Cardiology Flashcards
What is normal heart rhythm called?
Sinus rhythm
What causes sinus arrhythmias?
Changes in the autonomic NS
Due to the rate of respiration
Pathological causes of sinus bradycardia?
MI- inferior affecting the R coronary artery Sick sinus syndrome Hypothermia Hypothyroidism Cholestatic jaundice Raised ICP Drugs: b-blockers, digoxin, verapamil
Management of symptomatic sinus bradycardia?
IC atropine
Think about a pacemaker if persistent
Pathological causes of sinus tachycardia?
Anxiety Fear Anaemia Heart failure Thyrotoxicosis Phaechromocytoma Drugs: b-agonists (bronchodilators)
What is sick sinus syndrome?
Fibrosis and degenerative changes/ischaemia of the SA node
Which arrhythmias can sick sinus syndrome cause?
Sinus bradycardia Sinoatrial block Paroxysmal atrial fibrillation Paroxysmal atrial tachycardia Atrioventricular block
Presentation of sick sinus syndrome?
Palpitations
Dizzy spells
Syncope
Types of atrial tachycardias?
Atrial ectopic beats
Atrial tachycardia
Atrial flutter
Atrial fibrillation
Presentation of atrial ectopic beats?
Usually asymptomatic
May feel like a skipped/missed beat
ECG of atrial ectopic beats?
Premature but normal QRS complex
When and how do you treat atrial ectopic beats?
If intrusive beats
B-blockers
Causes of atrial tachycardia?
Increased atrial automaticity
Sinoatrial disease
Digoxin toxicity
Management of atrial tachycardia?
B-blockers, anti-arrhythmic drugs
Catheter ablation if due to an ectopic site
Cause of atrial flutter?
Large re-entry circuit usually in the RA
What is happening in atrial flutter?
The atrium are contracting very quickly -> atrial rate about 300/min
Not all of these atrial beats are conducted to the ventricles -> tachycardia
All the atrial beats can be conducted in young people -> heart rate up to 300/min
Conduction of atrial beats is often 2:1 or 3:1 or 4:1 -> 150, 100, 75 bpm heart rate
ECG of atrial flutter?
Sawtooth flutter waves
More atrial sawtooth waves than QRS complexes
Management of atrial flutter?
Rate limitation: digoxin, b-blockers, verapamil to control the ventricular rate
Direct current cardioversion or IV amiodarone can restore sinus rhythm
Catheter ablation very effective for those with persistent symptoms
Pathology of atrial fibrillation?
Abnormal autonomic firing and presence of multiple interacting re-entry circuits
Initiate by ectopic beats (usually from the pulmonary veins)
Maintained by re-entry in the atria
ECG in atrial fibrillation?
Irregularly irregular
No P waves
Narrow complex
Types of atrial fibrillation?
Paroxysmal: intermittent, will self terminate
Persistent: prolonged episodes terminated by electrical/chemical cardioversion
Permanent
Causes of atrial fibrillation?
CHD Valvular heart disease: especially mitral valve disease Hypertension Sinoatrial disease Hyperthyroidism Alcohol Cardiomyopathy Congenital heart disease Chest infection Pulmonary embolism Pericardial disease Idiopathic
Presentation of atrial fibrillation?
Palpitation
Dyspnoea
Fatigue
Asymptomatic
How do you measure stroke risk for non-valvular atrial fibrillation?
CHA2DS2-VASc score
Management of atrial fibrillation?
Treat ant acute condition
Rhythm control: electrical cardioversion/pharmacological cardioversion with anticoagulation, catheter ablation
Rate control: digoxin, b-blockers, rate limiting calcium antagonists
Oral anticoagulation to prevent VTE
Types of supraventricular tachycardias?
Atrial fibrillation Atrial flutter Sinus tachycardia Wolff-Parkinson-White syndrome Atrioventricular nodal re-entrant tachycardia (AVNRT) Can occur with a bundle branch block
ECG of supraventricular tachycardias?
Narrow complex tachycardia
Presentation of AVNRT?
Rapid, very forceful, regular heart beat Chest discomfort Light-headedness Dyspnoea Polyuria due to release of ANP
Management of supraventricular tachycardia?
Vagal manoeuvres: carotid sinus pressure, valsalva manoeuvre
Adenosine/verapamil to restore sinus rhythms
Catheter ablation if recurrent
Wolff-Parkinson-White syndrome on ECG?
Delta waves
Narrow complex
Tachycardia
How do ventricular arrhythmias often present?
As cardiac arrest
Pathology of ventricular ectopic beats?
Rapid and simultaneous activation of the ventricles
Ectopic beats produce low stroke volume -> irregular pulse with weak/missed beats
ECG for ventricular ectopic beats?
Broad complexes
Random broad and deep complexes
When and how do you treat ventricular ectopic beats?
If highly symptomatic
B-blockers
Catheter ablation
When do people get ventricular ectopic beats?
Older age
During an acute MI
Heart failure
Digoxin toxicity
When do ventricular tachycardias occur?
Acute MI
Chronic coronary artery disease
Cardiomyopathy
Extensive ventricular disease
ECG in ventricular tachycardia?
Tachycardia
Broad, abnormal complexes
Left axis deviation
Presentation of ventricular tachycardia?
Palpitation
Symptoms of low cardiac output
Management of ventricular tachycardia?
Restore sinus rhythm:
Synchronised DC cardioversion if unstable
IV amiodarone
Correct abnormal electrolytes
Prophylaxis:
B-blockers
Implantable cardiac defibrillator
Surgery or catheter ablation
What is Torsades de pointes?
A ventricular tachycardia
ECG of Torsades de pointes?
Tachycardia Polymorphic Broad complexes Complexes oscillating Non-sustained Repetitive Prolonged QT (often when in sinus rhythm)
Management of Torsades de pointes?
Treat underlying cause
IV magnesium sulphate
B-blockers to prevent syncope
Defibrillation implantation: extreme QT prolongation, at risk patients
ECG in ventricular fibrillation?
Tachycardia
Rapid, bizarre and irregular ventricular complexes
Management of ventricular fibrillation?
As soon as possible
Defibrillation to induce sinus rhythm and normal cardiac output
Differentials for a regular broad complex tachycardia?
Ventricular tachycardia
Any cause of a narrow tachycardia + bundle branch block or metabolic broadening of the QRS complex
Differentials for an irregular broad complex tachycardia?
Torsades de pointes
Any cause of a narrow tachycardia + bundle branch block or metabolic broadening of the QRS complex
Differentials for a regular narrow complex tachycardia?
Sinoventricular tachycardia
Sinus tachycardia
Atrial flutter
Differentials fro an irregular narrow complex tachycardia?
Atrial fibrillation
What makes a tachycardia unstable?
Shock
Syncope
Myocardial ischaemia
Heart failure
Management of an unstable tachycardia?
Synchronised DC shock
Amiodarone 300 mg IV over 10-20 mins
Repeat shock
Amiodarone 900 mg over 24 hours
Types of atrioventricular heart block?
First degree
Second degree: Mobitz type I and Mobitz type II
Third degree/complete
What is first degree AV heart block?
AV conduction is delayed
All atrial impulses reach the ventricle
ECG of first degree AV heart block?
Bradycardia
Prolonged PR interval
Pathology of second degree AV heart block?
Some impulses from the atria fail to conduct to the ventricles -> dropped beat
ECG of Mobitz type I second degree AV heart block?
Bradycardia
Progressively lengthening successive PR intervals
Leads to a dropped beat
Cycle then repeats
ECG of Mobitz type II second degree AV heart block?
Bradycardia
PR intervals are constant
Some P waves are not conducted to the ventricles
Pathology of third degree/complete heart block?
Complete failure of the AV conduction
Atria and ventricles beat independently
ECG of third degree/complete heart block?
Bradycardia
Does not vary with exercise
Clinical features of third degree/complete heart block?
Bradycardia
Large volume pulse
Cannon waves in the neck
Intensity of S1 varies due to loss of AV synchrony
Management of third degree/complete heart block?
Pacemaker
What is a Stokes-Adam attack?
Episodes of ventricular asystole
Clinical features of a Stokes-Adam attack?
Sudden LOC Brief anoxic seizure Pallor/death like appearance Characteristic flush when heart starts to beat again Rapid recovery
Causes of right bundle branch block?
Normal variant
Right ventricular hypertrophy
Congenital heart disease
Coronary artery disease
Causes of left bundle branch block?
Coronary heart disease
Hypertension
Aortic valve disease
Cardiomyopathy
Pathology of a bundle branch block?
Block in the bundle branches
Depolarisation has to go slower through the myocardium
Delayed conduction into the ventricles
ECG of bundle branch block?
Broad QRS complex
ECG of a left bundle branch block?
WiLLiaM
ECG of a right bundle branch block?
MaRRoW
What is cardiac arrest?
Sudden and complete loss of cardiac output due to:
Asystole- VT, VF
Loss of mechanical cardiac contraction
Causes of cardiac arrest?
Coronary artery disease
VF or VT- often in the first few hours of a MI
Presentation of a cardiac arrest?
Unconscious
Pulseless
Breathing may take some time to stop completely
Death
How does ventricular tachycardia cause cardiac arrest?
When the ventricular rate is so high that effective mechanical contraction and relaxation doesn’t occur
What is asystole?
When there is no contraction due to no electrical activity in the ventricles
Management of asystole?
Precordial thump
External cardiac massage
IV atropine or adrenaline
Permanent pacemaker implantation
What is pulseless electrical activity?
When there is no effective cardiac output despite the presence of organised electrical activity
Causes of pulseless electrical activity?
Hypovolaemia Cardiac tamponade Tension pneumothorax Hypoxia Hypokalaemia Hyperkalaemia Metabolic causes Toxins Thrombosis: coronary or pulmonary
Causes of sudden cardiac death?
Coronary artery disease- 85%
Myocardial ischaemia
Acute MI
Prior MI with myocardial scarring
Structural heart disease- 10% Aortic stenosis Hypertrophic cardiomyopathy Dilated cardiomyopathy Arrhythmogenic right ventricular dysplasia Congenital heart disease
Non-structural heart disease- 5% Long QT syndrome Brugada syndrome Wolff-Parkinson-White syndrome Adverse drug reaction Severe electrolyte abnormalities
Baseline hypertension values?
140/90
Types of hypertension?
Essential- 95%
Secondary- 5%
Lifestyle management for hypertension?
Lose weight Ideal BMI Reduce alcohol Diet low in: salt, saturated fat Diet high in: fruit, vegetables, oily fish Exercise Smoking cessation
When to manage hypertension with drugs?
Severe hypertension (>180/>110)
Confirmed stage 2 hypertension (160/100)
Stage 1 hypertension (140/90) if target organ damage/disease, diabetes, 10 year CVD risk > 20%
Drug management for hypertension?
Stage 1:
> 55 years or black -> amlodipine (CCB)
< 55 years -> lisinopril (ACEi)
Stage 2:
Amlodipine + lisinopril
Stage 3:
Amlodipine + lisinopril + thiazide diuretic
Stage 4:
Amlodipine + lisinopril + thiazide diuretic + spironolactone
Stage 5:
Specialist referral
Which is the bad lipid to have?
LDL
Cholesterol
Management of hyperlipidaemia and hypercholestrolaemia?
Statin therapy- atorvastatin
Ezetimibe
Alirocumab
What is the pathological process causing atherosclerosis?
Progressive inflammation
Risk factors for atherosclerosis?
Age Sex Fix Smoking Hypertension Hypercholestrolaemia Diabetes mellitus Haemostatic factors- platelet activation, high plasma fibrinogen concentration, antiphospholipid antibodies Physical inactivity Obesity Alcohol Deficits of fruit, vegetables Polyunsaturated fats Social deprevation
Management of atherosclerosis?
Lifestyle advice
Statin therapy
Blood pressure optimisation
Anticoagulation if evidence of vascular disease
Causes of coronary artery disease?
Atheroma (most common)
Aortitis
Polyarteritis
Connective tissue disorders
Manifestations of coronary artery disease?
Stable angina Unstable angina Myocardial infarction Heart failure Arrhythmia Sudden death
What is acute coronary syndrome?
Unstable angina
Myocardial infarction
What is angina?
Symptomatic reversible myocardial ischaemia
Causes of angina?
Atheroma (main)
Rare: anaemia, coronary artery spasm, aortic stenosis, hypertrophic obstructive cardiomyopathy, arteritis/small vessel disease
Triggers of angina?
Exertion
Emotion
Cold weather
Heavy meals
Clinical features of angina?
Constricting/heavy discomfort to the chest, jaw, neck, shoulders, arms
Symptoms bought on by exertion
Symptoms reversed by 5 min rest or GTN
Catagories of angina?
Typical angina- all 3 features
Atypical angina- 2 features
Non-Anginas chest pain- 0/1 features
Types of angina?
Stable angina
Unstable angina
Decubitis angina: when lying flat
Variant angina: due to coronary artery spasm
What is the clinical difference between unstable angina and a NSTEMI?
NSTEMI has troponin changes
Investigations in angina?
Examination
ECG
Bloods: FBC, U&Es, TFTs, lipids, HbA1c, cardiac enzymes
Management of angina?
Treat any exacerbating factors: anaemia, tachycardia, thyrotoxicosis
Secondary prevention of CV disease: Lifestyle factors Optimise hypertension and diabetes control Antiplatelet therapy- 75 mg aspirin Statin therapy Consider ACEi
PRN symptomatic relief:
GTN spray or sublingual tablets
Anti-anginal medication: B-blocker- atenolol Calcium antagonist- amlodipine Long acting nitrates- isosorbide mononitrate Ivabradine (reduce HR and not affect BP) Ranolazine Nocorandil
Revascularisation if needed: PCI, CABG
What does PCI stand for?
Percutaneous coronary intervention
What does CABG stand for?
Coronary artery bypass graft?
Pathology of a myocardial infarction?
Myocardial necrosis due to acute occlusion of a coronary artery due to plaque rupture or erosion with superimposed thrombosis
Types of myocardial infarction?
STEMI
NSTEMI
What is a STEMI?
Acute coronary syndrome with ST elevation or new onset LBBB
What is a NSTEMI?
Troponin positive acute coronary syndrome without ST elevation
Symptoms of a myocardial infarction?
Chest pain: central, acute onset, severe, prolonged, radiation Nausea Vomiting Sweatiness Dyspnoea Palpitations Collapse/syncope Anxiety Fear of impending death
Signs of a myocardial infarction?
Sympathetic activation: pallor, sweating, tachycardia
Vagal activation: vomiting, bradycardia
Impaired myocardial function: hypotension, oliguria, cold peripheries, narrow pulse pressure, raised JVP, third heart sound, quiet first heart sound, diffuse apical impulse, lung crepitations
Tissue damage: fever
Complications e.g. mitral regurgitation, pericarditis
Investigations for a myocardial infarction?
ECG
Bloods: FBC, U&Es, glucose, lipid, cardiac enzymes
Chest x-ray
Echocardiography
Diagnosis of a myocardial infarction?
Detection of a rise/fall of cardiac biomarker values and:
Symptoms OR new/presumed significant ST or T wave changes OR development of pathological Q waves OR imaging evidence of new loss of viable myocardium OR identification of an intra-coronary thrombus by angiography or post mortem
Management of a STEMI?
Aspirin 300 mg Ticagrelor 180 mg Morphine Anti-emetic Primary PCI within 2 hours If not available in 2 hours -> fibrinolysis
Contraindications for PCI?
Active internal bleeding
Previous subarachnoid or intracerebral haemorrhage
Uncontrolled hypertension
Recent surgery within a month
Recent trauma
High probability of an active peptic ulcer
Pregnancy
Management of a NSTEMI?
High flow oxygen
Analgesia
Nitrates
Aspirin 300 mg
High risk patients: fondaparinux, another antiplatelet, IV nitrate, oral b-blocker
Low risk (more likely an unstable angina): monitor
Secondary prevention of myocardial infarction?
Smoking cessation Diet Statin therapy Optimise blood pressure Optimise diabetes Aspirin and clopidogrel B-blockers Coronary revascularisation Implantable cardiac defibrillator
Complications of myocardial infarction?
Arrhythmias Cardiac arrest Ischaemia Acute circulatory failure Pericarditis Mechanical defaults Embolism Impaired ventricular function, remodelling and ventricular aneurysm Cardiac tamponade
What is heart failure?
When the heart cannot maintain adequate output for the body’s requirements
What is cardiac output determined by?
Preload
Afterload
Myocardial contractility
Clinical features of left heart failure?
Rised JVP Pulmonary oedema Cardiomegaly Pleural effusions Pitting oedema
Clinical features of right heart failure?
Raised JVP
Hepatomegaly
Ascites
Severe peripheral pitting oedema
Systolic heart failure?
Inability of the ventricle to contract normally -> reduced cardiac output
Ejection fraction < 40%
Causes of systolic heart failure?
Ischaemic heart disease
Myocardial infarction
Cardiomyopathy
Diastolic heart failure?
Inability of the ventricle to relax and fill normally -> increased filling pressure
Ejection fraction > 50%
Causes of diastolic heart failure?
Ventricular hypertrophy Constrictive pericarditis Cardiac tamponade Restrictive cardiomyopathy Obesity
How to assess severity of heart failure?
New York classification of heart failure
Management of acute heart failure?
Sit the patient upright High flow oxygen IV access ECG monitoring Treat any arrhythmias Diamorphine IV Furosemide IV GTN spray or SL tablets Nitrate infusion if BP > 100 Treat as cariogenic shock if BP < 100
Management of chronic heart failure?
Lifestyle Treat cause Treat exacerbating factors Avoid exacerbating factors Annual flu vaccine and one-off pneumococcal vaccine Diuretics (loop) ACEi (ARB if a cough) B-blockers Mineralocorticoid receptor antagonists Digoxine Vasodilators Implantable cardiac defibrillator Coronary revascularisation Heart transplant Ventricular assist devices (VADs)
Causes of peripheral arterial disease?
Atheroma is the main cause
Risk factors for peripheral arterial disease?
Smoking
Diabetes mellitus
Hyperlipidaemia
Hypertension
Clinical features of peripheral arterial disease?
Cerebral: TIA, amaurosis fugal, vertobrobasilar insufficiency
Renal: hypertension, renal failure
Mesenteric arteries: mesenteric angina, acute intestinal ischaemia
Limbs: intermittent claudication, critical limb ischaemia, acute limb ischaemia
What happens if the onset of peripheral arterial disease is slow?
Collaterals will develop
Clinical features of limb peripheral arterial disease?
Reduced/absent pulses Bruits Reduced skin temperature Pallor on elevation Rubor on dependency Superficial veins that fill sluggishly and empty on minimal elevation Muscle-wasting Dry/thin/brittle skin and nails Hair loss Ankle-brachial pressure index (ABPI) < 1
What is intermittent claudication?
Ischaemic pain affecting the legs on exertion
Management of intermittent claudication?
Smoking cessation
Regular exercise
Antiplatelet agent
Cholesterol reduction: diet, statin therapy
Diagnose and treat diabetes if present
Diagnose and treat other conditions e.g. hypertension, anaemia, heart failure
What is critical limb ischaemia?
Rest (night) pain requiring opiate analgesia and/or tissue loss for > 2 weeks
ABPI < 0.5
Causes of acute limb ischaemia?
Thrombotic occlusion of a pre-existing stenotic arterial segment
Thromboembolism
Trauma
Iatrogenic
Clinical features of acute lumbar ischaemia?
Pain Pallor Pulselessness Perishing cold Paraesthesia Paralysis
Management of acute limb ischaemia?
Discuss with vascular surgeon
IV heparin
If due to thrombosis: IV heparin, anti platelet agents, high-dose statins, IV fluids, correct anaemia, oxygen, sometimes prostaglandins
If due to embolism: revascularisation, surgical embolectomy, local thrombolysis
Irreversible ischaemia: early amputation, palliative care
What is an aortic aneurysm?
Abnormal dilation of the aortic lumen
Locations of aortic aneurysm?
Abdominal
Dilated thoracic e.g. Marfan’s
Saccular thoracic e.g. atheromatous, syphilitic
Types of aortic aneurysm?
Non-specific Marfan's syndrome Aortitis Thoracic aortic aneurysms Abdominal aortic aneurysms
Who gets abdominal aortic aneurysms?
Male
Older
Presentation of abdominal aortic aneurysms?
Incidental Pain Thromboembolic complications Compression of surrounding structures: bowel obstruction, vomiting, oedema, DVT Rupture
Investigations for an abdominal aortic aneurysm?
Ultrasound
CT
Management of an abdominal aortic aneurysm?
Surgical repair- open or endovascular aneurysm repair (EVAR)
What is aortic dissection?
When the wall of the aorta is damaged and it splits creating a false lumen and true lumen
Types of aortic dissection?
Type A
Type B
What is a type A aortic dissection?
In the aortic arch and proximal descending aorta
High risk of rupture
What is a type B aortic dissection?
In the descending aorta
Lower risk of rupture
Risk factors for aortic dissection?
Hypertension Aortic atherosclerosis Aortic coarctation Collagen disorders Fibromuscular displasia Previous aortic surgery Pregnancy Trauma Iatrogenic
Clinical features of aortic dissection?
Tearing chest pain
Collapse
Hypertension (unless a major haemorrhage)
Asymmetry of brachial, carotid or femoral pulses
Investigations for aortic dissection?
Chest x-ray ECG Dopple echocardiography Transoesophageal echocardiography CT and MRI angiography
Management of aortic dissection?
Analgesia
Anti-hypertensives
Type A -> emergency surgery to replace the ascending aorta
Type B -> treat medically with B-blockers
What is the pathology of varicose veins?
Valves in the veins are incompetent so blood can pass from the deep to superficial veins -> venous hypertension, dilation of the superficial veins
Risk factors for varicose veins?
Prolonged standing Obesity Pregnancy FHx Contraceptive pill
Symptoms of varicose veins?
Pain Cramps Tingling Heaviness Restless legs
Signs of varicose veins?
Oedema Eczema Ulcers Haemosiderin Haemorrhage Phlebitis Atrophie blanche Lipodermatosclerosis
How to do a venous examination for varicose veins?
Inspection Palpation Tap test Auscultation Soppler Trendelenburg's test
Management of varicose veins?
Avoid prolonged standing Elevate legs where possible Support stockings Weight loss Regular walks Radiofrequency ablation/endovenous laser ablation/surgery
Pathology of acute rheumatic fever?
Immune mediated delayed response to a group A streptococci infection
Clinical features of acute rheumatic fever?
Sydenham's chorea Prior sore throat Carditis Dyspnoea Syncope Pericarditis Carey Coombs murmur Aortic/mitral regurgitation Heart block Subcutaneous nodules Flitting polyarthritis and arthralgia Oedema Erythma marginatum
Criteria used to diagnose acute rheumatic fever?
Jones criteria
Management of acute rheumatic fever?
Benzylpenicillin Bed rest until CRP is normal Supportive therapy Aspirin to control inflammatory symptoms Haloperidol or diazepam for chorea
How many people who are affected by rheumatic fever with carditis develop chronic valvular disease?
At least 50%
What is the most common valve affected by rheumatic fever?
Mitral valve > aortic > tricuspid > pulmonary
What is the pathology of chronic valvular disease following rheumatic fever?
Progressive fibrosis
Once the valve is damaged -> altered haemodynamic stresses perpetuate and extend the damage
Causes of mitral stenosis?
Usually rheumatic fever
Calcification (older people)
Rare form of congenital mitral stenosis
Pathology of mitral stenosis?
Reduced blood flow from left atrium to ventricle
Left atrium pressure rises
Pulmonary venous congestion and dyspnoea
Dilation and hypertrophy of the left atrium
Heart rate increases to drive left ventricle filling
Shorter diastole where the mitral valve is open
Further rise in atrial pressure
Situations needing increased cardiac output (exercise, pregnancy) -> higher left atrium pressure
What conditions can result from pathological changes in mitral stenosis?
Atrial fibrillation due to progressive dilation of the left atrium
Pulmonary hypertension due to rise in left atrial pressure
Pathological effects of mitral stenosis?
Pulmonary congestion
Right heart failure
Low cardiac output
Atrial fibrillation
Symptoms of mitral stenosis?
Dyspnoea Fatigue Oedema Ascites Palpitations Haemoptysis Cough Chest pain Thromboembolic complications
Signs of mitral stenosis?
Atrial fibrillation Mitral facies Loud first heart sound Mid-diastolic murmur (bell at apex) Crepitations Pulmonary oedema Effusions Right ventricular heave Loud P2 (pulmonary hypertension)
Investigations for mitral stenosis?
ECG: right ventricular hypertrophy (tall R waves in V1-V3)
Chest x-ray: dilated LA, signs of pulmonary venous congestion
Echocardigraphy: thick immobile cusps, reduced valve area, enlarged LA, reduced rate of diastolic filling of LV
Doppler
Cardiac catheterisation
Management of mitral stenosis?
Rate control if in AF Anticoagulation Diuretics (pulmonary congestion) Balloon valvuoplasty or valve replacement Yearly follow ups as stenosis can recur
Causes of mitral regurgitation?
Rheumatic disease
Mitral valve prolapse
Dilation of the left ventricle and mitral valve ring e.g. coronary artery disease, cardiomyopathy
Damage to valve cusps and chord e.g. rheumatic heart disease, endocarditis
Ischaemia/infarction of the papillary muscle
Myocardial infarction
Following mitral valvotomy/valvuoplasty
Pathology of chronic mitral regurgitation
Gradual dilation of the left atrium with little increase in pressure -> few symptoms
Left ventricle slowly dilates too and ventricle and atrium pressures increase very gradually
Does acute mitral regurgitation cause symptoms?
Yes
Pathological processes in mitral regurgitation?
Pulmonary venous congestion Low cardiac output Atrial fibrillation Increased stroke volume Right heart failure
Symptoms of mitral regurgitation?
Dyspnoea Fatigue Palpitation Oedema Ascites
Signs of mitral regurgitation?
Atrial fibrillation/flutter
Cardiomegaly
Apical pansstolic murmur
Soft S1
Apical S3
Signs of pulmonary venous congestion- crepitations, pulmonary oedema, effusions
Signs of pulmonary hypertension and right heart failure
Investigations for mitral regurgitation?
ECG: left atrium and ventricle hypertrophy
Chest x-ray: enlarged left atrium and ventricle, pulmonary venous congestion, pulmonary oedema
Echocardiography: dilated left atrium and ventricle, dynamic left ventricle, structural abnormalities e.g. prolapse
Doppler: detects and quantifies regurgitation
Cardiac catheterisation
Management of mitral regurgitation?
Rate control if fast AF Anti-coagulate if AF Diuretics for symptoms Anti-hypertensives Regular review Valve replacement/repair if: worsening symptoms, progressive cardiomegaly, echocardiographic evidence of deteriorating left ventricle function
Causes of aortic stenosis?
Infants/children/adolescents:
Congenital aortic stenosis
Congenital subvalvular aortic stenosis
Congenital supravalvular aortic stenosis
Young adults/middle aged:
Calcification and fibrosis of congenitally bicuspid aortic valve
Rheumatic aortic stenosis
Middle aged/elderly:
Senile degenerative aortic stenosis
Calcification of bicuspid valve
Rheumatic aortic stenosis
Pathology of aortic stenosis?
Left ventricle hypertrophies and coronary blood flow may be inadequate here
Fixed outflow obstruction limits increase in cardiac output required on exercise
Pulmonary oedema
Symptoms of aortic stenosis?
Exertional dyspnoea Exertional syncope Angina Sudden death Episodes of acute pulmonary oedema
Signs of aortic stenosis?
Ejection systolic murmur Slow rising carotid pulse Thrusting apex beat Narrow pulse pressure Signs of pulmonary venous congestion e.g. crepitations
Investigations for aortic stenosis?
ECG: left ventricular hypertrophy, LBBB
Chest x-ray: normal, enlarged left ventricle, dilated ascending aorta, calcified valve
Echocardiography: calcified valve, hypertrophied left ventricle
Doppler: severity, associated aortic regurgitation
Cardiac catheterisation: CHD
When do you manage aortic stenosis?
When it become symptomatic
Management for aortic stenosis?
Prompt
Aortic valve replacement: surgery or TAVI
Causes of aortic regurgitation?
Congenital: bicuspid valve or disproportionate cusps
Acquired: rheumatic disease, infective endocarditis, trauma, aortic dilation
Signs of aortic regurgitation?
Large volume pulse Collapsing pulse Low diastolic pressure Increased pulse pressure Bounding peripheral pulses Carotid pulsation (Corrigan's sign) Capillary visual pulsation (Quincke's sign) Femoral bruit (Duroziez's sign) Pistol shot over femoral arteries (Traube's sign) Head nodding (de Musset's sign) Early diastolic murmur Austin Flint murmur Displaced, heaving apex beat Pre-systolic impulse Fourth heart sound Crepitations
Investigations for aortic regurgitation?
ECG: later LV hypertrophy, T wave inversion
Chest x-ray: cardiac dilation, aortic dilation, features of left heart failure
Echocardiography: dilated LV, hyper dynamic LV, reflux, fluttering anterior mitral leaflet
Cardiac catheterisation: dilated LV, aortic regurgitation, dilated aortic root
Management of aortic regurgitation?
ACE inhibitors
Echocardiogram every 6-12 months
Surgery if: severe enlarged ascending aorta, increasing symptoms, enlarging LV, deteriorating LV function, IE
Causes of tricuspid stenosis?
Rheumatic fever
Symptoms of tricuspid stenosis?
Hepatic discomfort
Peripheral oedema
Signs of tricuspid stenosis?
Raised JVP Hepatomegaly Ascites Peripheral pitting oedema Mid-diastolic murmur
Investigations for tricuspid stenosis?
Echocardiography with doppler
Management of tricuspid stenosis?
Diuretics
Valve repair
Causes of tricuspid regurgitation?
Rheumatic heart disease Endocarditis Ebstein's congenital anomaly Right ventricle dilation due to chronic left heart failure Right ventricular infarction Pulmonary hypertension
Symptoms of tricuspid regurgitation?
Usually non-specific Fatigue Oedema Hepatic enlargement Hepatic pain on exertion Ascites
Signs of tricuspid regurgitation?
Giant wave in the JVP Pansystolic murmur at left sternal edge Pulsatile liver Right ventricular heave Ascites
Investigations for tricuspid regurgitation?
Echocardiography: dilated RV, thickened valve leaflets (rheumatic), vegetations (endocarditis)
Management of tricuspid regurgitation?
Correct the cause of right ventricular overload
Diuretic and vasodilator in congestive cardiac failure
Tricuspid valve replacement if rheumatic damage
What is infective endocarditis?
Microbial infection of a heart valve, lining of a cardiac chamber/blood vessel or congenital abnormality
Causes of infective endocarditis?
Bacterial
Fungal
Other: SLE, malignancy
Risk factors for infective endocarditis?
Skin breaches Renal failure Immunosuppression Diabetes mellitus Aortic or mitral valve disease Tricuspid valves in IVDU Coarctation Patent ductus arteriosis Ventricular septal defects Prosthetic valve
Clinical features of infective endocarditis?
Septic signs of infection: fever, riggers, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing
Cardiac lesion: new murmur, change in murmur
Immune complex deposition: vasculitis, microscopic haematuria, glomerulonephritis, AKI, Roth spots, splinter haemorrhages, Osler’s nodes
Embolic signs: abscesses in organ (Janeway lesions on skin)
Investigations for infective endocarditis?
Bloods: FBC, U&Es, CRP, ESR, WCC Blood culture Urinalysis Echocardiography ECG Chest x-ray
When do you have to presume something is endocarditis?
Fever + new murmur
Unless proven otherwise
Criteria for diagnosing infective endocarditis?
Duke criteria
2 major or 1 major +3 minor or 5 minor
Management of infective endocarditis?
Antibiotic therapy
Surgery, if: heart failure, valvular obstruction, repeated emboli, fungal IE, persistent bacteraemia, myocardial abscess, unstable infected prosthetic valve
Causes of congenital heart disease?
Maternal rubella infection
Maternal alcohol misuse
Maternal lupus erythematosus
Genetic/chromosomal abnormalities
Clinical features of congenital heart disease at birth/neonatal?
Cyanosis
Heart failure
Clinical features of congenital heart disease in infancy/childhood?
Cyanosis Heart failure Arrhythmia Murmur Failure to thrive
Clinical features of congenital heart disease in adolescence/adulthood?
Heart failure Murmur Arrhythmia Cyanosis Hypertension Late consequences of previous cardiac surgery
Congenital heart disease causes of central cyanosis and digital clubbing?
Neonate: transposition of the great arteries
Older children: severe pulmonary stenosis or pulmonary vascular disease
Congenital heart disease causes of growth retardation?
Large left-to-right shunts
Congenital heart disease causes of syncope?
Due to arrhythmias
What causes pulmonary hypertension in congenital heart disease?
When the pulmonary flow is persistently raised (left-to-right shunt) -> increased pulmonary resistance -> pulmonary hypertension
What is Eisenmenger’s syndrome?
When a shunt reverses in severe pulmonary hypertension
What is persistent ductus arteriosus?
When the hole between the aorta and pulmonary artery remains open
Clinical features of persistent ductus arteriosus?
Retarded growth and development
Cardiac failure -> dyspnoea
Continuous murmur maximal in second left intercostal space
Thrill
Increased pulse volume
Eisenmenger’s syndrome: murmur quieter/only in systole/disappear
Management of persistent ductus arteriosus?
Neonatal period: prostaglandin synthetase inhibitor
Closed by an implantable occlusive device at cardiac catheterisation
If impaired lung perfusion: keep ductus open with prostaglandin treatment
What is coarctation of the aorta?
Narrowing of the aorta in the region where the ductus arteriosus joins
Clinical features of coarctation of the aorta?
Cardiac failure in the newborn
Headache
Leg weakness and cramps
Upper body hypertension and normal/hypotension in lower body
Femoral pulses are weak and delayed (compared to radial)
Ejection click and systolic murmur in aortic region
Collateral formation -> bruits
Investigations for coarctation of the aorta?
Chest x-ray: changes appear later on
MRI (best imaging here)
ECG: LV hypertrophy
Echocardiography: LV hypertrophy
Management of coarctation of the aorta?
Surgical correction
Stenosis can re-occur with growth -> balloon dilation and stunting
Long term follow up
What is atrial septal defect?
Hole between the two atria
Blood shunts from the left atrium to the right atrium
More blood going through the right side of the heart -> enlargement of right heart and pulmonary arteries
Clinical features of atrial septal defect?
Most are aysmptomatic Dyspnoea Chest infections Cardiac failure Arrhythmias: especially AF
Investigations for atrial septal defect?
Chest x-ray: enlargement of heart and pulmonary artery
ECG: incomplete RBBB
Echocardiography: defect, RV dilation, RV hypertrophy, pulmonary artery dilation
Transoesophageal echocardiography
Management of atrial septal defect?
Surgical closure at cardiac catheterisation with an implantable closure device
When not to surgically close an atrial septal defect?
Pulmonary hypertension, shunt reversal
What is a ventricular septal defect?
Hole between the two ventricles
Either congenital or acquired (post MI etc.)
Clinical features of a ventricular septal defect?
Pansystolic murmur
Cardiac failure in infants
Investigations for ventricular septal defect?
Chest x-ray
ECG: bilateral ventricular hypertrophy
Doppler echocardiography: to predict which smaller defects might close spontaneously
Management of ventricular septal defect?
Small -> no treatment
Infant cardiac failure: digoxin, diuretics
Persistent failure -> surgical repair (not in Eisenmenger’s)
Eisenmenger’s syndrome: heart-lung transplant
What is Tetralogy of Fallot?
Combination of: Pulmonary stenosis Overriding aorta Ventricular septal defect Right ventricular hypertrophy Causes high RV pressure and right-to-left shunting through septal defect
Clinical features of Tetralogy of Fallot?
Cyanosis Stunted growth Digital clubbing Polycythaemia Faloot's sign Loud ejection systolic murmur in the pulmonary area
Investigations for Tetralogy of Fallot?
ECG: RV hypertrophy
Chest x-ray: small pulmonary artery, boot shaped heart
Management of Tetralogy of Fallot?
Surgical correction of pulmonary stenosis
Surgical closure of ventricular septal defect
Follow up
Implantable defibrillation sometimes needed in adulthood
Effects of cardiac surgery in adulthood?
Correction of coarctation -> hypertension
Mustard repair of great vessel transposition -> RV failure
Atrial surgery -> atrial arrhythmias
Ventricle scars -> ventricular arrhythmias
What is cardiomyopathy?
Disease of the myocardium
Causes of cardiomyopathy?
Inherited
Infective
Toxic
Idiopathic
Types of cardiomyopathy?
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Arrhythmic right ventricular cardiomyopathy
What is dilated cardiomyopathy?
Dilation and impaired contraction of the left ventricle and often the right ventricle
Valve rings are dilated -> mitral and tricuspid incompetence
Causes of dilated cardiomyopathy?
Alcohol Hypertension Chemotherapeutics Haemochromatosis Peri- or post-partum Thyrotoxicosis Congenital Late autoimmune react to viral myocarditis
Symptoms of dilated cardiomyopathy?
Heart failure Asymptomatic Sporadic chest pain Fatigue Dyspnoea
Signs of dilated cardiomyopathy?
Tachycardia Hypotension Raised JVP Displaced and diffuse apex beat S3 gallop Mitral/tricuspid regurgitation Pleural effusion Oedema Jaundice Hepatomegaly Ascites
Investigations for dilated cardiomyopathy?
ECG
Echocardiography
Cardiac MRI
Management of dilated cardiomyopathy?
Bed rest Control heart failure B-blockers ACE inhibitors Anti-coagulation Biventricular pacing Cardiac transplantation
What is hypertrophic cardiomyopathy?
Left ventricular hypertrophy
Left ventricular outflow obstruction
Cause of hypertrophic cardiomyopathy?
Autosomal dominant inheritance
Symptoms of hypertrophic cardiomyopathy?
Angina on effort
Dyspnoea on effort
Syncope on effort
Sudden death
Signs of hypertrophic cardiomyopathy?
Jerky pulse Palpable left ventricular hypertrophy Double impulse at apex Mid-systolic murmur at the base Pansystolic murmur at the apex
Investigations for hypertrophic cardiomyopathy?
ECG: LV hypertrophy, progressive T wave inversion, deep Q waves, AF, WPW syndrome, ventricular ectopics, VT
Echocardiography: asymmetrical septal hypertrophy, small LV cavity with hyper contractile properties, mid-systolic closure of aortic valve, systolic anterior movement of mitral valve
MRI
Cardiac catheterisation: assess severity, CAD, mitral regurgitation
Exercise test
What helps stratify risk and severity in hypertrophic cardiomyopathy?
Cardiac catheterisation
Exercise test
Management of hypertrophic cardiomyopathy?
B-blockers or verapamil for symptoms Amiodarone for arrhythmias Anti-coagulation for paroxysmal AF or systemic emboli Septal myomectomy Implantable defibrillator
What is restrictive cardiomyopathy?
When ventricular filling is impaired as the ventricles are too stiff -> high atrial pressures, atrial hypertrophy/dilation, AF
Causes of restrictive cardiomyopathy?
Amyloidosis Idiopathic Haemochomatosis Sarcoidosis Scleroderma Löffler's eosinophilic endocarditis Endomyocardial fibrosis
Clinical features of restrictive cardiomyopathy?
Like constrictive pericarditis Right heart failure Raised JVP Hepatomegaly Ascites Oedema
Investigations for restrictive cardiomyopathy?
Echocardiography
MRI
Cardiac catheterisation
Management of restrictive cardiomyopathy?
Treat the underlying cause
What is arrhythmogenic right ventricular cardiomyopathy?
When areas of right ventricular myocardium are replaced with fibrous and fatty tissue
Risks of arrhythmogenic right ventricular cardiomyopathy?
Ventricular arrhythmias
Sudden death
Right sided heart failure
Investigations for arrhythmogenic right ventricular cardiomyopathy?
ECG: slightly broad QRS, inverted T waves in right precordial leads
MRI
Management of arrhythmogenic right ventricular cardiomyopathy?
Implantable cardiac defibrillator
What is pericarditis?
Inflammation of the pericardium
Causes of pericarditis?
Idiopathic
Secondary to: viruses, bacteria, fungi, autoimmune systemic diseases, drugs, metabolic, trauma, surgery, malignancy, radiotherapy
Clinical features of pericarditis?
Central chest pain worse on inspiration/lying flat
Pain may be relieved sitting forward
Pericardial friction rub
Evidence of pericardial effusion: dyspnoea, chest pain, local structures being compressed, bronchial breathing at left base, muffled heart signs
Evidence of cardiac tamponade: tachycardia, hypotension, pulses paradoxes, raised JVP, Kussmaul’s sign, muffled heart signs
Fever
Investigations for pericarditis?
ECG: concave (saddle shaped) ST segment elevation
Bloods: FBC, U&Es, ESR, cardiac enzymes
Chest x-ray: cardiomegaly
Echocardiography: if you suspect an effusion
Management of pericarditis?
NSAIDs or aspirin with gastric protection
Colchicine
Rest
Treat the cause
Treat pericardial effusion/cardiac tamponade
What is constrictive pericarditis?
When the heart is encased in a rigid pericardium
Causes of constrictive pericarditis?
Idiopathic
TB
After any pericarditis
Clinical features of constrictive pericarditis?
Similar to right heart failure Raised JVP Kussmaul's sign Soft, diffuse apex beat Quiet heart sounds D3 Diastolic pericardial knock Hepatosplenomegaly Ascites Oedema
Investigations for constrictive pericarditis?
Chest x-ray: small heart, pericardial calcification
CT/MRI: to distinguish form restrictive cardiomyopathy
Echocardiography
Cardiac catheterisation
Management of constrictive pericarditis?
Surgical excision
