Cardiology Flashcards
Define the diagnostic criteria for abdominal aortic aneurysm
Diameter of >3cm or >50% larger than normal size
Recall 3 groups of risk factors for AAA and give examples of each
CV: hyperlipidaemia, atherosclerosis
Inflammatory: takasayu’s arteritis
Connective tissue: Marfan’s, Ehlers-Danlos
Where is pain felt in a ruptured AAA?
Abdomen, back or loin
Describe the nature of pain in a rutured AAA
sudden + severe
Recall the symptoms of a ruptured AAA
Pain
Syncope
Shock
Recall the signs of AAA
3Bs: bulging, bruits, bruising
Pulsatile and laterally expansile mass
Abdominal bruit
Grey Turner’s sign
What is Grey Turner’s sign?
Flank bruising
What causes Grey-Turner’s sign in AAA?
Retroperitoneal damage
What scans can be used to detect AAA?
US can see aneurysm but not rupture
CT contrast can see rupture
Define aortic dissection
Tear in aortic intima –> blood surge into aortic wall
What is the difference between types A and B aortic dissection?
Type A = in ascending aorta
Type B = in descending aorta
How can surrounding arteries be damaged in aortic dissection?
Expansion of the false lumen can obstruct the subclavian/ coeliac/ carotid or renal arteries
What is the main risk factor for aortic dissection?
HTN
Between which 2 layers of the aortic wall does a false lumen develop in aortic dissection?
Inner and outer tunica media
What is the main symptom of aortic dissection?
Tearing chest pain that may radiate to the back between the shoulder blades
If the carotid artery is obstructed by an aortic aneurysm, what would the symptoms be?
Hemiparesis
Dysphasia
Loss of consciousness
Why might an aortic dissection present with abdominal pain?
Obstruction of coeliac artery
Recall the signs of aortic dissection
Wide Pulse Pressure
Aortic Regurgitation
Back Murmur
Blood pressure difference between arms
What might hypotension with aortic dissection indicate?
Cardiac tamponade
What form of specialised imaging could be used in aortic dissection as well as CXR and CT?
Cardiac catheterisation and aortography
Define aortic regurgitation
Reflux from aorta into left ventricle during diastole
Recall the 2 groups of causes of aortic regurgitation and give examples of both
- Valve abnormality: infective endocarditis, trauma
2. Aortic root dilatation: HTN, aortitis, arthritides, aortic dissection
What arthritides are present in the case of aortic regurgitation?
Aortic valve incompetence due to reumatoid arthritis
Which 2 measures of cardiac output are changed by aortic regurgitation and why is this?
End Diastolic Volume (EDV) and Stroke Volume (SV) are elevated due to LV dilatation
Recall the consequence of chronic and acute aortic regurgitation
Chronic: leads to heart failure
Acute: leads to a sudden CV collapse
Important: Recall the 4 key signs of aortic regurgitation
Early diastolic murmur
Collapsing pulse
Wide Pulse Pressure
Displaced and heavy apex beat
Define aortic stenosis
Narrowing of left ventricular outflow at level of aortic valve
What is the most common cause of aortic stenosis?
Rheumatic heart disease
When symptomatic, what symptoms may aortic stenosis cause?
Angina
Syncope on exercise
Symptoms of left heart failure: dyspnoea and orthopnoea
Recall the signs of aortic stenosis
Narrow Pulse Pressure Ejection Systolic Murmur Thrusting Apex Beat Aortic Thrill Slow-rising Pulse
Think of 2 ECG signs that may be seen in aortic stenosis
Signs of LV hypertrophy
LBBB
Which patients are most at risk of arterial ulcer?
Those with severe atheroma
What is the hallmark symptom of arterial ulcers?
Night pain
Describe the appearance of an arterial ulcer
Punched-out
Hairless
What are the effects of an arterial ulcer downstream of the artery it affects?
Nail dystrophy
Absence of pulses
What is the key investigation for arterial ulcers?
Duplex ultrasonography of lower limbs
What are the 3 subdivisions of atrial fibrillation?
Permanent
Persistent
Paroxysmal
What symptoms are possible with atrial fibrillation?
Palpitations
Syncope
What is the main complication risk of atrial fibrillation?
Thromboembolism
Describe the pulse in atrial fibrillation
Irregularly irregular
What key examination finding is indicative of atrial fibrillation?
Difference between apical beat and radial pulse
Which electrolytes need to be measured in AF, and why?
K+, Mg2+, Ca2+
There is a risk of digoxin toxicity if potassium or magnesium are low, or if calcium is high
What is the characteristic appearance of atrial flutter on ECG?
Saw tooth baseline
How is rhythm controlled in acute atrial fibrillation?
If <48 hours: DC cardioversion, chemical cardioversion (amiodarone/flecainide)
If >48 hours since onset: anticoagulate, then do as above
Recall 3 drugs used to control rate in AF
Digoxin
Verapamil
Beta blockers
How is longterm medication for AF decided?
Depends on stroke risk
Low risk patients = aspirin
High risk patients = warfarin
How do you measure stroke risk?
CHADS-vasc score
Recall the reversible causes of cardiac arrest
4 Hs and 4Ts Hypokalaemia Hypothermia Hypovolaemia Hypoxia Tamponade Tension pneumothorax Thromboembolic Toxins
What drug is given in cases of asystole?
Atropine
Which drugs are given between each round of CPR in VF cardiac arrest?
shock + no drug CPR shock + adrenaline CPR shock + amiodarone
What are the defining characteristics of heart failure?
Cardiac output does not equal demand
Venous pressure is NORMAL
Recall the mnemonic for and the causes of left heart failure
Heart failure leaves you sitting in a CHAIR Cardiomyopathy Hypertension Aortic valve disease Ischaemic heart disease Regurgitation (mitral)
Recall 5 causes of right heart failure
Cardiomyopathy Tricuspid regurgitation Respiratory causes Infarction As secondary to LHF
Recall 4 causes of biventricular heart failure
Cardiomyopathy
Myocarditis
Arrhythmia
Drug toxicity (–> arrhythmia)
Recall 3 causes of HIGH output heart failure
Demand is increased so:
Pregnancy
Anaemia
Hyperthyroidism
Recall the 3 key symptoms of left heart failure
Dyspnoea
Paroxysmal nocturnal dyspnoea
Orthopnoea
Recall one weird sign that is present in acute left ventricular failure
Pink frothy sputum
What are left heart failure symptoms a result of?
Pulmonary congestion
Recall the symptoms of right heart failure
Swollen ankles and oedema
Reduced exercise tolerance
Fatigue
In which type of heart failure is the apex beat displaced?
Left
In which type of heart failure is there tachycardia and tachypnoea?
Left, acute LV
Which type of heart failure can produce hepatomegaly?
Right
Which type of heart failure presents with a murmur, and what is it?
Left
Mitral regurgitation
Which type of heart failure causes a raised JVP?
Right
Bilateral basal crackles are present in which type of heart failure?
Left
What is the key sign to look for in any LV systolic impairment?
Pulsus alternans
Which 2 specific markers do you need to remember to order in the blood tests during acute cardiac failure?
Troponin
BNP
What do inverted T waves show on an ECG?
Ischaemic changes
What do you use to measure valve wedge pressures?
Swan-Ganz catheter
How do you treat cardiogenic shock in acute cardiac failure?
Inotropes like dobutamine
Recall the types of cardiomyopathy
Dilated
Restrictive
Hypertrophic
Give 3 causes of dilated cardiomyopathy
Post-viral
Thyrotoxicosis
Drugs/alcohol
Recall 3 causes of restrictive cardiomyopathy
sarcoidosis
amyloidosis
haemachromatosis
Which type of cardiomyopathy is usually asymptomatic?
hypertrophic
Recall the general symptoms of heart failure
TOAD: Tired/ thromboembolism Arrhythmias Oedema Dyspnoea
In which types of cardiomyopathy would the JVP be raised?
dilated + restrictive
Recall 3 signs of dilated cardiomyopathy
JAM
JVP raised
Apex beat displaced
Mitral AND tricuspic regurgitation
Which type of cardiomyopathy can result in hepatomegaly?
Restrictive
How will restrictive cardiomyopathy affect an ECG?
Low voltage complexes
Define constrictive pericarditis
Chronic pericardial inflammation leading to thickening and scarring of cardiac tissue
Recall the usual aetiology of constrictive pericarditis
Usually idiopathic but can be viral
What is the usual timeline of onset of constrictive pericarditis?
Gradual
In advanced cases of constrictive pericarditis, how does the patient appear?
Jaundiced and cachexic
May have signs of right heart failure
What is the diagnostic test for constrictive pericarditis?
Echocardiogram
What must you always examine for in cases of DVT?
PE
How does DVT feel for the patient?
May actually be painless, just a swollen limb
What special sign can be elicited in DVT?
Homan’s sign
Force dorsiflexion of the ankle causes pain
What risk score is used to calculate DVT risk?
Well’s score
What is the gold standard investigation for DVT?
Doppler ultrasound
Recall the steps of management of DVT
- Anticoagulate with heparin and warfarin
Wait till INR is in target range of 2-3
If it extends beyond the knee: observed anticoagulation for 6 months
If it does not extend beyond the knee: observed anticoagulation for 3 months - IVC filter
- Prophylactic stockings and heparin
Compare the epidemiology of gangrene and nectrotising fasciitis
Gangrene is common
Necrotising fasciitis is rare
Recall the different types of gangrene
- Wet with superimposing infection
- Gas
- Dry
What is the cause of gas gangrene?
Clostridia perfringens
Compare the seriousness of gangrene and necrotising fasciitis
Gangrene = limb-threatening NF = life-threatening
Define necrotising fasciitis
Life-threatening polymicrobial infection causing tissue necrosis and rapidly spreading across fascial planes
Recall 4 risk factors for gangrene
Diabetes
Peripheral vascular disease
Malignancy
Steroid/immunosuppressant drugs
Why does gangrene appear black?
Hb breakdown
Which type of gangrene is most odourous?
Wet
Which type of gangrene causes crepitus?
Gas
Recall 2 signs of necrotising fasciitis that differentiate it from gangrene
Haemorrhagic blistering
Signs of sepsis
How is 1st degree heart block seen on an ECG?
Prolonged conduction through AVN
Differentiate between mobitz type 1 and 2 heart block
Type 1 = progressive prolongation of AVN conduction until skipped beat
Type 2 = intermittent/ regular conduction failure
Recall the 2 major causes of heart block
IHD
MI
What symptoms does heart block cause?
Stokes-adams attacks
What is a stokes-adams attack?
syncope caused by ventricular asystole
In which grades of heart block are stokes-adams attacks seen?
MNII/ 3rd
Recall a specific sign of 3rd degree heart block
Cannon A waves in JVP
Recall 3 blood tests to order in heart block
Troponin
Cardiac enzymes
DIGOXIN
What is the first step in management of acute heart block?
IV atropine
What are the diagnostic criteria for hypertension?
BP >140/90 on 3 separate occasions
What are the diagnostic criteria for malignant hypertension?
> 200/130
What % of hypertension cases are essential?
90%
Recall 4 possible causes of secondary HTN
Pregnancy
Renal
Endocrine
Drugs
What might be seen on fundoscopy in hypertension?
Silver wiring
Recall the management of malignant hypertension
IV beta blocker
Labetolol
Hydralesine
Sodium nitroprusside
What is the main risk to be aware of when treating malignant hypertension?
If you drop the BP too rapidly it may cause a cerebral infarction due to autoregulatory vasoconstricting response
What is the target BP for diabetics?
Without proteinuria: <130/80
With proteinuria: <125/75
Recall the 3 most commonly implicated pathogens in infective endocarditis
Streptococcus
Staphylococcus
Enterococcus
Recall the mnemonic for and the symptoms of infective endocarditis
Severe Cardiac Affliction Makes Many Feverish Skin lesions Confusion Arthralgia Myalgia Malaise Fever
Recall the mnemonic for and signs of infective endocarditis
Numerous Signs Can Point To Valve Sickness New regurgitant murmur Splenomegaly Clubbing Pyrexia Tachycardia Vascular lesions (Osler's nodes. Janeway lesions, roth spots, splinter haemorrhages) Signs of arrhythmia
What will the FBC show in infective endocarditis?
Anaemia of chronic disease
Neutrophilia
Recall 2 findings on urine dipstick in infective endocarditis
Microscopic haematuria
Proteinurua
How are investigation results compiled to make a diagnosis of infective endocarditis?
Duke’s classification
What is the treatment for infective endocarditis?
Antibiotics for 4-6 weeks
Which antibiotics are first line in a streptococcal infective endocarditis?
Benzylpenicillin and gentamycin
Which 4 conditions come under the umbrella term of “ischaemic heart disease”?
Stable angina
Unstable angina
STEMI
NSTEMI
Summarise the pathophysiology of atherosclerotic plaque production
Macrophages engulf LDL –> foam cells
GF released by foam cells
Collagen produced by SMCs
Recall the signs of MI (non-silent)
Pale
Sweaty
Slightly pyrexial
Which markers should be checked in the blood in suspected cases of the acute coronary syndrome?
AST (raised 24 hours post-MI)
LDH (raised 48 hours post-MI)
Recall 2 signs that may be seen on an ECG of unstable angina or NSTEMI
Inverted T waves or ST depression
What sort of branch block is often seen in STEMIs?
LBBB
What constitutes a “fail” on an exercise ECG?
failure to produce 85% of max predicted HR
Which 4 investigations should be done in patients presenting with likely ischaemic heart disease?
Bloods
ECG
Exercise ECG
Echo
If stable angina patients are on max doses of GTN spray and prophylactic medication but pain persists, what can be done?
PCI or CABG
Recall the mnemomic for and the management of unstable angina/NSTEMI
MONABASH Morphine Oxygen Nitrates Anticoagulants Beta-blockers ACE-inhibitors Statins Heparin
How does STEMI management differ from NSTEMI?
Same but in addition:
Clopidogrel
PCI asap
Thrombolysis if within 12 hours and there are ECG changes
Define mitral regurgitation
Flow of blood from the left ventricle to the left atrium during systole
In which demographic is mitral valve prolapse common?
Young females
What is the most common cause of mitral valve damage?
Rheumatic heart disease
What are the symptoms of acute and chronic mitral regurgitation? (mnemonic for chronic symptoms)
Acute: LV failure
Chronic: APEX (Atrial fibrillation, Palpitations, Exertional dyspnoea, eXtreme tiredness)
Describe the pulse in mitral regurgitation
Irregularly irregular (as AF is present)
Describe the ECG in mitral regurgitation
May be normal
May have p mitrale = broad, notched p waves
Which heart murmur causes left atrial dilation on echo?
Mitral regurgitation
Describe the LVEF in mitral regurgitation
Reduced
What is the most common cause of mitral stenosis?
Rheumatic fever
What are the symptoms of mitral stenosis?
APEX AF Palpitations Exertional dyspnoea eXtreme tiredness ALSO ORTHOPNOEA
Recall the mnemonic for and the signs of mitral stenosis
If inspection Points to Mitral Pathology so Commence Heart Protection
Irregularly
Irregular
Pulse
Malar flush
Peripheral
Cyanosis
Heaves
(Parasternal)
In which conditions might p mitrale be seen on ECG?
mitral regurgitation and mitral stenosis
What would a CXR show in mitral valve disease
Left atrial enlargement
What is the most common cause of myocarditis and pericarditis in Europe?
Coxsackie B virus
Recall the different types of pericarditis
Acute
Subacute
Chronic
Which disease increases risk of myocarditis and pericarditis?
SLE
Describe the symptoms of myocarditis
“flu like” prodromal fever
Breathlessness
Palpitations
Describe the symptoms of pericarditis
Chest pain that extends to the pleura, relieved by sitting forwards
Recall 2 signs of pericarditis
Friction rub
Tamponade
What ECG changes are seen in myocarditis?
Non-specific T and ST changes
What ECG changes are seen in pericarditis?
Widespread saddle-shaped ST elevation
What is the treatment for cardiac tamponade?
Pericardiocentesis (emergency)
What is the treatment for constrictive pericarditis?
Pericardectomy
Recall 3 possible complications of pericarditis
Pericardial effusion
Tamponade
Arrhythmias
What are the different types of peripheral vascular disease?
Intermittent claudication Critical limb ischaemia Acute limb ischaemia Arterial ulcers Gangrene
In which artery is the pathology when there is intermitent claudication of the thigh or leg?
Femoral
In which artery is the pathology when there is intermitent claudication of the buttock?
Iliac
What classification is used for critical limb ischaemia?
Fontaine
Recall the mnemonic for and the signs of peripheral vascular disease
6Ps Pulseless Pain Pale Paralysis Perishingly cold Paraesthesia
What is the first-line investigation in peripheral vascular disease?
colour duplex ultrasound
Recall 2 major risk factors for pulmonary hypertension
Left ventricular failure
Pulmonary emboli
Recall the mnemonic for and symptoms of pulmonary hypertension
AT BEST Angina Tachycardia Breathlessness Exertional dyspnoea Syncope Tiredness
Which heart murmurs result when there is pulmonary hypertension?
Pulmonary and tricuspid regurgitation
Recall 3 signs of pulmonary HTN
Tricuspid and pulmonary regurgitation
Raised JVP
Peripheral oedema
What can confirm a diagnosis of pulmonary hypertension
Right heart catheterisation
Define supraventricular tachycardia
Regular, narrow-complex tachycardia: no p waves, supraventricular origin
Recall the 2 possible pathologies underlying a supraventricular tachycaradia
AVRT
AVNRT
Which drug carries risk of causing supraventricular tachycardia?
Digoxin
What are the signs of Wolff-Parkinson White?
Tachycardia
Secondary cardioyopathy
How can you differentiate between AVRT and AVNRT on ECG?
AVRT –> delta waves (slurred QRS upstroke + short PR)
AVNRT - relatively normal, just a narrow QRS and tachycardia
What are delta waves?
Slurred QRS upstrokes on ECG
Recall the steps of medical management of supraventricular tachycardia
- IV adenosine
- If haemodynamically stable: IV beta blocker, dilitiazem and verapamil
- If haemodynamically unstable: DC cardioversion
How can an AVRT or AVNRT be cured?
Radiofrequency ablation
Define tricuspid regurgitation
Backflow of blood from right ventricle to right atrium during systole
What is the most common cause of tricuspid regurgitation?
Infective endocarditis
Recall the mnemonic for and symptoms of tricuspid regurgitation
Learn Symptoms By Just Nailing Acronyms: Tricuspid Errors Produce Heart Palpitations
Leg
Swelling
Breathlessness
Jaundice
Nausea
Anorexia
Tiredness
Epigastric
Pain
Headache
Palpitations
How does the JVP appear in tricuspid regurgitation?
Raised with giant V waves due to high right ventricular pressure
What sort of murmur is tricuspid regurgitation?
Pansystolic
What is another name for cor pulmonale?
Right sided heart failure
What would be seen on a CXR in tricuspid regurgitation?
Right atrial hypertrophy
Recall 4 causes of secondary varicose veins
Valve damage following DVT Outflow obstruction: - pregnancy - ascites - pelvic malignancy
Recall 3 symptoms of varicose veins
Itching
Swelling
Bleeding
How should you examine varicose veins?
With pt standing up: TAP TEST
How do you perform a tap test?
Feel distally whilst tapping saphenofemoral junction - if you feel something the valves are incompetent
Other than the tap test, what test can show valve incompetency?
Trendelenberg
What investigation may be done for varicose veins?
Duplex ultrasound
What are two possible complications of varicose veins and how do you treat these?
Venous telangiectasia and reticular veins
Scleropatherapy
Which vein is usually implicated in varicose veins?
Long saphenous
What is the cause of vasovagal syncope?
Excessive vasovagal discharge
What are 2 common triggers of a vasovagal syncope episode?
Emotion
Orthostatic stress
Alongside a faint, what symptoms may be experienced in vasovagal syncope?
Sweating
Dizziness
Where is the most common site of venous ulcers?
Just superior to medial malleolus
What is the pathophysiology of venous ulcers?
Valve incompetency –> venous stasis –> increased venous pressure -> ulceration
Describe the appearance of a venous ulcer
Irregular margin
In addition to a venous ulcer, what skin changes may be seen in the area?
Stasis eczema
Dark colour from haemosiderin deposition
What is the main investigation to do in venous ulcers?
ABPI (ankle brachial pressure index)
What is the treatment for venous ulcers?
Graduated compression
Define ventricular fibrillation
Irregular broad complex tachycardia
What will VF survivors need as part of their long-term management?
ICD (defibrillator implant)
What is the main complication seen in survivors of VF?
Anoxic encephalopathy
Define ventricular tachycardia
Regular broad-complex tachycardia with AV dissociation
Describe the aetiology of ventricular tachycardia
Electrical impulses arise from ventricular ectopic focus
Recall some signs indicative of ventricular tachycardia
Raised JVP with hypotension due to inefficient pumping
Respiratory distress with bibasal crackles
Which is more common out of SVT and VT?
VT
If somebody has VF but is not in cardiac arrest, how should you manage them?
Unstable: DC cardioversion
Stable: Amiodarone
Define Wolff-Parkinson-White syndrome
Congenital supraventricular tachycardia
Pre-excitation syndrome
Recall the aetiology of Wolff-Parkinson-White
Bundle of Kent accessory pathway
What are the symptoms of WPW?
Dizziness
Syncope
Palpitations
What unusual sign may be observed in paroxysmal WPW?
May be followed by polyuria: atrial dilatation –> ANP production –> polyuria
In what case would a WPW patient have a normal ECG?
If Bundle of His and Bundle of Kent have same conduction speed
What is the main possible abnormality on ECG in WPW?
Shortened PR interval