raised JVP
tender smooth hepatomegaly
pitting oedema
ascites
signs of LVF
cold peripheries +/- cyanosis
often in AF
cardiomegaly w displaced apex
S3 + tachycardia = gallop rhythm
wheeze
bibasal creps
CXR signs of HF
ABCDE
Alveolar shadowing
Kerley B lines
Cardiomegaly
Upper lobe Diversion
Effusions
Fluid in the fissures
what is the normal ejection fraction?
60%
key investigation of heart failure?
Echo
what is a biomarker of HF?
BNP
(>100)
what mx have shown to reduce mortality in chronic HF?
ACEi + BB + Spironolactone
Mx of chronic HF
1st line
ACEi
e.g. lisinopril or candesartan
+
BB
e.g. carvedilol or bisoprolol
+
Loop Diuretic
e.g. furosemide or bumetanide
Mx of Chronic HF
2nd line
seek specialist advice
spironolactone
ACEi + ARB
Vasodilators: hydralazine + ISDN (isosorbide dinitrate)
Symptoms of Pulmonary Oedema
SOB
Orthopnoea and PND
Pink frothy Sputum
Cardioresp signs of pulmonary oedema
raised JVP
Gallop rhythm/ S3
Bibasal creps
Wheeze
Causes of supraventricular tachycardias?
Sinus tachycardia: may be physiological, e.g. response to illness
Atrial tachyarrhythmias: AF (irregular rhythm), atrial flutter,
Junctional tachycardias: AVRT (e.g. WPW), AVNRT
what electrolyte abnormalities cause prolonged QT interval?
low Mg, K, Ca
atrial tachycardia
abnormally shaped P waves
normal QRS complexes
rate > 150
may be assoc w AV block
causes of broad complex tachycardias?
VT
Torsades de pointes
VF
SVT with BBB or SVT with WPW
Is it a VT or SVT with BBB?
VT more likely if:
hx of recent infarction
AV dissociation
broad QRS complexes (> 140ms)
Concordant QRS direction in V1-V6
Fusion and capture beats
Peaked P wave on ECG?
P Pulmonale
Causes: generally due to Right atrial hypertrophy from tricuspid stenosis/ pulmonary HTN
a broad bifid P wave on ECG?
P mitrale
due to Left atrial hypertrophy e.g. Mitral stenosis
How to diagnose RVH on ECG?
Tall R wave in V1 ( > 7mm)
Deep S wave in V6 (>7 mm)
Right Axis deviation
may be T wave inversion in V1-V3
cause: cor pulmonale
How to diagnose LVH on ECG?
deep S wave in V1 + Tall R wave in V6
( S + R > 35mm)
may have left axis deviation
rhythm regular, rate N, p wave N
PR short
QRS: usually wide
Delta wave: slurred upstroke of QRS
can establish reentrant circuit -> SVT
irregularly irregular broad QRS complexes
-> AF + WPW
ST segment elevation > 2mm in >1 of V1-V3
followed by negative T wave
brugada syndrome
pseudo RBBB
features of HyperK on ECG?
tall tented T waves
widened QRS complexes
Absent P waves
Sine wave appearance
Features of HypoK on ECG?
Small T waves
ST depression
Prolonged QT interval
Prominent U waves
Digoxin toxicity
Reverse tick sign: down sloping ST depression
Also: flattened, inverted or biphasic T waves, shortened QT interval
Causes Of Bradycardia?
Drugs: Amiodarone, BB, CCB (verapamil), Digoxin
Ischaemia/ Infarction: Inf MI (SA node affected)
Vagal hypertonia: Carotid sinus syndrome, athletes
Infection
Sick sinus syndrome: structural damage or fibrosis of SAN, AVN or conducting tissue
Amyloid/ Sarcoid/ Haemochromatosis, Muscular dystrophy
Hypothyroid/ HypoK/ Hypothermia
Raised ICP
Types of bradycardias?
sinus bradycardia
First degree heart block: PR > 200 ms
Second Degree Heart Block: Mobitz I and II
Complete Heart Block:
Junctional- narrow QRS @ 50 bpm
Ventricular- broad QRS @ 40bpm
tx of bradycardia?
if asymptomatic and rate> 40, no tx needed
If symptomatic/ rate <40:
- tx underlying cause e.g. drugs, MI
- Medical: atropine 500 mcg (max 3mg) IV
or isoprenaline 5 mcg/min IVI
or transcutaneous pacing
- External pacing
what is sick sinus syndrome?
structural damage or fibrosis of SAN, AVN or conducting tissue
PC: SVT alternating w sinus bradycardia +/- arrest or SA/ AV block
Mx of bradyarrhythmias: Pacing
Tachyarrhythmias: Amiodarone
what do vagal manouevres accomplish in mx of SVT?
transiently increases AV block and may unmask underlying atrial rhythm
Adenosine MOA in mx of SVT?
- > transient AV block, unmasking atrial rhythm
- > cardioverts junctional tachycardias (AVRT/AVNRT) to sinus rhythm
AF mx?
- rate control w BB (metoprolol) or digoxin
- if onset <48h consider cardioversion w amiodarone or DC shock
- consider anticoagulation w LMWH +/- warfarin
if sinus tachycardia requires tx?
(ie not a physiological response to fever/ hypovolaemia)
B- blocker rate control
What should be remembered about giving adenosine?
Adenosine 6mg IV bolus into a large vein
- followed by 0.9% saline flush
while recording rhythm strip
if unsuccessful, after 2 min give 12mg, then one further 12mg bolus
warn about SEs! -transient chest tightness, dyspnoea, headache, flushing
what are relative contraindications of adenosine?
asthma
2nd/ 3rd degree heart block
or sinoatrial disease
drug interactions of adenosine?
potentiated by dipyridamole
antagonized by theophylline
if adenosine fails in SVT mx, what next?
Use verapamil 5mg IV over 2-3 min (NOT if on BB)
alternatives: amiodarone, atenolol
if unsuccesful -> DC cardioversion
if Junctional tachycardias are not cardioverted to sinus rhythm with adenosine?
Try BBs
if medications are insufficient -> try radiofrequency ablation
Risk of SVT w WPW?
degeneration to VF and sudden death
Tx of WPW?
flecainide, propafenone, sotalol or amiodarone
refer to cardiologist for electrophysiology and ablation of the accessory pathway
what dose to administer amiodarone?
amiodarone 300 mg IVI over 20-60 min
then 900mg over 24h
First thing to ask if pt has broad complex tachy?
pulse present?
if no -> CPR
if yes -> gain IV access, ECG and give O2
Mx of broad complex tachycardia?
pulse present
no adverse features
correct electrolyte abnormalities esp low K+ and low Mg2+
Then assess rhythm:
if regular: treat as VT
amiodarone 300mg IV over 20 or more mins via central line
if known hx of SVT w BBB: consider adenosine
if irregular:
Torsades de pointes: MgSO4 2g IV over 10 min
pre-excited AF: consider amiodarone
Prevention of recurrent VT?
may need antiarrhythmic tx: sotalol (if good LV function) or amiodarone (if poor LV function)
Surgical isolation of arrhythmogenic area or an ICD
pathophysiology of AF?
Focal atrial activity usually originates in roots of pulmonary veins, overwhelming normal impulses generated by SA node in RA
-> recurrent, uncoordinated contraction @ 300-600 bpm
AVN responds intermittently -> irregular ventricular rate
atrial contraction responsible for ~25% of CO -> heart failure
causes of AF:
cardiac: HTN, ischaemic heart disease, valvular heart problems
endocrine: hyperthyroidism, excess alcohol
resp: PE
symptoms of AF?
asymptomatic or
palpitations, dyspnoea, anginal chest pain, presyncope (faintness)
signs of AF?
irregularly irregular pulse
or fast AF-> loss of diastolic filling -> no palpable pulse
Signs of LVF
Mx of Acute AF (onset < 48h)?
if heamodynamically unstable -> emergency cardioversion
Electrical Cardioversion or pharmacological (IV Amiodarone)
2nd line IV flecainide (if no structural heart disease)
Anticoagulate with LMWH
Mx of acute AF (<48h onset) with stable patient?
Control ventricular rate: BB (bisoprolol) OR rate limitning CCB (e.g. verapamil)
Anticoagulate with LMWH
Cardioversion: DC shock or medical amiodarone
what is paroxysmal AF?
spontaneous termination within <7d (most often within 48h)
recurring and may degenerate into sustained AF
Mx of paroxysmal AF?
Rhythm: “pill in pocket”: flecainide or sotalol PRN
Prevention: BB, sotalol or amiodarone
Anticoagulate: Use CHA2DS2-VAS score
what is persistent AF?
> 7d, not self terminating, may recur after cardioversion
Mx of persistent AF?
Rhythm Control: elective cardioversion
1st line rhythm control if symptomatic of CCF, <65, presenting first time w lone AF, secondary to treated precipitant
Beforehand: anticoagulate w warfarin for > 3 wks or use TOE to exclude mural thrombus
Pre-treatment >4 wks w sotalol or amiodarone if increased risk of failure
Rate: monotherapy BB (bisoprolol, metoprolol) or rate limiting CCB 1st line
Anticoagulation: use CHA2D2VAS score
What is permanent AF?
long stnading > 1yr, not succesfully terminated by cardioversion/ unlikely to succeed
Mx of permanent AF?
Rate control: BB or digoxin
Anticoagulate: use CHADVAS score
Rhythm control: Radiofrequency ablation of AV node +/- Pacing, Maze procedure,
What is CHADVAS score?
determines neccessity of anticoagulation in AF
what is the CHADSVAS score made of
Congestive Cardiac Failure
HTN
Age ≥ 75 (2 points)
DM
Stroke or TIA (2 points)
VAS
Vascular disease
Age 65-74
Sex: female
What CHADSVAS scores mean what?
0: dont need anticoagulation
if 1: male -> anticoagulate
≥ 2: Warfarin (INR 2-3)
what is the HASBLED score for?
determines bleeding risk in those starting or on anticoagulation
HTN
Abnormal Kidney or liver function (1 each)
Stroke
Bleeding tendency
Labile INR
Elderly
Drug (NSAIDs + alcohol): 1 each
what HASBLED score means what?
≥ 3 = high risk
AVOID oral anticoagulation
Modifiable risk factors of Acute coronary syndromes?
HTN
DM
Smoking
High cholesterol
Obesity
non modifiable risk factors of acute coronary syndrome?
age
male
FH (MI< 55 yrs)
what ECG findings show a STEMI?
ST elevation
Q waves: full thickness infarct
T wave inversion
or
New onset LBBB also -> STEMI
ECG findings of NSTEMI?
ST depression
T wave inversion
ECG findings of Pericarditis?
saddle shaped ST elevation
+/- PR depression
mx of pericarditis?
NSAIDs: ibuprofen
Echo to exclude effusion
ECG findings of ventricular aneurysm?
persistent ST elevation
Mx of ventricular aneurysm?
anticoagulation
consider surgical excision
Ix of angina?
Bloods: FBC, U+E, lipids, glucose, ESR, TFTs
ECG: usually normal
May show ST ↓, flat/inverted T waves, past MI
Consider exercise ECG
Stress echo
Perfusion scan
CT coronary Ca2+ score
Angiography (gold standard)
mx of atrial flutter?
is similar to that of atrial fibrillation although medication may be less effective
atrial flutter is more sensitive to cardioversion however so lower energy levels may be used
radiofrequency ablation of the tricuspid valve isthmus is curative for most patients
inheritance of Marfans?
AD
Spontaneous mutation in 25%
what is the most sensitive ecg marker for pericarditis?
PR depression: most specific ECG marker for pericarditis
presentation of Marfans?
Cardiac
- Aortic aneurysm and dissection
- Aortic root dilatation → regurgitation
- MV prolapse ± regurgitation
Ocular
Lens dislocation: superotemporal
MSK
High-arched palate
Arachnodactyly
Arm-span > height
Pectus excavatum
Scoliosis
Pes planus
Joint hypermobility
complications assoc w Marfans?
Ruptured aortic aneurysm
Spontaneous pneumothorax
Diaphragmatic hernia
Hernias
Mx of Marfans?
Refer to ortho, cardio and ophthal
Life-style alteration: ↓ cardiointensive sports
Beta-blockers slow dilatation of the aortic root
Regular cardiac echo
Surgery when aortic root ≥5cm wide
pathogenesis of Ehlers-Danlos?
Rare heterogeneous group of collagen disorders. 6 subtypes w varying severity Commonest types (1 and 2) are autosomal dominant
presentation of ehlers danlos syndrome?
Hyperelastic skin
Hypermobile joints
Cardiac: MVP , AR, MR and aneurysms
Fragile blood vessels → easy bruising, GI bleeds
Poor healing
bicuspid aortic valve assoc w?
aortic stenosis +/- regurgitation
pre disposes to IE/ subacute endocarditis
Pathology of Tetralogy of Fallot?
VSD
Pulmonary stenosis
RV Hypertrophy
Overriding aorta
Tetralogy of Fallot associated with which congenital syndrome?
Di George’s Syndrome
CATCH 22
Ix of Tetralogy of Fallot?
ECG: RVH + RBBB
CXR
Echo: anatomy + degree of stenosis
presentation of tetralogy of fallot in adults?
often asymptomatic
unoperated: cyanosis, ESM of Pulm Stenosis
Repaired: Dyspnoea, palpitations, RVF
mx of tetralogy of fallot?
surgical closure of VSD + correction of the pulmonary stenosis
usually before 1 yo
causes of VSD?
congenital
acquired: post MI
Signs of VSD?
Smaller holes -> louder murmurs
harsh PSM @ LLSE
Systolic thrill
Left parasternal heave
larger holes -> Pulmonary HTN
complications of VSD?
infective endocarditis
Pulmonary HTN
Eisenmengers
Ix of VSD?
ECG: if small- normal.
if large: LVH + RVH
CXR: small- mild pulmonary plethora
large - cardiomegaly + marked pulmonary plethora
Echo to visualise
Mx of VSD?
surgical closure indicated
what is coarctation of the aorta?
Congenital narrowing of the aorta
Usually occurs just distal to origin of left subclavian
M>F
signs of coarctation of the aorta?
radio-femoral delay / radial radial delay
weak femoral pulse
HTN
systolic murmur/ bruit heard best over left scapula
complications of coarctation of aorta?
heart failure
IE
Ix of coarctation of aorta?
CXR: rib notching
ECG: LV strain
CT angiogram
mx of coarctation of aorta?
balloon dilatation + stenting
Complications of Atrial septal defect?
Paradoxical emboli
Eisenmengers syndrome:
increased RA pressure -> cyanotic R to L shunt
mx of atrial septal defect?
transcatheter closure
recommended in adults if high pulmonary to systemic blood flow ratio (≥1.5:1)
signs of atrial septal defect?
AF
raised JVP
pulmonary ESM
Pulm HTN -> Tricuspid regurg or Pulm Regurg
Causes of Dilated Cardiomyopathy?
- Dystrophy: muscular, myotonic
- Infection: complication of myocarditis
- Late pregnancy: peri-partum
- Autoimmune: SLE
- Toxins: alcohol, cyclophosphamide, radiotherapy
- Endocrine: thyrotoxicosis
presentation of dilated cardiomyopathy?
right HF and L HF
Arrhythmias
Signs of Dilated cardiomyopathy
Displaced apex beat
S3 gallop
raised JVP
low BP
MR/ TR
Ix of dilated cardiomyopathy?
CXR: cardiomegaly, pulmonary oedema
ECG: T inversion, poor progression
Echo: globally dilated, hypokinetic heart + decreased ejection fraction
Catheter + biopsy: myocardial fibre disarray
Mx of dilated cardiomyopathy?
Bed rest
medical: Diuretics, ACEi, Digoxin, anticoagulation
Non medical: Biventricular pacing, ICD
Surgical: heart transplant
What is an Atrial myxoma?
rare, benign cardiac tumour
may be familial
e.g. Carney Complex: cardiac and cutaneous myxoma, skin pigmentation, endocrinopathy (e.g. Cushings)
90% in L atrium, most commonly attached to fossa ovalis of the interatrial septum
features of cardiac myxoma?
Clubbing, fever, weight loss, Raised ESR
Signs similar to Mitral stenosis (Mid diastolic murmur, systemic emboli, AF)
which varies w posture
symptoms typically due to effect of tumour obstructing normal flow of blood (SOBOE, paroxysmal nocturnal dyspnoea, syncope)
diagnosis of cardiac myxoma?
echo
tx of cardiac myxoma?
excision
Causes of restrictive cardiomyopathy?
Sarcoid
Systemic sclerosis
Haemochromatosis
Amyloidosis
Primary: endomyocardial fibrosis
Eosinophilia (Loffler’s eosinophilic endocarditis)
Neoplasia: carcinoid (-> TR and PS)
Pathophysiology of HOCM?
LV outflow obstruction from asymmetrical septal hypertrophy
Familial form AD inheritance
B-myosin heavy chain mutation commonest
symptoms of HOCM?
Angina
SOB
Palpitations: AF, WPW, VT
exertional syncope or sudden death
signs of HOCM?
jerky pulse
double apex beat
harsh ESM @ LLSE w systolic thrill
S4
ix of HOCM
ECG: LVH/L axial deviation, ventricular ectopics/ VT
echo
exercise test +/- holter monitor to quantify risk
Mx of HOCM?
Medical:
- ve inotropes: BB (2nd verapamil)
amiodarone: arrhythmias
anticoagulate if AF or emboli
if severe symptoms: septal myomectomy
consider ICD
causes of acute myocarditis?
Idiopathic (50%)
viral: coxsackie B, flu, HIV
Bacterial: S aureus, syphilis
Drugs: Cyclophosphamide
Autoimmune: giant cell myocarditis assoc w SLE
Ix of acute myocarditis?
Bloods: +ve troponin, raised CK
ECG: ST elevation or depression
T wave inversion
transient AV block
Mx of acute myocarditis?
supportive
tx cause
Causes of Cardiac Tamponade?
Accumulation of pericardial fluid -> increased intra pericardial pressure -> poor ventricular filling -> decreased Cardiac output
Any cause of pericarditis
Aortic dissection
Warfarin
Trauma
Signs of cardiac tamponade?
Becks triad: Raised JVP, hypotension, muffled heart sounds
Pulsus paradoxus: pulse fades on inspiration
Ix of cardiac tamponade?
ECG: low voltage QRS +/- electrical alternans
CXR: large globular heart
Echo: diagnostic, echo- free zone around heart
Mx of cardiac tamponade?
urgent pericardiocentesis
- 20 ml syringe + long 18G cannula
- generally done under ultrasound guidance
- subxiphoid appraoch: under the xiphoid process, up and leftwards
- parasternal approach: between 5th and 6th ICS at L sternal border
- aspirate continuously and watch ECG
tx cause
send fluid for cytology, ZN stain and culture
Causes of Pericardial Effusion?
Acute pericarditis
infection: viral, bacterial, fungal
MI
Dresslers
Ix of pericardial effusion?
CXR: enlarged globular heart
ECG: low voltage QRS complexes, Alternating QRS amplitude (electrical alternans)
Echo: echo free zone around heart
Clinical features of pericardial effusion?
Dyspnoea
raised JVP (prominent X descent)
Bronchial breathing @ L base
- Ewart’s sign: large effusion compresion LLL
Signs of cardiac tamp present
Mx of pericardial effusion?
tx cause
pericardiocentesis may be diagnostic or therapeutic: culture, ZN stain, cytology
Clinical features of constrictive pericarditis?
Heart encased in a rigid pericardium
RHF w raised JVP
Kussmaul’s sign: raised JVP w inspiration
Quiet HS
S3
Hepatomegaly, ascites, oedema
Ix of Constrictive pericarditis?
CXR: small heart + pericardial calcification
Echo
Cardiac Catheterisation
Mx of constrictive pericarditis?
surgical excision
clinical features of acute pericarditis?
central chest pain: sharp, worse lying down, relieved by sitting forward, radiates to L shoulder, pleuritic
pericardial friction rub
Fever
Signs of effusion/ tamponade
ix of acute pericarditis?
Bloods: FBC, ESR, Trop (may be raised), cultures, virology
ECG: saddle shaped ST elevation +/- PR depression
causes of acute pericarditis?
Viral: coxsackie, flu, EBV, HIV
bacterial: rheumatic fever, pneumonia, TB
Fungal
Post MI, Dressler’s syndrome
Drugs: penicillin, isoniazid, procainamide, hydralazine
Other: uraemia, RA, SLE, Sarcoid, radiotx
Organism responsible for rheumatic fever?
Group A beta-haemolytic strep
e.g. strep pyogenes
epidemiology of rheumatic fever?
5-15 yrs
rare in West
v common in developing world
pathophysiology of rheumatic fever?
Antibody cross reactivity following S pyogenes infection -> Molecular mimicry
abs vs myocardium ie. myosin, muscle glycogen and Smooth muscle cells
Pathology: Aschoff bodies and Anitschkow myocytes
Revised Jones criteria for rheumatic fever
for diagnosis?
Evidence of Group A strep infection
+
2 major criteria
or
1 major + 2 minor
Revised Jones criteria
- what is considered evidence for group a strep infection?
Positive ASOT titre or DNase B titre
+ve throat culture
Rapid Strep Ag test
Recent scarlet fever
What are the major criteria for the Revised Jones criteria for diagnosis of rheumatic fever?
need 2 major
or 1 major + 2 minor
PACES
Pancarditis
Arthritis
subCutaneous nodules
Erythema marginatum
Sydenham’s chorea
What are the minor criteria for the revised Jones criteria for diagnosis of Rheumatic fever?
need 2 minor criteria if only 1 major present
Arthralgia (not if arthritis is major)
Fever
Raised ESR or CRP
prolonged PR interval (not if carditis is cause)
prev rheumatic fever
Features of Rheumatic Fever?
Pancarditis:
pericarditis, myocarditis, endocarditis (MR, AR)
Arthritis: migratory polyarthritis of large joints
Subcut nodules: small mobile, painless nodules on extensor surfaces esp elbows
Erythema marginatum
Sydenhams chorea: due to damage of basal ganglia
Ix of rheumatic fever?
ASOT titre
Strep antigen test
FBC, ESR/ CRP
Echo
ECG
Mx of rheumatic fever?
bed rest until CRP normal for 2 weeks
Benpen: 0.6- 1.2 mg IM for 10 days
Analgesia: aspirin / NSAIDs
Add oral prednisolone if CCF, cardiomegaly, 3rd degree HB
Chorea: haloperidol
Secondary prophylaxis against Rheumatic fever?
indicated in those with carditis for 10 yrs after last attack or 25 yrs of age (whichever is longer)
severe valvular disease/ surgery: lifelong
Without proven carditis: for 5 yrs after last attack/ 18 yrs of age
Pen V PO
prognosis of valves in rheumatic fever?
regurgitation -> stenosis
Mitral (70%)
Atrial (40%)
Tricuspid (10%)
Pulmonary (2%)
pathophysiology of infective endocarditis?
cardiac valves develop vegetations composed of bacteria and platelet-fibrin thrombus
risk factors of infective endocarditis?
Faulty valves:
prosthetic valves
prev rheumatic fever
degenerative valvuopathy
Dental caries
IVDU (tricuspid valve)
Immunocompromised (ie DM)
Organisms causing Infective endocarditis?
Strep viridans - most common if subacute bacterial endocarditis
Strep bovis- assoc w colon cancer
Staph aureus - most common if acute, IVDU
Strep epidermidis - prosthetic valves
HACEK organisms
endocarditis assoc w SLE?
Libman Sacks endocarditis
non bacterial
mitral valve typically affected
General clinical features assoc w infective endocarditis?
FLAWS
splenomegaly
clubbing
new/ changing murmur (Mitral regurg: 85%, AR: 55%)
what murmurs are most common with infective endocarditis?
mitral regurg (PSM)
followed by aortic regurg
what embolic phenomena may occur in Infective endocarditis?
abscesses in brain, heart, kidney, spleen, gut and lung
Janeway lesions: painless palmar macules
Splinter haemorrhages: due to septic emboli from infected heart valves
What signs of immune complex deposition occur in Infective endocarditis?
microhaematuria due to GN
Vasculitis
Roth spots: boat shaped retinal haemorrhages w pale centre
Osler’s nodes: painful, purple papules on finger pulps
How is diagnosis of infective endocarditis confirmed?
Duke Criteria
- 2 major
- 1 major + 3 minor
- All 5 minor
What are the Major criteria in Duke Criteria for Infective endocarditis?
- +ve blood culture
- typical organism in 2 separate cultures or
- persistently +ve cultures e.g. 3, >12 h apart - Endocardium involved
- +ve echo - vegetation, abscess, valve dehiscence
- new valvular regurgitation
What are the minor criteria of Duke criteria for infective endocarditis?
- Predisposition: Cardiac lesion, IVDU
- Fever >38
- Emboli: Septic infarcts, splinter haemorrhages, Janeway lesions
- Immune phenomenon: GN, Osler nodes, Roth spots
- +ve blood culture not meeting major criteria
Ix of Infective endocarditis?
Bloods:
Anaemia, raised ESR/ CRP, +ve IgG RF, Cultures x 3 >12 h apart, Serology for unusual organisms
urine: microscopic haematuria
ECG: AV block
Echo:
TOE most sensitive, TTE detects vegetations > 2mm
mx of infective endocarditis?
staph aureus
Flucloxacillin +/- Rifampicin IV
Empiric tx of acute severe infective endocarditis?
Flucloxacillin + Gentamicin IV
Empiric tx of subacute bacterial endocarditis?
Benpen + gent IV
Causes of tricuspid regurgitation?
Functional: RV dilatation
Rheumatic fever
Infective endocarditis
Carcinoid syndrome
Pts with rheumatic fever are recommended bed rest until?
CRP normal for 2 weeks
what antibiotic regimen is used in rheumatic fever?
Benzylpenicillin 1.2g STAT IV
then
Penicillin V 250-500mg QDS PO for 10 days
symptoms of tricuspid regurgitation?
fatigue
hepatic pain on exertion
ascites, oedema
signs of tricuspid regurgitation?
raised JVP w giant V waves
RV heave
PSM loudest @ LLSE on inspiration (carvallo’s sign)
Pulsatile hepatomegaly
Ascites, oedema
Ix of tricuspid regurgitation?
LFTs
Echo
mx of tricuspid regurgitation?
Tx cause
Medical: diuretics, ACEi, digoxin
Surgical: valve replacement
causes of tricuspid stenosis?
rheumatic fever w Mitral valve and aortic valve disease
Symptoms of tricuspid stenosis?
fatigue
ascites
oedema
signs of tricuspid stenosis?
Large A waves
opening snap
EDM loudest at LLSE on inspiration
mx of tricuspid stenosis?
medical: diuretics
Surgical: repair, replacement
causes of pulmonary regurgitation?
any cause of pulmonary HTN
PR secondary to pulmonary HTN from mitral stenosis = Graham-Steell murmur
murmur of pulmonary regurgitation?
Decrescendo EDM @ ULSE
causes of pulmonary stenosis?
usually congenital: e.g. Turner’s, Fallots
rheumatic fever
carcinoid syndrome
features of pulmonary stenosis?
dyspnoea, fatigue
dysmorphia
large A wave
RV heave
ejection click, soft P2
ascites, oedema
ESM loudest at ULSE, radiating to L shoulder
Ix of pulmonary stenosis?
ECG: P pulmonale, Right Axis deviation, RBBB
CXR: prominent pulmonary arteries: post stenotic dilatation
Cardiac Catheterisation: diagnostic
Causes of mitral regurgitation?
mitral valve prolapse
LV dilatation: AR, AS, HTN
rheumatic fever
Annular calcification -> contraction (elderly)
post MI: papillary muscle dysfunction/ rupture
connective tissue: Marfans, Ehlers-Danlos
symptoms of mitral regurgitation?
dyspnoea, fatigue
AF -> palpitations + emboli
Pulmonary congestion -> HTN + oedema
signs of Mitral Regurgitation?
AF
Left parasternal heave (RVH
Apex: displaced
-> LV hypertrophy
Heart Sounds: soft S1
Murmur: Blowing PSM best heard at apex, radiates to axilla, louder in left lateral position in end expiration
clinical indicators of severe Mitral regurg?
Lagrer Left ventricle
Decompensation: LVF
AF
ix of mitral regurgitation?
Bloods: FBC, U+E, glucose, lipids
ECG: AF, P mitrale, LVH
CXR: LA and LV hypertrophy, Mitral valve calcification, pulmonary oedema
Echo: assess MR severity
Cardiac catheterisation: confirm Dx, assess coronary artery disease
Mx of Mitral Regurgitation?
Medical:
Refer to cardiologist for regular follow up w echo
Optimise RFs: Statins, antihypertensives, DM
AF: rate control and anticoagulate
drugs to decrease afterload can help decrease symptoms:
ACEi or BB (esp carvedilol)
Diuretics
Surgical: Valve replacement or repair
indications for surgical repair of mitral regurgitant valve?
severe symptomatic MR
or
severe asymptomatic MR w diastolic dysfunction: reduced ejection fraction
causes of Barlow Syndrome?
ie. mitral valve prolapse
commonest valve problem ~ 5%
primary: myxomatous degeneration
MI
marfans, ehlers danlos
Turners
Features of MV prolapse/ Barlow Syndrome?
usually asymptomatic
autonomic dysfunction: atypical chest pain, palpitations, anxiety, panic attack
MR: fatigue, SOB
Murmur
complications of Barlow Syndrome?
mitral regurgitation
Cerebral emboli
arrhythmias -> sudden death
mx of Barlow Syndrome?
BB may relieve palpitations and chest pain
Surgery if severe MR
Causes of mitral stenosis?
rheumatic fever
prosthetic valve
congenital (rare)
what medications are recommended for secondary prevention following an MI?
dual antiplatelet therapy:
Aspirin 75 mg + Clopidogrel 75 mg
angiotensin-converting enzyme (ACE) inhibitor: e.g. lisinopril 2.5mg
beta-blocker e.g. bisoprolol 1.25 mg OD
statin e.g. atorvastatin 80mg
Causes of mitral regurg?
Mitral valve prolapse
LV dilatation: AR, AS, HTN
Annular calcification -> contraction (elderly)
post-MI: papillary muscle dysfunction/ rupture
rheumatic fever
connective tissue: marfans, Ehlers -Danlos
symptoms of mitral regurgitation?
SOB, fatigue
AF -> palpitations + emboli
Pulmonary congestion -> HTN + oedema
signs of mitral regurg?
AF
left parasternal heave (RVH)
apex: displaced
(volume overload as ventricle has to pump forward SV and regurgitant volume)
heart sounds: soft S1 + Blowing PSM at the apex, accentuated in Left lateral position in end expiration + radiates to the axilla
differentials of PSM loudest at mitral region?
Tricuspid regurg
aortic stenosis
VSD
clinical indicators of severe mitral regurg?
larger LV
decompensation: LVF
AF
ix of mitral regurgitation?
Bloods: FBC, U+E, glucose, lipids
ECG: AF, P mitrale, LVH
CXR: LA + LV hypertrophy, mitral valve calcification, pulmonary oedema
Echo: Doppler echo to assess MR severity, TOE to assess severity and suitability of repair
Cardiac Catheterisation: confirm Dx, assess coronary artery disease
What criteria is used to assess severity of MR on echo?
jet width >0.6cm
Systolic pulmonary flow reversal
regurgitant flow volune > 60ml
Mx of Mitral Regurg?
Conservative: monitor w regular follow up and echo
medical:
Optimised RFs: statins, anti-hypertensives, DM
AF: rate control and anticoagulate
Drugs to decrease afterload can help symptoms: ACEi or BB (esp Carvedilol), Diuretics
Surgical:
valve replacement or repair
indications for surgical mx of mitral regurgitation?
severe symptomatic MR
severe asymptomatic MR w diastolic dysfunction: decreased ejection fraction
commonest valve problem?
mitral valve prolapse
causes of mitral valve prolapse?
primary: myxomatous degeneration
Post-MI: papillary muscle rupture
Marfans, Ehlers Danlos
Turner’s
symptoms of mitral valve prolapse?
usually asymptomatic
autonomic dysfunction: atypical chest pain, palpitations, anxiety, panic attack
MR: SOB, fatigue
mitral valve prolapse signs?
mid systolic click + late systolic murmur
complications of mitral valve prolapse?
MR
cerebral emboli
arrhythmias -> sudden death
mx of mitral valve prolapse?
BB may relieve palpitations and chest pain
surgery if severe
pathophysiology of mitral stenosis?
valve narrowing -> ↑ left atrial pressure -> loud S1 and atrial hypertrophy -> AF
pulmonary oedema and pulmonary HTN
-> RVH, TR, R heart failure
symptoms of mitral stenosis?
SOB, fatigue
chest pain
AF -> palpitations + emboli
haemoptysis: rupture of bronchial veins
signs of mitral stenosis?
AF
Malar flush (back pressure)
JVP raised
Left parasternal heave (RVH 2º to Pulm HTN)
tapping apex (palpable S1)
HS: Loud S1, Loud P2 (if PHT), early diastolic opening snap + rumbling mid diastolic murmur in apex louder in Left lateral position in end expiration, radiates to the axilla
complications of Mitral stenosis?
pulmonary HTN
emboli: TIA, CVA, PVD, ischaemic colitis
Hoarseness: recurrent laryngeal n palsy
dysphagia (oesophageal compression)
bronchial obstruction
Ix of mitral stenosis?
Bloods: FBC, U+E, glucose, lipids
ECG: AF, P mitrale, RVH w strain
CXR: LA enlagement, pulmonary oedema (ABCDE), mitral valve calcification
Echo: to assess severity, use TOE to look for left atrial thrombus if intervention considered
Cardiac catheterisation: assess coronary arteries
what criteria would determine severe mitral stenosis on echo?
valve orifice < 1cm2
pressure gradient > 10 mmHg
Pulmonary artery systolic pressure > 50 mmHg
Mx of mitral stenosis?
Medical:
optimise RFs: statins, anti-hypertensives, DM
Regular followup w echo
AF: anticoagulation and rate control
Consider prophylaxis vs RF: Pen V
diuretics provide symptomatic relief
Surgical:
indicated in mod-severe MS
percutaneous balloon valvuloplasty
valve repair
valve replacement if repair not possible
what is the surgical tx of choice in Mitral stenosis?
Percutaneous mitral balloon Valvotomy (commissurotomy)
causes of aortic regurgitation?
Acute
Infective endocarditis
Type A aortic dissection
Chronic
Congenital: bicuspid aortic valve
Rheumatic heart disease
Connective tissue: Marfan’s, Ehler’s Danlos
Autoimmune: Ank spond, RA
symptoms of aortic regurgitation?
LVF:
signs of aortic regurgitation?
collapsing pulse (corrigans pulse)
wide pulse pressure
Apex: displaced (volume overloaded)
Heart sounds: soft/ absent S2 +/- S3
+ Early diastolic murmur at URSE, sitting forward in end expiration
+/- Ejection systolic flow murmur
Underlying cause:
high-arched palate
spondyloarthropathy
embolic phenomena
Corrigans sign: Carotid pulsation
de mussets: head nodding
Quinckes: capillary pulsation in nail bed
Traubes: pistol shot sound over femorals
Austin Flint murmur: rumbling MDM @ apex due to regurgitant jet fluttering ant mitral valve cusp = severe AR
Duroziez’s: systolic murmur over the femoral artery w proximal compression, diastolic murmur w distal compression
clinical indicators of severe AR?
wide PP and collapsing pulse
S3
long murmur
austin flint murmur
decompensation: LVF
Ix of aortic regurgitation?
Bloods: FBC, U+E, Lipids, glucose
ECG: LVH (S1 + R6 >35mm)
CXR: cardiomegaly, dilated ascending aorta, pulmonary oedema
Echo: assess severity of aortic regurg, aortic valve structure and morphology (e.g. bicuspid), evidence of Infective endocarditis (vegetations), LV function: ejection fraction
Cardiac catheterization: coronary artery disease
what are the criteria to assess severity of aortic regurg on echo?
Jet width (>65% outflow tract = severe)
Regurgitant jet volume
premature closure of mitral valve
mx of aortic regurgitation?
Medical:
optimise Risk factors: anti-hypertensives, statins, DM
monitor w regular follow up + echo
decrease systolic HTN: ACEi, CCB (decrease afterload -> decrease regurg)
Surgery: aortic valve replacement
when is aortic valve replacement indicated?
in severe AR
if symptoms of HF
asymptomatic w LV dysfunction: low ejection fraction
e.g.s of thrombolytics?
alteplase
tenecteplase
streptokinase
how do thrombolytics work?
Thrombolytic drugs activate plasminogen -> plasmin. This in turn degrades fibrin and help breaks up thrombi. They in primarily used in patients who present with a STEMI. Other indications include acute ischaemic stroke and pulmonary embolism, although strict inclusion criteria apply.
contraindications to thrombolysis?
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
pregnancy
severe hypertension
side effects of thrombolysis?
haemorrhage
hypotension - more common with streptokinase
allergic reactions may occur with streptokinase
Ix to confirm diagnosis of HTN?
both ambulatory blood pressure monitoring (ABPM) and
home blood pressure monitoring (HBPM)
measure BP in both arms:
If the difference in readings between arms is > 20 -> measurements should be repeated. If difference remains > 20 then subsequent blood pressures should be recorded from the arm with the higher reading.
classification of HTN?
Stage 1:
Clinic BP >= 140/90 and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Stage 2:
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Severe HTN:
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
Malignant:
BP > 180/110 + papilloedema and/or retinal haemorrhage
what is isolated systolic HTN?
SBP ≥140, DBP <90
what is
Ambulatory blood pressure monitoring (ABPM)?
at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
use the average value of at least 14 measurements
what is
Home blood pressure monitoring (HBPM)?
for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements
mx if BP >180/110 in clinic?
immediate treatment should be considered
if there are signs of papilloedema or retinal haemorrhages -> same day assessment by a specialist
NICE also recommend referral if a phaeochromocytoma is suspected (labile or postural hypotension, headache, palpitations, pallor and diaphoresis)
causes of aortic stenosis?
degenerative calcification (most common cause in older patients > 65 years)
bicuspid aortic valve (most common cause in younger patients < 65 years)
William’s syndrome (supravalvular aortic stenosis)
post-rheumatic disease
subvalvular: HOCM
Clinical features of symptomatic disease
of aortic stenosis?
chest pain
dyspnoea
syncope
Features of severe aortic stenosis?
narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure
signs of aortic stenosis?
slow rising pulse w narrow Pulse pressure
aortic thrill
apex: forceful, non-displaced (pressure overload)
heart sounds: Quiet A2, early syst ejection click if pliable (young) valve +/- S4
Murmur: ESM @ right 2nd ICS,
sitting forward in end expiration, radiates to carotids
aortic stenosis vs aortic sclerosis?
aortic stenosis:
valve narrowing due to fusion of the commissures
narrow PP, slow rising pulse
forceful apex
ESM radiating -> carotids
ECG: LVF
aortic sclerosis:
valve thickening
ESM w no radiation
differential for aortic stenosis?
Mitral regurg
coronary artery disease
aortic sclerosis
HOCM: ESM murmur which increases in intensity w valsalva
Ix of Aortic Stenosis?
Bloods: FBC, u+E, glucose, lipids
ECG: LVH, LV strain, LBBB or complete AV block (septal calcification) -> may need pacing
CXR: LVH, calcified Aortic valve, evidence of heart failure, post-stenotic aortic dilatation
Echo + doppler: diagnostic
- thickened, calcified, immobile valve cusps
- assess severity of AS
Cardiac catheterisation + angiography:
can assess LV function, valve gradient
assess coronaries in all pts planned for surgery
Exercise stress test:
contraindicated if symptomatic
may be useful to assess exercise capacity in asympto pts
what is the criteria to assess severity of aortic stenosis on echo?
pressure gradient > 40 mmHg
jet velocity >4m/s
Valve area <1 cm2
Mx of aortic stenosis?
medical:
regular follow ups w echo
optimise risk factors: statins, anti-hypertensives, DM
Angina: BB
Heart failure: ACEi, diuretics
Avoid nitrates
Surgical:
Valve replacement
Options for unfit pts: TAVI - transcatheter aortic valve implantation,
balloon valvuloplasty
indications for valve replacement in aortic stenosis?
severe asymptomatic AS
severe asymptomatic AS w decreased ejection fraction (<50%)
severe AS undergoing CABG or other valve op
*poor prognosis if symptomatic:
- angina/ syncope: 2-3 yrs
- LVF: 1-2 yrs
what are the differences between prosthetic and mechanical valves?
mechanical last longer but need anticoagulation:
younger pts
prosthetic valves do not require anticoagulation but fail sooner
when is a TAVI indicated?
used in aortic stenosis
- for unfit patients not suitable for valve replacement
folded valve deployed in aortic root
adverse effects of statins?
myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase.
liver impairment: the 2014 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
some evidence that statins may increase the risk of intracerebral haemorrhage in patients who’ve previously had a stroke
causes of HTN?
Primary: 95%
Renal: RAS, GN, APKD
Endo: Cushings, phaeo, acromegaly, Conns, thyrotoxicosis
Drugs: cocaine, NSAIDs, OCP
Coarctation of aorta
end organ damage due to HTN?
CANER
Cardiac: Ischaemic heart disease, LVH -> CCF, AR, MR
Aortic: dissection, aneurysm
Neuro: CVA: ischaemic, haemorrhagic, encephalopathy (malignant HTN)
Eyes: hypertensive retinopathy
renal: proteinuira, chronic renal failure
ix of HTN?
24h ABPM (for dx)
urine: haematuria, Alb:Cr ratio
bloods: FBC, U+Es, eGFR, glucose, lipids
12 lead ECG: LVH, old infarct
calculate 10 yr CV risk
treatment ladder for antihypertensives?
<55: start with ACEi (or ARB)
e.g. lisinopril (or candesartan)
>55 or afrocarribean: start with CCB (e.g. nifedipine/ amlodipine)
step 2:
ACEi + CCB
step 3:
add thiazide diuretic (e.g. chlorthalidone or indapamide)
step 4:
- consider further diuretic treatment
- if potassium < 4.5 mmol/l add spironolactone 25mg od
- if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
- if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker
Patients who fail to respond to step 4 measures should be referred to a specialist.
Blood pressure targets in clinic?
Age >80: 150/90
age <80: 140/90
blood pressure targets for ABPM/ HBPM?
age >80: 145/85
age <80: 135/85
options for pts who are intolerant of established antihypertensive drugs?
direct renin inhibitors
e.g. Aliskiren
by inhibiting renin blocks the conversion of angiotensinogen to angiotensin I
-> reduces BP
CTPA vs V/Q scan?
CTPA is imaging of choice
if CTPA -ve -> pts do not need further ix or tx for PE
V/Q scan may be used instead if pt has allergy to contrast media or renal impairment. and may be used initially if CXR is normal, and no significant symptomatic concurrent cardiopulmonary disease
Large saddle embolus straddling the main pulmonary artery bifurcation
CT pulmonary angiogram
-> PE
e.g. of thiazide like diuretic used in step 3 of HTN?
chlortalidone 25-50mg OD
indapamide
what is the gold standard ix for PE?
Pulmonary angiography CT
Indications for pharmacological tx of HTN?
<80 yo: Stage I HTN +
- target organ damage
- 10yr CV risk >20%
- established CVD
- DM
- renal disease
anyone w stage 2 HTN (>160/100)
severe/ malignant HTN (specialist referral)
consider specialist opinion if <40 yrs w stage I HTN and no end organ damage
Mx of HTN?
Conservative:
lifestyle interventions- exercise, decrease smoking/ alcohol/ salt/ caffeine
Medical:
ACEi / CCB (if >55 or afrocarribean)
Statins for pirmary prevention of CVD
aspirin may be indicated: evaluate risk of bleeding
mx of malignant HTN?
controlled decrease in BP over days to avoid stroke
atenolol or long acting CCB PO
encephalopathy/ CCF: frusemide + nitroprusside / labetalol IV
- aim to decrease BP to 110 diastolic over 4 h
- nitroprusside requires intral arterial BP monitoring
definition of cardiogenic shock??
inadequate tissue perfusion primarily due to pump failure
causes of cardiogenic shock?
Infarction: MI
Electrolytes: HyperK
Infection: endocarditis
arrhythmias
aortic dissection
Obstructive: tension pneumo, massive PE
mx of cardiogenic shock?
A-> E approach
Oxygen: 15L via non rebreather mask
IV access + monitor ECG (bloods for U+E, troponin, ABG)
Diamorphine 2.5-5mg IV + metoclopramide 10mg IV
Correct any electrolyte disturbance, arrhythmias, acid-base abnormalities
Ix: CXR, Echo, CT thorax (PE/ dissection)
consider need for dobutamine
tx underlying cause
causes of pulmonary oedema?
cardiogenic:
MI
arrhythmia
fluid overload: renal, iatrogenic
non-cardiogenic:
ARDS: sepsis, post op, trauma
Upper airway obstruction
neurogenic: head injury
Mx of severe pulmonary oedema?
A-> E approach
sit pt up
O2 via 15L nonrebreather mask
IV access + monitor ECG (bloods for U+E, troponin, BNP, ABG)
-> tx any arrhythmias
Morphine 5mg IV + metoclopramide 10mg IV
Frusemide 40-80mg IV
GTN tabs sublingual or nitrate IVI (unless SBP < 90)
if worsening, consider:
CPAP
more frusemide or increase nitrate infusion
haemofiltration/ dialysis
if SBP <100: tx as cardiogenic shock
consider inotropes (dobutamine)
role of morphine in pulmonary oedema?
make pt more comfortable
pulmonary venodilators -> decrease pre load -> optimise position on starling curve
continuing therapy for pts w severe pulmonary oedema after acute mx
daily weights
DVT prophylaxis
repeat CXR
change to oral frusemide/ bumetanide
ACEi + BB if HF
consider spironolactone
consider digoxin +/- warfarin (esp if in AF)
how long should pts be anticoagulated for after a PE?
LMWH or fondaparinux initially (unless thrombolysed)
Warfarin within 24h of diagnosis and continued for at least 3 months
- if unprovoked PE: 6 months or longer
- if pt w active cancer: LMWH for 6 months
mx of stable angina?
conservative: lifestyle changes
medical: optimise RFs, antihypertensives, statins, aspirin
Sublingual GTN to abort angina attacks
1st line- BB or CCB (rate limiting one e.g. verapamil or diltiazem)
2nd: BB + CCB (then use long acting CCB e.g. modified release nifedipine)
Interventional: Percutaneous coronary intervention
Surgery: CABG
can BB be prescribed w verapamil?
no.
risk of complete heart block!!
verapamil - rate limiting CCB
If giving BB + CCB in angina -> use long acting dihydropyridine CCB e.g. modified release nifedipine
Which one of the following types of anti-anginal medication do patients commonly develop tolerance to?
standard release isosorbibe mononitrate
(not seen in modified release)
- develop tolerance and reduced efficacy
the BNF advises that patients who develop tolerance should take the second dose of isosorbide mononitrate after 8 hours, rather than after 12 hours. This allows blood-nitrate levels to fall for 4 hours and maintains effectiveness
pt who requires anticoagulation but do not want regular monitoring?
consider NOACs
e.g. rivaroxaban
What mutation leads to hypertrophic obstructive cardiomyopathy?
usually due to mutation of gene encoding B-myosin heavy chain protein
common cause of sudden death
echo findings of HOCM?
mitral regurg
systolic anterior motion of the anterior mitral valve
asymmetric septal hypertrophy
what is arrhythmogenic right ventricular dysplasia?
R ventricular myocardium is replaced by fatty and fibrofatty tissue
~50% of pts have mutation of one the genes that encode desmosome
ECG abnormalities in V1-3, typically T wave inversion.
An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex
types of cardiomyopathies?
genetic: both auto dom
- implantable cardioverter-defibrillator often inserted to reduce incidence of sudden cardiac death
1. HOCM
2. Arrhythmogenic right ventricular dysplasia
mixed: genetic predisposition which is triggered by a secondary process
1. dilated cardiomyopathy
2. restrictive cardiomyopathy
acquired:
- peripartum cardiomyopathy
- Takotsubo cardiomyopathy
Secondary - pathological myocardial involvement as part of generalized systemic disorder
infective, infiltrative, inflammatory, neuromuscular, autoimmune, storage etc
causes of dilated cardiomyopathy?
genetic predisposition to cardiomyopathy which is then triggered by the secondary process
Classically:
- alcohol
- Coxsackie B virus
- wet beri beri
- doxorubicin
causes of restrictive cardiomyopathy?
genetic predisposition to cardiomyopathy which is then triggered by the secondary process
classically:
amyloidosis
post-radiotx
Loeffler’s endocarditis
what is peripartum cardiomyopathy?
typically during last month of pregnancy - 5 months post partum
what is Takotsubo cardiomyopathy?
‘Stress’-induced cardiomyopathy e.g. patient just found out family member dies then develops chest pain and features of heart failure
Transient, apical ballooning of the myocardium
(Takotsubo = jap for octopus trap)
ST elevation + normal coronary angiogram
Treatment is supportive
E.g.s of secondary cardiomyopathies?
infective: coxsackie B virus, Chagas disease
infiltrative: amyloidosis
storage: haemochromatosis
toxicity: doxorubicin, alcoholic cardiomyopathy
inflammatory: sarcoidosis
endocrine: DM, thyrotoxicosis, acromegaly
neuromuscular: Friedreichs ataxia, duchenne muscular dystrophy, myotonic dystrophy
Nutritional deficiencies: beriberi (thiamine)
autoimmune; SLE
if drug therapy fails in managing ventricular tachycardia?
electrophysiological study
implantable cardioverter-defibrillator (ICD) - particularly indicated in pts w significantly impaired LV fn
when is adrenaline given during a VF/VT cardiac arrest?
adrenaline 1 mg given once chest compressions have restarted after the third shock and then every 3-5 mins
scale for determining intensity of murmur?
The Levine Scale:
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
what causes a late systolic murmur?
mitral valve prolapse
coarctation of aorta
early diastolic murmur?
aortic regurg (high pitched and blowing in character)
Graham-Steel murmur (pulm regurg)
mid late diastolic murmur?
mitral stenosis
austin-flint murmur- severe aortic regurg
continuous machine like murmur?
patent ductus arteriosus
Monitoring of pts taking amiodarone prior to starting treatment?
TFTs: risk of thyrotoxicosis
LFTs
U+Es: low K+
CXR: risk of pulmonary fibrosis/ pneumonitis
long term monitoring of pts taking amiodarone?
TFT, LFT every 6 months
how does amiodarone work?
blocks K+ channels which inhibits repolarisation and hence prolongs Action potential
- long half life
- should be given into central veins (causes thrombophlebitis)
- proarrhythmic effects due to lengthening of QT interval
adverse effects of amiodarone use?
thyroid dysfunction: hypo + hyperthyroid
eyes: corneal deposits, photosensitivity
pulm fibrosis/ pneumonitis
liver fibrosis/ hepatitis
peripheral neuropathy, myopathy
slate grey appearance
lengthens QT interval, bradycardia
cardioversion of paroxysmal AF?
if haemodynamically unstable: electrical cardioversion
pharmacological: amiodarone, flecainide (if no structural heart disease)
can adenosine be administered through small peripheral vein?
no
Adenosine half-life is less than 10 seconds and therefore, a central route or large-calibre vein is required to administer adenosine effectively.
BNF:
For rapid intravenous injection give over 2s into central or large peripheral vein followed by rapid Sodium Chloride 0.9% flush; injection solution may be diluted with Sodium Chloride 0.9% if required.
what is adenosine enhanced/ blocked by?
enhanced by dipyridamole (anti-platelet)
blocked by theophyllines
avoided in asthmatics due to possible bronchospasm
complete heart block after MI - which artery is affected?
Right coronary artery
AV node is supplied by the posterior interventricular artery, which in the majority of patients is a branch of the right coronary artery.
common side effects of thiazide diuretics?
dehydration
postural hypotension
hypoNa, hypoK, hyperCa*
gout
impaired glucose tolerance
impotence
A 65-year-old patient with a known history of stable angina is presented to his GP with poor control of his symptoms. He is taking atenolol for the angina. The patient’s allergy notes indicate that he had developed ankle oedema when tried on nifedipine in the past for hypertension. According to NICE guidelines, which of the following drugs can be added to help control his symptoms?
if a patient is on monotherapy and cannot tolerate the addition of a CCB or a BB then consider one of the following drugs: a long-acting nitrate, ivabradine, nicorandil or ranolazine
1st line tx in bradycardia w signs of haemodynamic compromise?
Atropine
If this fails to work, or there is the potential risk of asystole then transvenous pacing is indicated
causes of prolonged QT interval?
Congenital:
Jervell-Lange-Nielsen syndrome
Romano-Ward Syndrome
Drugs:
amiodarone, sotalol, class 1a antiarrhythmic drugs
TCAs
chloroquine
erythromycin
Electrolytes: hypoCa, hypoK, hypoMg
acute MI, myocarditis
hypothermia
subarachnoid haemorrhage
Type B dissection, seen in descending aorta
mx:
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
Type A Aortic Dissection
seen in ascending aorta
mx:
surgical management, but BP should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention
Mx of Type 1 HTN?
only treat medically if: diabetic, renal disease, QRISK2 >20%, established coronary vascular disease, or end organ damage
lifestyle advice: low salt diet, decrease caffeine intake, stop smoking, drink less, exercise more, lose weight
if QRISK2 10-20% -> offer statin therapy
Causes of RBBB?
normal variant - more common with increasing age
right ventricular hypertrophy
chronically increased right ventricular pressure - e.g. cor pulmonale
pulmonary embolism
myocardial infarction
atrial septal defect (ostium secundum)
cardiomyopathy or myocarditis
most common cause of death following an MI?
VF ->cardiac arrest/ arrhythmias
complications of MI?
immediate:
cardiac arrest (VF)
cardiogenic shock
bradyarrhythmias (AV block)
early:
pericarditis
rupture of interventricular seputm -> VSD
acute mitral regurg due to papillary muscle rupture
late:
Dressler’s syndrome (2-6 wks)
chronic heart failure
L ventricular aneurysm
L ventricular free wall rupture
mx of acute mitral regurg due to papillary muscle rupture after MI?
vasodilator therapy
often require emergency surgical repair
Mx of rupture of interventricular septum following MI?
rupture -> VSD
features: acute HF w pan systolic murmur
echo is diagnostic
urgen surgical correction needed
mx of left ventricular aneurysm following MI?
ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation
-> persistent ST elevation and LV failure
thrombus may form in the aneurysm and increase risk of stroke
Pts should be anticoagulated
mx of Dressler’s syndrome?
NSAIDs
or
prolonged course of colchicine or steroids
mx of chronic heart failure following MI?
Loop diuretics such as furosemide decrease fluid overload
ACEi and BBs improve long term prognosis
mx of left ventricular free wall rupture following MI?
Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)
urgent pericardiocentesis and thoracotomy needed
mx of pt w chest pain in last 12 hrs (now settled) w an abnormal ECG?
emergency admission
mx of pt w chest pain 12-72h ago?
refer to hospital for same day assessment
features of Atrial septal defect?
ejection systolic murmur, fixed splitting of S2
embolism may pass from venous system to left side of heart causing a stroke
ostium secundum ECG: RBBB w RAD
what statin dose is used for secondary prevention?
prev IHD/ CVD/ PAD
Atorvastatin 80mg OD
what dose of statin is used for primary prevention?
ie chronic kidney disease, T1DM, 10yr CV risk >10%
Atorvastatin 20mg OD
(can titrate up after)
what protein is affected in Marfans?
fibrillin-1
auto dom connective tissue disorder
defect in the FBN1 gene
SEs of Beta blockers?
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
Contraindications of beta blockers?
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
ECG changes seen in hypothermia?
bradycardia
‘J’ wave - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
Why are AF patients only cardioverted when its new onset <48h or anticoagulated for 3 wks beforehand?
the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke. Imagine the thrombus formed in the fibrillating atrium suddenly being pushed out when sinus rhythm is restored.
For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.
what scenarios would u choose to rhythm control AF instead of rate control?
Use rhythm control to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause
e.g. amiodarone
Immediate DC cardioversion is only recommended when there is life-threatening haemodynamic instability caused by new-onset atrial fibrillation.
which valve is most commonly affected by IE in IVDU?
Tricuspid
most common organism causing infective endocarditis?
staph aureus
coarctation of aorta assoc w?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
causes of postural hypotension?
hypovolaemia
autonomic dysfunction: diabetes, Parkinson’s
drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives
alcohol
long term antiplatelets after Peripheral arterial disease?
1st line: lifelong clopidogrel
2nd: lifelong aspirin
long term antiplatelets after ischaemic stroke?
1st line: lifelong clopidogrel
2nd line: lifelong aspirin + dipyridamole
long term antiplatelet therapy after TIA?
1st line: lifelong clopidogrel
2nd line: lifelong aspirin + dipyridamole
long term antiplatelet therapy after Percutaneous coronary intervention?
1st line: Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
2nd line: lifelong clopidogrel
long term antiplatelets after acute coronary syndrome (medically treated)?
1st line: Aspirin (lifelong) & ticagrelor (12 months)
2nd line: lifelong clopidogrel
Patients on warfarin undergoing emergency surgery?
give four-factor prothrombin complex concentrate
If surgery can wait for 6-8 hours - give 5 mg vitamin K IV
causes of cardiac syncope?
arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
structural: valvular, MI, HOCM
others: PE
causes of orthostatic syncope?
primary autonomic failure: Parkinson’s, Lewy body dementia
secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
drug-induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhage, diarrhoea
causes of reflex syncope?
vasovagal: triggered by emotion, pain or stress. Often referred to as ‘fainting’
situational: cough, micturition, gastrointestinal
carotid sinus syncope
evaluation of pt with syncope?
cardiovascular examination
postural blood pressure readings: a symptomatic fall in systolic BP > 20 mmHg or diastolic BP > 10 mmHg or decrease in systolic BP < 90 mmHg is considered diagnostic
ECG
carotid sinus massage
tilt table test
24 hour ECG
What is the pulse like in Severe Left HF?
Pulsus alternans:
regular alternation of the force of the arterial pulse
(strong-weak-strong-weak)
diagnostic test of choice for cardiac tamponade?
echocardiogram
Mx of chronic limb ischaemia?
Non-surgical:
- CV risk factor control
- Antiplatelet agents
- Analgesia
- Graded exercise programs: walk through pain
Interventional:
Angioplasty ± stenting
- *Surgical:**
- Reconstruction
- Endarterectomy
- Amputation
Mx of acute limb ischaemia?
Resus: NBM, hydration, analgesia
UH IVI: prevent thrombus extension
Angiography: only if incomplete occlusion
Surgery
- Embolectomy w Fogarty catheter
- Emergency reconstruction
Treat cause
- e.g. warfarinise
- Mx CV risk
SEs of GTN?
hypotension
tachycardia
headaches
flushing
Statins + erythromycin/clarithromycin -??
statin-induced myopathy
Mx of Long QT syndrome?
beta-blockers***
implantable cardioverter defibrillators in high risk cases
***not sotalol
when should a gpIIb./IIIa receptor antagonist be used in STEMI?
e.g. eptifibatide or tirofiban
should be given to patients who have an intermediate - high risk of adverse CV events, and who are scheduled to undergo angiography within 96 hours of hospital admission.
(ie. PCI)
What dose of adrenaline should be given during a cardiac arrest?
1mg
what are Ticagrelor and prasugrel?
now the preferred second antiplatelet instead of clopidogrel
What is the dose of hydrocortisone administered in anaphylaxis?
200mg
What is the dose of adrenaline administered in anaphylaxis?
0.5 ml 1:1000 or 500 mcg
What is the dose of chlorphenamine administered in anaphylaxis?
10mg
If unsure of anaphylaxis, what ix can be used to confirm?
Serum tryptase levels
remain elevated for up to 12h following an acute episode of anaphylaxis.
Mx of Aortic stenosis general rules?
if asymptomatic -> conservative
if symptomatic -> valve replacement
if asymptomatic but valve gradient >40mmHg and features of LV systolic dysfn -> consider surgery
Critical AS not fit for valve replacement -> balloon valvuloplasty
An elderly man with aortic stenosis is assessed. Which one of the following would make the ejection systolic murmur quieter?
Left ventricular systolic dysfunction will result in a decreased flow-rate across the aortic valve and hence a quieter murmur.
Apart from clopidogrel, what other antiplatelets can be added to aspirin post-MI?
ticagrelor and prasugrel (also ADP-receptor inhibitors)
stop the second antiplatelet after 12 months
What mx for patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction?
treatment with an aldosterone antagonist licensed for post-MI treatment (e.g. eplerenone) should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy
what diuretic increases risk of gout?
Thiazide diuretics reduce uric acid excretion from the kidneys
ECG finding of hyperCa?
Shortening of QT interval
Heart failure medical mx?
1st: ACEi + BB
2nd: aldosterone antagonist, ARB or hydralazine + nitrate
3rd: cardiac resynchronisation therapy or digoxin or ivabradine
**diuretics should be given for fluid overload
normal corrected QT interval?
< 430 ms in males and 450 ms in females.
congenital causes of a prolonged QT interval?
Jervell-Lange-Nielsen syndrome (includes deafness)
Romano-Ward syndrome (no deafness)
Drugs that cause Long QT syndrome?
amiodarone, sotalol
TCAs, SSRIs (esp citalopram)
erythromycin
haloperidol
causes of long QT syndrome?
electrolyte: hypoCa, hypoK, hypoMg
MI
myocarditis
hypothermia
subarachnoid haemorrhage
Mx of Long QT syndrome?
avoid drugs which prolong the QT interval and other precipitants if appropriate (e.g. Strenuous exercise)
BBs
ICD in high risk cases
monitoring of pts taking amiodarone?
TFT, LFT, U&E, CXR prior to treatment
TFT, LFT every 6 months
