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Year 4 Semester 2 > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What is normal heart rhythm called?

A

Sinus rhythm

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2
Q

What causes sinus arrhythmias?

A

Changes in the autonomic NS

Due to the rate of respiration

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3
Q

Pathological causes of sinus bradycardia?

A 
MI- inferior affecting the R coronary artery
Sick sinus syndrome
Hypothermia
Hypothyroidism
Cholestatic jaundice
Raised ICP
Drugs: b-blockers, digoxin, verapamil
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4
Q

Management of symptomatic sinus bradycardia?

A

IC atropine

Think about a pacemaker if persistent

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5
Q

Pathological causes of sinus tachycardia?

A 
Anxiety
Fear
Anaemia
Heart failure
Thyrotoxicosis
Phaechromocytoma
Drugs: b-agonists (bronchodilators)
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6
Q

What is sick sinus syndrome?

A

Fibrosis and degenerative changes/ischaemia of the SA node

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7
Q

Which arrhythmias can sick sinus syndrome cause?

A 
Sinus bradycardia
Sinoatrial block
Paroxysmal atrial fibrillation
Paroxysmal atrial tachycardia
Atrioventricular block
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8
Q

Presentation of sick sinus syndrome?

A

Palpitations
Dizzy spells
Syncope

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9
Q

Types of atrial tachycardias?

A

Atrial ectopic beats
Atrial tachycardia
Atrial flutter
Atrial fibrillation

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10
Q

Presentation of atrial ectopic beats?

A

Usually asymptomatic

May feel like a skipped/missed beat

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11
Q

ECG of atrial ectopic beats?

A

Premature but normal QRS complex

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12
Q

When and how do you treat atrial ectopic beats?

A

If intrusive beats

B-blockers

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13
Q

Causes of atrial tachycardia?

A

Increased atrial automaticity
Sinoatrial disease
Digoxin toxicity

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14
Q

Management of atrial tachycardia?

A

B-blockers, anti-arrhythmic drugs

Catheter ablation if due to an ectopic site

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15
Q

Cause of atrial flutter?

A

Large re-entry circuit usually in the RA

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16
Q

What is happening in atrial flutter?

A

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

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17
Q

ECG of atrial flutter?

A

Sawtooth flutter waves

More atrial sawtooth waves than QRS complexes

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18
Q

Management of atrial flutter?

A

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

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19
Q

Pathology of atrial fibrillation?

A

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

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20
Q

ECG in atrial fibrillation?

A

Irregularly irregular
No P waves
Narrow complex

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21
Q

Types of atrial fibrillation?

A

Paroxysmal: intermittent, will self terminate
Persistent: prolonged episodes terminated by electrical/chemical cardioversion
Permanent

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22
Q

Causes of atrial fibrillation?

A 
CHD
Valvular heart disease: especially mitral valve disease
Hypertension
Sinoatrial disease
Hyperthyroidism
Alcohol
Cardiomyopathy
Congenital heart disease
Chest infection
Pulmonary embolism
Pericardial disease
Idiopathic
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23
Q

Presentation of atrial fibrillation?

A

Palpitation
Dyspnoea
Fatigue
Asymptomatic

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24
Q

How do you measure stroke risk for non-valvular atrial fibrillation?

A

CHA2DS2-VASc score

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25
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
26
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 ```
27
ECG of supraventricular tachycardias?
Narrow complex tachycardia
28
Presentation of AVNRT?
``` Rapid, very forceful, regular heart beat Chest discomfort Light-headedness Dyspnoea Polyuria due to release of ANP ```
29
Management of supraventricular tachycardia?
Vagal manoeuvres: carotid sinus pressure, valsalva manoeuvre Adenosine/verapamil to restore sinus rhythms Catheter ablation if recurrent
30
Wolff-Parkinson-White syndrome on ECG?
Delta waves Narrow complex Tachycardia
31
How do ventricular arrhythmias often present?
As cardiac arrest
32
Pathology of ventricular ectopic beats?
Rapid and simultaneous activation of the ventricles | Ectopic beats produce low stroke volume -> irregular pulse with weak/missed beats
33
ECG for ventricular ectopic beats?
Broad complexes | Random broad and deep complexes
34
When and how do you treat ventricular ectopic beats?
If highly symptomatic B-blockers Catheter ablation
35
When do people get ventricular ectopic beats?
Older age During an acute MI Heart failure Digoxin toxicity
36
When do ventricular tachycardias occur?
Acute MI Chronic coronary artery disease Cardiomyopathy Extensive ventricular disease
37
ECG in ventricular tachycardia?
Tachycardia Broad, abnormal complexes Left axis deviation
38
Presentation of ventricular tachycardia?
Palpitation | Symptoms of low cardiac output
39
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
40
What is Torsades de pointes?
A ventricular tachycardia
41
ECG of Torsades de pointes?
``` Tachycardia Polymorphic Broad complexes Complexes oscillating Non-sustained Repetitive Prolonged QT (often when in sinus rhythm) ```
42
Management of Torsades de pointes?
Treat underlying cause IV magnesium sulphate B-blockers to prevent syncope Defibrillation implantation: extreme QT prolongation, at risk patients
43
ECG in ventricular fibrillation?
Tachycardia | Rapid, bizarre and irregular ventricular complexes
44
Management of ventricular fibrillation?
As soon as possible | Defibrillation to induce sinus rhythm and normal cardiac output
45
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
46
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
47
Differentials for a regular narrow complex tachycardia?
Sinoventricular tachycardia Sinus tachycardia Atrial flutter
48
Differentials fro an irregular narrow complex tachycardia?
Atrial fibrillation
49
What makes a tachycardia unstable?
Shock Syncope Myocardial ischaemia Heart failure
50
Management of an unstable tachycardia?
Synchronised DC shock Amiodarone 300 mg IV over 10-20 mins Repeat shock Amiodarone 900 mg over 24 hours
51
Types of atrioventricular heart block?
First degree Second degree: Mobitz type I and Mobitz type II Third degree/complete
52
What is first degree AV heart block?
AV conduction is delayed | All atrial impulses reach the ventricle
53
ECG of first degree AV heart block?
Bradycardia | Prolonged PR interval
54
Pathology of second degree AV heart block?
Some impulses from the atria fail to conduct to the ventricles -> dropped beat
55
ECG of Mobitz type I second degree AV heart block?
Bradycardia Progressively lengthening successive PR intervals Leads to a dropped beat Cycle then repeats
56
ECG of Mobitz type II second degree AV heart block?
Bradycardia PR intervals are constant Some P waves are not conducted to the ventricles
57
Pathology of third degree/complete heart block?
Complete failure of the AV conduction | Atria and ventricles beat independently
58
ECG of third degree/complete heart block?
Bradycardia | Does not vary with exercise
59
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
60
Management of third degree/complete heart block?
Pacemaker
61
What is a Stokes-Adam attack?
Episodes of ventricular asystole
62
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 ```
63
Causes of right bundle branch block?
Normal variant Right ventricular hypertrophy Congenital heart disease Coronary artery disease
64
Causes of left bundle branch block?
Coronary heart disease Hypertension Aortic valve disease Cardiomyopathy
65
Pathology of a bundle branch block?
Block in the bundle branches Depolarisation has to go slower through the myocardium Delayed conduction into the ventricles
66
ECG of bundle branch block?
Broad QRS complex
67
ECG of a left bundle branch block?
WiLLiaM
68
ECG of a right bundle branch block?
MaRRoW
69
What is cardiac arrest?
Sudden and complete loss of cardiac output due to: Asystole- VT, VF Loss of mechanical cardiac contraction
70
Causes of cardiac arrest?
Coronary artery disease | VF or VT- often in the first few hours of a MI
71
Presentation of a cardiac arrest?
Unconscious Pulseless Breathing may take some time to stop completely Death
72
How does ventricular tachycardia cause cardiac arrest?
When the ventricular rate is so high that effective mechanical contraction and relaxation doesn't occur
73
What is asystole?
When there is no contraction due to no electrical activity in the ventricles
74
Management of asystole?
Precordial thump External cardiac massage IV atropine or adrenaline Permanent pacemaker implantation
75
What is pulseless electrical activity?
When there is no effective cardiac output despite the presence of organised electrical activity
76
Causes of pulseless electrical activity?
``` Hypovolaemia Cardiac tamponade Tension pneumothorax Hypoxia Hypokalaemia Hyperkalaemia Metabolic causes Toxins Thrombosis: coronary or pulmonary ```
77
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 ```
78
Baseline hypertension values?
140/90
79
Types of hypertension?
Essential- 95% | Secondary- 5%
80
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 ```
81
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%
82
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
83
Which is the bad lipid to have?
LDL | Cholesterol
84
Management of hyperlipidaemia and hypercholestrolaemia?
Statin therapy- atorvastatin Ezetimibe Alirocumab
85
What is the pathological process causing atherosclerosis?
Progressive inflammation
86
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 ```
87
Management of atherosclerosis?
Lifestyle advice Statin therapy Blood pressure optimisation Anticoagulation if evidence of vascular disease
88
Causes of coronary artery disease?
Atheroma (most common) Aortitis Polyarteritis Connective tissue disorders
89
Manifestations of coronary artery disease?
``` Stable angina Unstable angina Myocardial infarction Heart failure Arrhythmia Sudden death ```
90
What is acute coronary syndrome?
Unstable angina | Myocardial infarction
91
What is angina?
Symptomatic reversible myocardial ischaemia
92
Causes of angina?
Atheroma (main) Rare: anaemia, coronary artery spasm, aortic stenosis, hypertrophic obstructive cardiomyopathy, arteritis/small vessel disease
93
Triggers of angina?
Exertion Emotion Cold weather Heavy meals
94
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
95
Catagories of angina?
Typical angina- all 3 features Atypical angina- 2 features Non-Anginas chest pain- 0/1 features
96
Types of angina?
Stable angina Unstable angina Decubitis angina: when lying flat Variant angina: due to coronary artery spasm
97
What is the clinical difference between unstable angina and a NSTEMI?
NSTEMI has troponin changes
98
Investigations in angina?
Examination ECG Bloods: FBC, U&Es, TFTs, lipids, HbA1c, cardiac enzymes
99
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
100
What does PCI stand for?
Percutaneous coronary intervention
101
What does CABG stand for?
Coronary artery bypass graft?
102
Pathology of a myocardial infarction?
Myocardial necrosis due to acute occlusion of a coronary artery due to plaque rupture or erosion with superimposed thrombosis
103
Types of myocardial infarction?
STEMI | NSTEMI
104
What is a STEMI?
Acute coronary syndrome with ST elevation or new onset LBBB
105
What is a NSTEMI?
Troponin positive acute coronary syndrome without ST elevation
106
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 ```
107
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
108
Investigations for a myocardial infarction?
ECG Bloods: FBC, U&Es, glucose, lipid, cardiac enzymes Chest x-ray Echocardiography
109
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
110
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 ```
111
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
112
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
113
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 ```
114
Complications of myocardial infarction?
``` Arrhythmias Cardiac arrest Ischaemia Acute circulatory failure Pericarditis Mechanical defaults Embolism Impaired ventricular function, remodelling and ventricular aneurysm Cardiac tamponade ```
115
What is heart failure?
When the heart cannot maintain adequate output for the body's requirements
116
What is cardiac output determined by?
Preload Afterload Myocardial contractility
117
Clinical features of left heart failure?
``` Rised JVP Pulmonary oedema Cardiomegaly Pleural effusions Pitting oedema ```
118
Clinical features of right heart failure?
Raised JVP Hepatomegaly Ascites Severe peripheral pitting oedema
119
Systolic heart failure?
Inability of the ventricle to contract normally -> reduced cardiac output Ejection fraction < 40%
120
Causes of systolic heart failure?
Ischaemic heart disease Myocardial infarction Cardiomyopathy
121
Diastolic heart failure?
Inability of the ventricle to relax and fill normally -> increased filling pressure Ejection fraction > 50%
122
Causes of diastolic heart failure?
``` Ventricular hypertrophy Constrictive pericarditis Cardiac tamponade Restrictive cardiomyopathy Obesity ```
123
How to assess severity of heart failure?
New York classification of heart failure
124
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 ```
125
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) ```
126
Causes of peripheral arterial disease?
Atheroma is the main cause
127
Risk factors for peripheral arterial disease?
Smoking Diabetes mellitus Hyperlipidaemia Hypertension
128
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
129
What happens if the onset of peripheral arterial disease is slow?
Collaterals will develop
130
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 ```
131
What is intermittent claudication?
Ischaemic pain affecting the legs on exertion
132
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
133
What is critical limb ischaemia?
Rest (night) pain requiring opiate analgesia and/or tissue loss for > 2 weeks ABPI < 0.5
134
Causes of acute limb ischaemia?
Thrombotic occlusion of a pre-existing stenotic arterial segment Thromboembolism Trauma Iatrogenic
135
Clinical features of acute lumbar ischaemia?
``` Pain Pallor Pulselessness Perishing cold Paraesthesia Paralysis ```
136
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
137
What is an aortic aneurysm?
Abnormal dilation of the aortic lumen
138
Locations of aortic aneurysm?
Abdominal Dilated thoracic e.g. Marfan's Saccular thoracic e.g. atheromatous, syphilitic
139
Types of aortic aneurysm?
``` Non-specific Marfan's syndrome Aortitis Thoracic aortic aneurysms Abdominal aortic aneurysms ```
140
Who gets abdominal aortic aneurysms?
Male | Older
141
Presentation of abdominal aortic aneurysms?
``` Incidental Pain Thromboembolic complications Compression of surrounding structures: bowel obstruction, vomiting, oedema, DVT Rupture ```
142
Investigations for an abdominal aortic aneurysm?
Ultrasound | CT
143
Management of an abdominal aortic aneurysm?
Surgical repair- open or endovascular aneurysm repair (EVAR)
144
What is aortic dissection?
When the wall of the aorta is damaged and it splits creating a false lumen and true lumen
145
Types of aortic dissection?
Type A | Type B
146
What is a type A aortic dissection?
In the aortic arch and proximal descending aorta | High risk of rupture
147
What is a type B aortic dissection?
In the descending aorta | Lower risk of rupture
148
Risk factors for aortic dissection?
``` Hypertension Aortic atherosclerosis Aortic coarctation Collagen disorders Fibromuscular displasia Previous aortic surgery Pregnancy Trauma Iatrogenic ```
149
Clinical features of aortic dissection?
Tearing chest pain Collapse Hypertension (unless a major haemorrhage) Asymmetry of brachial, carotid or femoral pulses
150
Investigations for aortic dissection?
``` Chest x-ray ECG Dopple echocardiography Transoesophageal echocardiography CT and MRI angiography ```
151
Management of aortic dissection?
Analgesia Anti-hypertensives Type A -> emergency surgery to replace the ascending aorta Type B -> treat medically with B-blockers
152
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
153
Risk factors for varicose veins?
``` Prolonged standing Obesity Pregnancy FHx Contraceptive pill ```
154
Symptoms of varicose veins?
``` Pain Cramps Tingling Heaviness Restless legs ```
155
Signs of varicose veins?
``` Oedema Eczema Ulcers Haemosiderin Haemorrhage Phlebitis Atrophie blanche Lipodermatosclerosis ```
156
How to do a venous examination for varicose veins?
``` Inspection Palpation Tap test Auscultation Soppler Trendelenburg's test ```
157
Management of varicose veins?
``` Avoid prolonged standing Elevate legs where possible Support stockings Weight loss Regular walks Radiofrequency ablation/endovenous laser ablation/surgery ```
158
Pathology of acute rheumatic fever?
Immune mediated delayed response to a group A streptococci infection
159
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 ```
160
Criteria used to diagnose acute rheumatic fever?
Jones criteria
161
Management of acute rheumatic fever?
``` Benzylpenicillin Bed rest until CRP is normal Supportive therapy Aspirin to control inflammatory symptoms Haloperidol or diazepam for chorea ```
162
How many people who are affected by rheumatic fever with carditis develop chronic valvular disease?
At least 50%
163
What is the most common valve affected by rheumatic fever?
Mitral valve > aortic > tricuspid > pulmonary
164
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
165
Causes of mitral stenosis?
Usually rheumatic fever Calcification (older people) Rare form of congenital mitral stenosis
166
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
167
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
168
Pathological effects of mitral stenosis?
Pulmonary congestion Right heart failure Low cardiac output Atrial fibrillation
169
Symptoms of mitral stenosis?
``` Dyspnoea Fatigue Oedema Ascites Palpitations Haemoptysis Cough Chest pain Thromboembolic complications ```
170
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) ```
171
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
172
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 ```
173
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
174
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
175
Does acute mitral regurgitation cause symptoms?
Yes
176
Pathological processes in mitral regurgitation?
``` Pulmonary venous congestion Low cardiac output Atrial fibrillation Increased stroke volume Right heart failure ```
177
Symptoms of mitral regurgitation?
``` Dyspnoea Fatigue Palpitation Oedema Ascites ```
178
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
179
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
180
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 ```
181
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
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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
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Symptoms of aortic stenosis?
``` Exertional dyspnoea Exertional syncope Angina Sudden death Episodes of acute pulmonary oedema ```
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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 ```
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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
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When do you manage aortic stenosis?
When it become symptomatic
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Management for aortic stenosis?
Prompt | Aortic valve replacement: surgery or TAVI
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Causes of aortic regurgitation?
Congenital: bicuspid valve or disproportionate cusps Acquired: rheumatic disease, infective endocarditis, trauma, aortic dilation
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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 ```
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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
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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
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Causes of tricuspid stenosis?
Rheumatic fever
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Symptoms of tricuspid stenosis?
Hepatic discomfort | Peripheral oedema
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Signs of tricuspid stenosis?
``` Raised JVP Hepatomegaly Ascites Peripheral pitting oedema Mid-diastolic murmur ```
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Investigations for tricuspid stenosis?
Echocardiography with doppler
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Management of tricuspid stenosis?
Diuretics | Valve repair
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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 ```
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Symptoms of tricuspid regurgitation?
``` Usually non-specific Fatigue Oedema Hepatic enlargement Hepatic pain on exertion Ascites ```
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Signs of tricuspid regurgitation?
``` Giant wave in the JVP Pansystolic murmur at left sternal edge Pulsatile liver Right ventricular heave Ascites ```
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Investigations for tricuspid regurgitation?
Echocardiography: dilated RV, thickened valve leaflets (rheumatic), vegetations (endocarditis)
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Management of tricuspid regurgitation?
Correct the cause of right ventricular overload Diuretic and vasodilator in congestive cardiac failure Tricuspid valve replacement if rheumatic damage
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What is infective endocarditis?
Microbial infection of a heart valve, lining of a cardiac chamber/blood vessel or congenital abnormality
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Causes of infective endocarditis?
Bacterial Fungal Other: SLE, malignancy
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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 ```
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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)
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Investigations for infective endocarditis?
``` Bloods: FBC, U&Es, CRP, ESR, WCC Blood culture Urinalysis Echocardiography ECG Chest x-ray ```
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When do you have to presume something is endocarditis?
Fever + new murmur | Unless proven otherwise
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Criteria for diagnosing infective endocarditis?
Duke criteria | 2 major or 1 major +3 minor or 5 minor
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Management of infective endocarditis?
Antibiotic therapy Surgery, if: heart failure, valvular obstruction, repeated emboli, fungal IE, persistent bacteraemia, myocardial abscess, unstable infected prosthetic valve
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Causes of congenital heart disease?
Maternal rubella infection Maternal alcohol misuse Maternal lupus erythematosus Genetic/chromosomal abnormalities
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Clinical features of congenital heart disease at birth/neonatal?
Cyanosis | Heart failure
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Clinical features of congenital heart disease in infancy/childhood?
``` Cyanosis Heart failure Arrhythmia Murmur Failure to thrive ```
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Clinical features of congenital heart disease in adolescence/adulthood?
``` Heart failure Murmur Arrhythmia Cyanosis Hypertension Late consequences of previous cardiac surgery ```
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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
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Congenital heart disease causes of growth retardation?
Large left-to-right shunts
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Congenital heart disease causes of syncope?
Due to arrhythmias
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What causes pulmonary hypertension in congenital heart disease?
When the pulmonary flow is persistently raised (left-to-right shunt) -> increased pulmonary resistance -> pulmonary hypertension
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What is Eisenmenger's syndrome?
When a shunt reverses in severe pulmonary hypertension
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What is persistent ductus arteriosus?
When the hole between the aorta and pulmonary artery remains open
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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
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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
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What is coarctation of the aorta?
Narrowing of the aorta in the region where the ductus arteriosus joins
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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
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Investigations for coarctation of the aorta?
Chest x-ray: changes appear later on MRI (best imaging here) ECG: LV hypertrophy Echocardiography: LV hypertrophy
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Management of coarctation of the aorta?
Surgical correction Stenosis can re-occur with growth -> balloon dilation and stunting Long term follow up
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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
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Clinical features of atrial septal defect?
``` Most are aysmptomatic Dyspnoea Chest infections Cardiac failure Arrhythmias: especially AF ```
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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
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Management of atrial septal defect?
Surgical closure at cardiac catheterisation with an implantable closure device
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When not to surgically close an atrial septal defect?
Pulmonary hypertension, shunt reversal
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What is a ventricular septal defect?
Hole between the two ventricles | Either congenital or acquired (post MI etc.)
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Clinical features of a ventricular septal defect?
Pansystolic murmur | Cardiac failure in infants
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Investigations for ventricular septal defect?
Chest x-ray ECG: bilateral ventricular hypertrophy Doppler echocardiography: to predict which smaller defects might close spontaneously
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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
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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 ```
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Clinical features of Tetralogy of Fallot?
``` Cyanosis Stunted growth Digital clubbing Polycythaemia Faloot's sign Loud ejection systolic murmur in the pulmonary area ```
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Investigations for Tetralogy of Fallot?
ECG: RV hypertrophy | Chest x-ray: small pulmonary artery, boot shaped heart
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Management of Tetralogy of Fallot?
Surgical correction of pulmonary stenosis Surgical closure of ventricular septal defect Follow up Implantable defibrillation sometimes needed in adulthood
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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
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What is cardiomyopathy?
Disease of the myocardium
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Causes of cardiomyopathy?
Inherited Infective Toxic Idiopathic
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Types of cardiomyopathy?
Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy Arrhythmic right ventricular cardiomyopathy
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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
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Causes of dilated cardiomyopathy?
``` Alcohol Hypertension Chemotherapeutics Haemochromatosis Peri- or post-partum Thyrotoxicosis Congenital Late autoimmune react to viral myocarditis ```
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Symptoms of dilated cardiomyopathy?
``` Heart failure Asymptomatic Sporadic chest pain Fatigue Dyspnoea ```
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Signs of dilated cardiomyopathy?
``` Tachycardia Hypotension Raised JVP Displaced and diffuse apex beat S3 gallop Mitral/tricuspid regurgitation Pleural effusion Oedema Jaundice Hepatomegaly Ascites ```
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Investigations for dilated cardiomyopathy?
ECG Echocardiography Cardiac MRI
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Management of dilated cardiomyopathy?
``` Bed rest Control heart failure B-blockers ACE inhibitors Anti-coagulation Biventricular pacing Cardiac transplantation ```
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What is hypertrophic cardiomyopathy?
Left ventricular hypertrophy | Left ventricular outflow obstruction
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Cause of hypertrophic cardiomyopathy?
Autosomal dominant inheritance
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Symptoms of hypertrophic cardiomyopathy?
Angina on effort Dyspnoea on effort Syncope on effort Sudden death
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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 ```
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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
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What helps stratify risk and severity in hypertrophic cardiomyopathy?
Cardiac catheterisation | Exercise test
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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 ```
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What is restrictive cardiomyopathy?
When ventricular filling is impaired as the ventricles are too stiff -> high atrial pressures, atrial hypertrophy/dilation, AF
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Causes of restrictive cardiomyopathy?
``` Amyloidosis Idiopathic Haemochomatosis Sarcoidosis Scleroderma Löffler's eosinophilic endocarditis Endomyocardial fibrosis ```
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Clinical features of restrictive cardiomyopathy?
``` Like constrictive pericarditis Right heart failure Raised JVP Hepatomegaly Ascites Oedema ```
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Investigations for restrictive cardiomyopathy?
Echocardiography MRI Cardiac catheterisation
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Management of restrictive cardiomyopathy?
Treat the underlying cause
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What is arrhythmogenic right ventricular cardiomyopathy?
When areas of right ventricular myocardium are replaced with fibrous and fatty tissue
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Risks of arrhythmogenic right ventricular cardiomyopathy?
Ventricular arrhythmias Sudden death Right sided heart failure
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Investigations for arrhythmogenic right ventricular cardiomyopathy?
ECG: slightly broad QRS, inverted T waves in right precordial leads MRI
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Management of arrhythmogenic right ventricular cardiomyopathy?
Implantable cardiac defibrillator
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What is pericarditis?
Inflammation of the pericardium
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Causes of pericarditis?
Idiopathic Secondary to: viruses, bacteria, fungi, autoimmune systemic diseases, drugs, metabolic, trauma, surgery, malignancy, radiotherapy
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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
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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
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Management of pericarditis?
NSAIDs or aspirin with gastric protection Colchicine Rest Treat the cause Treat pericardial effusion/cardiac tamponade
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What is constrictive pericarditis?
When the heart is encased in a rigid pericardium
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Causes of constrictive pericarditis?
Idiopathic TB After any pericarditis
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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 ```
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Investigations for constrictive pericarditis?
Chest x-ray: small heart, pericardial calcification CT/MRI: to distinguish form restrictive cardiomyopathy Echocardiography Cardiac catheterisation
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Management of constrictive pericarditis?
Surgical excision

Year 4 Semester 2 (3 decks)

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