Cardiology Flashcards
Aortic stenosis
Features : Narrow PP ESM Soft absent S2 S4 Thrill LVH
Causes: age seven/calc
Aortic stenosis
Aortic stenosis:
Features: Narrow PP, Slow rising pulse, Thrill, ESM, Absent/soft S2, S4, LVH.
Causes: >65 – Age related/calc. <65 – Bicuspid valve, Williams syndrome (supravalvular AS) Post rheumatic dx, HOCM (subvalv)
Mx
– if Symptomatic, Gradient <40 Replace – Do angio for co-existent CVD
- Asx – observe
Lipid management
Lipids:
- Fibrates increase HDL: - Activate PPAR receptor Lipoprotein lipase activity increase. rduces TG + increase HDL
WPW
Accessory pathway
Don’t give adenosine OR Verapamil as will Block AVN -
increase accessory pathway
Use flecainide sotalol or amiodarone and DC cardioversion
Atrial naturetic peptiode:
Secreted by Right atrium – in response to High BP
Works by antagoinising AT2 + aldosterone – promotes NA excrtetion and BP lowering.
Broken down by Andopeptidase.
BNP – Vasodialtor _ diuretic – suppresses sympathetic tone + RAAS
I.E.
following procedures do not require prophylaxis:
•dental procedures
•upper and lower gastrointestinal tract procedures
•genitourinary tract; this includes urological, gynaecological and obstetric procedures and childbirth
•upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy
The guidelines do however suggest:
- any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing
- if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection they should be given an antibiotic that covers organisms that cause infective endocarditis
Causes:
1) Staph A,
2) Steph epidermis if <2/12 post valve surgery or in dwelling lines .
3) streptococcus viridens = sanguinis - dental check
4) strep bovis - associate with colorectal Ca
Culture negative causes:
- prior abx therapy
- coxiella burnetti
- bartonella
- Brucella
- HÁČEK
NOTE STREP INFECTIONS - good prognosis
Strongest R.F - Previous I.E.
Other RF - Rheumatic valve dx, Prosthetic valves, congenital heart defect, IVDU,
Indications for surgery:
- sev valvular incompetence
- aortic abscess - lengthened PR
- cardiac fx refractory to standard medical therapy
- recurrent emboli after abx is
HTN targets:
- Syss inc 20 and dias increase 90 for grades.
- Target: <80 – 140/90 >80 150/90
Exercise tolerance test:
CI – MI <1/52, unstable angine, uncontrolled HTN or hypotension, A.S>, LBBB
Terminate if:
- Exhaustion
- Chest pain
- Drop of Sys BP <20 or Sys BP >230
- STEMI >2mm ST depression >3mm
- Arryhtmia
- HR decrease >20%
- Max HR attained – 220 – age
Cholesterol embolization:
Recognised folling coronary angipography + vascular surgery:
- Eosinophilia
- Purpura
- Renal Fx
- Liverdo reticularis
Hypothermia – ECG changes:
- J waves on QRS - hump
- first degree HB, - long QT
- Arrythmia
DVLA + CVDx
HTN – no unless side effecrs
Angioplasty 1 week
CABG 4/52
ACS – 4/52
ICD – prophylactic 1/12 or ventric arrhythmia 6/12 – PERMANT FOR GROUP 2
Cath ablation - 2/7
AA - notify and annuyal review
Heart failure Management:
- ACEI + Betablocker
- 2nd = spiro/eplerenone, or ARB or hydralazine + nitrate
- 3rd CRT or Dig
- Features of overload - diuretics.
- Annual influenza vax and one off pneumococcal
- Mortality benefits: ACEI, Betablockers, spironolactone, hydralazine + nitrates.
1) pulsus paradoxus
2) slow rising
3) collapsing
4) pulsus alternans
5) Bisferiens Pulse
6) Jerky pulse
1) greater than 10mmHg fall in says BP on insp - sev asthma, tamponade
2) AS
3) AR, PDA, hyperkinetic states
4) Sev LVF - alt of of force of arterial pulse
5) mixed AV disease - double
Pulse
6) HOCM
Tetralogy of
Fallout
Pulmonary valve stenosis
VSD
Overriding aorta
rVH
Get a BOOT shaped heart
Ft in infants/children –> cyanotic attacks
- Tuck legs to chest if baby or ask child to squat –> increase Systemic vas resistance and decrease venour return. (H+ causes infundibular spasm)
Mx:
- two part surgical repair
- Beta-blocker prophylaxis vs cyanotic attacks –> decreadse infundibular spasm.
Canon A Waves
Caused by RA contacting against closed Tricuspid Valve.
Regular:
VT
AVNRT
Irregular:
Complete heart block
Warfarin
ODEVICES:
Omeprazole Disulifram Erythromycin Valproate Isoniazid Cipro + cimetidine Ethanol - acute Sulphonamides
PCBRAS - stop warfarin - inducers
Phenytoin Carbamazepine Barbiturates Rifampicin Alcohol - chronic Sulphonylureas
Others:
St. John’s wort - inducer - decrease warf
Cranberry juice - increase warf
Heart sounds
S1 - closure of MV + TV- prolonged in MR or PR - loud in MS
S2 - closure of AV + PV - soft in AS - splitting during inso is Normal
S3 - caused by diatomic filling of Ventricle - normal if <30. - causes LVF, MR, constrictive pericarditis
S4 - caused by atrial contraction against stiff ventricle - AS, HTN, HOCM - P wave
Causes of LBBB
Acute MI Aortic stenosis cardiomyopathy HTN Rare: idiopathic fibrosis, digoxin toxicity, hyperkalaemia
Stable angina and assessing CVD
Probability for CAD:
<30% - CT Ca Score
30-60% - myocardial perfusion scintigraphy
> 60% - invasive coronary angiography
pulmonary artery hypertension management
Definition: PA pressure >= 25mmHg
Causes: COPD/CLD, drugs, idiopathic - AD
Ft: progressive exertional dyskinesia, exertional syncope/vest pain and peripheral oedema. Cyanosisz
Findings: RV heave , loud P2, raises JVP with a waves, tricuspid regurg.
Management:
Acute vasodilator test —> aims to show a sig fall in pulm Artery pressure following admin of vasodilator m.
+ve response to acute vasodilator testing: PO ca channel blocker
-ve response:
Prostacyclin - illoprost and treprostrinil
Endothelin receptor antagonists - bosentan, ambrosentan
PDE-V - sildenafil
Progressive sx —> heart/lung transplant
Hyperlipidsemia - primary prevention
Use QRISK2 if <85 - >=10% give atorvastatin 20mg
QRISK2 not used if:
DB1
eGFR <60 and/or albuminuria
Hx of familial hyperlipidaemia
QRISK underestimates if: Treated for HIV Serious mental health Antipsychotics, corticosteroids or immunosuppressant drugs —> dyslipidaemia AI DX or systemic inflamm dx (SLE)
Aim for a reducing of non-HDL cholesterol of >40% in 3 months
If don’t meet target —> concordance and lifestyle advice —> increased dose
Measuring lipids:
Total chol >7.5 & famil hx of prem CVD —> consider familial
Total chol >9 or non-HDL >7.5 —> refer
Hyperlipidaemi - secondary prevention
Give atorvastatin 80
To all CVD
Hyperlipidaemia special situations
DB1:
Consider in all adults with type 1
Give atorvastatin 20 if:
- >40 yes or dB >10 years or nephropathy or other CVD Rf
CKD:
Give atorvastatin 20mg
Warfarin targets
AF: 2-3
Venous thromboembolism: 2.5 or 3.5 if recurrent. If unprovoked—> lifelong
Prosthetic valve: 2.5
Metallic valve: 3 if AVR. If recurrent DVT 3.5. 3.5 if MVR.
HOCM
A.D
Mutations in beta myosin heavy chain protein, Troponin T
Septal hypertrophy —> LV outflow obstruction
Poor prognostic factors: Syncope FHx of suddenly death Young age of px Non-sustained Ventricular tachy Abnormal BP change on ex
Septal wall thickness increase >3cm
On Evho - BAD
Mx: A - Amiodarone B - beta block/CCB C - cardioverter defib D - dual chamber pacer E - Endocarditis prophylaxis
Drugs to avoid:
- Nitrates
- Inotropes
- ACEI
Fabry disease
X-linked recessive
Deficiency of alpha-galactosidase A
Px:
F - fever A - angiomeratomas - bathing suit B - burning pain R - renal - proteinuri YX - Xlinked recessive S - stroke/CV disease
Corneal Whirls on slit lamp
Rheumatic fever
Recent strep pyogenes infection
aInnate immune system —> Ag presenting T cells —> aB and T cells —> prod IgG, and IgM and CD4 T cells —> X tactics immune with myosin.
Aschoff bodies
Diagnosis: 1
Major or 2
Minor
Major - JONES criteria: J - joints - polyarthritis O - think heart - carditis + valvulitis N - nodules- subcutaneous E - erythema marginatum S - Sydenham chorea
Minor criteria: Raised ESR Pyrecia Arthralgia Prolonged PR
Indications for surgery:
- lengthx ened PR - aortic root abscess
- severe valvular incompetence
- refractory infection
- refractory CHF
- recurrent emboli post abx
Cardiac markers
Trops are most common - components of thin filaments
Others:
Myoglobin increasesfirst
CK-mb is goo to look at reinfarction as it returns to normal after 2-3 days (whereas trop takes up to 10days)
RIght ventricular MI
Px:
ECG features of MI with triad of:
- Clear lung field
- raised JVP
- hypotension
Don’t give nitrates as will decrease preload and worsen
HOCM VS PAH
Both cause syncope / suddenly death in young adults with family history
Murmur: HOCM - Y. PAH - N
Heart sounds: HOCM-N PAH - loud S2
Increased SOB: HOCM - N PAH - Yes
Restrictive Cardiomyopathy
Ft: Prominent apical size , Increased heart size , ECG abnormalities = Q waves or BBB
Causes:
- UK most common - Amyloidosis following Myeloma
- haemochromatosis
- loffler’s syndrome
- sarcoidosis
- scleroderma
Atrial Myxoma
features:
Clubbing Pre-sys murmur - normally mid diastolic AF Anaemia Fever Atrial Plop
Warfarin Mx of High INR
Major bleed:
- Stop Warfarin
- IV Vit K 1-5mg - rpt INR @ 24hr if INR still high –>rpt dose
- Prothrombin complex
INR >8.0 with minor bleed:
- Stop Warfarin
- IV Vit K 1-3mg - rpt INR @ 24hr if INR still high –>rpt dose
- restart warfarin once INR <5.0
INR>8.0 with no bleed:
- Stop Warfarin
- Vitk K 1-5mg (PO) - rpt INR @ 24hr if INR still high –>rpt dose
- restart Warfarin once INR<5.0
INR 5.0 - 8.0 w/ minor bleed:
- Stop Warfarin
A - IV Vit K 1-3mg - rpt INR @ 24hr if INR still high –>rpt dose
- Restart Warfarin when INR <5.0
INR 5.0 - 8.0:
- Stop Warfarin
- Reduce subsequent maintenance dose
In emergent surgery:
- can’t wait give PTCC 25-50units/Kg
- can wait give IV Vit K 5mg and wait 6-8hrs
Brugada syndrome
Inherited - A.D.
Young asian px with syncope or sudden death, often due to arrythmias
PrMutation in gene coding for Na channels. Therefore furing cardiac cycle, don’t get theapid influx of Na for dep. As a result get slow conduction –> “short circuiting” –> reverse in direction of depolarisation –> cycling –> re-entrant tachy
ECG Changes:
- Convex ST elevation with assoc. neg Trop
- RBBB (partial)
Mx: ICD
Thrombolysis in STEMI
Remember contraidicated if risk of bleed.
Post-Thrombolysis
- rpt ECG @ 90min
- Aim is reduction of >50%
- If <50% –> PCI
I.E - dukes criteria
Diagnosis: Pathological criteria +ve 2 major 1 major and 3 minor 5 minor
Pathological criteria:
- + histology or micro from
Cardiac tissue directly - autopsy or surgery
Major:
Positive blood cultures:
- 2 + BCs of typical ( strep viridans and HÁČEK) or
- persistent bachatas is from 2 BCs taken >12 he apart or >= 3 In less specific orgabsisms (staph A or staph Ep)
- serology - coxiella burnetii, bartonella or chlamidyia psittaci or
- molecular assay for specific gene targets
Evidence of Endocardial involvement:
- echo or
- new valvular regurg (murmur)
Minor criteria:
- predisposing heart condition or IVdU
- micro that doesn’t meet major
- fever >38
- vascular phenomena
- immunological phenomena - Glomerularnephritis, oslers nodes, Roth spots
Angina management
1) aspirin + statin + GTN
2) beta blocker or CCB
- if ccb - mono then use verapamil Or diltiazrm
- if with beta blocker - nifdedipine as risk of heart block with verapamil
3) if poor intiial response —> increase dose
4) use combo of advice
- if any tolerate addition of one or the other, use long acting nitrate, ivabradine,
Nicorandil or ranolazine
5) only add 3rd drug if awaiting assessment for PPI or CABG
Central acting anti-HTN
Methyldopa - mx of htn in preg
Moxonidine - mx of essential
Htn when normal therapy fails
Colonidine - stimulate alpha-2 adrenoreceptors in vasomotor centre
Dilated cardiomyopathy
- Causes:
idiop[athic + ABCCCD
All4 chambers LV>RV.
Ft - arrhythmia, MR, emboli
Causes:
- Idiopathic
- EtOH
- Postpartum
- HTN
ABCCCD:
- Alcohol/beriberi (Wet)/Chagas/coxsackie/cocaine/doxurubicin
Others:
- inherited
- infective
- endocrine - hypothyroid
- infiltrative- haneochromatosus, sarcoidosis
- DMd
MI Secondary prevention
All patients: ACEI, Beta-Blocker, statin, aspirin, clopidogrel/ticagrelor/pasugrel
Diet + lifestyle:
- Mediterranean diet
- 20-40 mins of ex - slight breathlessness
- can resume sexual activity at 4 weeks. Doesn’t increase risk of MI, can use viagra at 6/12
Post MI:
Ticafrelor and aspirin preferred
Stop ticagrelor at 12montgs
Post PCI:
Stop 2nd antiplatelet at 12 months
Malignant HTN
Basics:
Severe htn >200/130
Fibrinoud necrosis of blood vessels —-> retinal haemorrhages, exudates, proteinuria, haematuria
Can lead to cerebral oedema—> encephalopathy
Ft:
- sev headache. n/v. Visual symptoms
- chest pains + dyspnoea
- papilloedena
- encephalopathy —> seizure
Mx:
- reduce Dias no more than 100mmHg in 24hr
- oral use atenolol
- of severe —> IV sodium nitroprusside/labetolol
Familial hypercholesterolaemi
Autosomal Dominant —> high LDL
Simon broome criteria:
- adults: TC > 7.5. And. LDL >4.9
- children: TC >6.7. And LDL >4
- for definite: tendon Xanthoma in pt with 1st or 2nd degree relative with DNA evidence of FH
- possible: FHx of MI <50 in 2nd degree relative or <60 in 1st defeee.
Management:
Do not use QRISK
Referral to special lipid clinic
High dose station first line
Screen 1st degree relatives
Statin should be discontinued 3/12 before conception
Stent thrombosis vs restonosis
Thrombosis:
- within first month
- often get ACS
Restonosis:
- 3 to 6 months
- worsening angina
Adenosine
Enhanced by anti-platelets and dipyridamole
Reduced by - aminophylline
Cyanotic vs acyanotic heart defects
Cyanotic:
At birth most common - Transposition of great arteries
- > 1-2months - tetarology
- tricuspid atresia
Acyanotic:
VSD - most common ASD PDA Coarctation AV stenosis
Arrythmogenic RV cardiomyopathy
Autosomal doninant
Replacement of RIGHT myocardium with fatty and fibrofatty tissue.
Features:
Present with palpitations and syncopal episodes.
ECG - inverse T waves in V1-V3.
- epsilon wave = notch on QRS
Echo - hypokinetic thin free wall of RV
MRI is diagnostic
Mx:
Sotalol
Catheter ablation
ICD
Pericarditis
Causes:
Viral (coxsackie), TB, Uraemia, Trauma, post Mi, CT dx,hypothyroid, malignancy
ECG features:
Widespread ST elevation
PR DEPRESSION- most specific
Mx: NSAIDs and tx underlying cause
Raised JVP causes
Normal Waveform
- HFx
- Fluid overload
Kusmails sign
- Raised on insp and decreased on exp
- Sign of RV inability to expand
- Tamponade/effusion/constrictive
Loss of normal pulsatation
-SVC syndrome - obstruction due to medialstinal malignancy
JVP pathology
A waves:
- Absent - AF
- Large - RHFx/Pulm HTN
- Cannon : Reg AVNRT/VT Irreg - 3rd degree HB
V waves:
- Giant = TR
X wave
- Steep = Tamponade/constriction
Y wave:
- Steep = Constriction
- Slow = TS
Apexe Pulses pathology
Heaving = LVH Thrusting = LV vol incre = MR/AR/PDA/VSD Tapping = M.S Displaced = LV impairment/dilatation Dbl impact - w/dyskinesia = LV aneurysm w/o dyskinesia = HOCM Pericardial knock = Constrictive parasternal heave = RVH palpable 3rd heart sound = HFx/Sev MR
PAthological S2
Wid split:
- A2 early: MR/VSD
- P2 Late; RBBB/PS/ASD
Single HS:
- A2 Soft - AS
P2 Soft - PS/TOF
Reverse split:
- A2 late - LBBB/HOCM/A.S
- P2 early - TR/PDA/WPW
Fixed split:
- ASD - When prssure is equal across atria - no widening with Exp/
Opening snap
Mitral stenosis
just after S2
closer it is to S2 the more severe the stenosis.
Mitral stenosis
Most commonly post rheumatic Heart dx - rare carcinoid/SLE/mucopolysacchridosis.
Ft: 0 Mid-late dias urmur - loud S1 - low vol pulse - Malar flush AF
Ft of severity:
- Increase length of murmur
- opening snap closer to S2
CXR:
- LA enlargement -> dysphagia
Echo
X section <1sq cm (nornlaa 4-6)
Mitral regurg
Can be common in healthy
increase sev –> CO cant meet O2 supply.
RF:
- Female
- low bmi
- age
- renal dysgn
- prev mi
- prior MS r prolapse
- Collagen disorder - MArfans - Ehlers-D
Causes:
- MI –> apillary muscle rupture
- MV prolase
- I.E.
- Rhuemativ fever
- congenital
Ft:
- Asx
- LVF/arrythmia/pulmHTN
- pansystolic murmur/ Sev –> Wide split S2
inx:
- Broad P wave –> Atrial enlarg
- CXR –> cardiomegaly
- ECHOCARFIOGRAPHY
Mx:
- Acute = medical - Nitratrs/ diuretics/ psitive imotropes –> intraortic baloon pump
- HFx mx.
- acute severe regurg –> Surgery
A.R. - features
Early diastolic murmur –> increase on handgrip
Collapsing pulse
Wide PP
Quinkes sign - nail bed pulse
De Mussets sign - head bobbing
Flint’s murmur - mid diastolic - partial closure of valve due to backflow.
AR causes
Valvular:
- rheumativc fever
- IE
- CT dx - SLE/RA
- Bicuspid
Aortic root : - Aortc dissection - ankylosing spondylitits - Collagen disorders - Syphilis HTN
Tricuspid regurg
Low freq pansystolic murmur
Giant V wave
Causes:
- RV dialation
- Carcinoid
- infective
- post rheumatic fever
- Ebsteins anomaly
PEricarditis vs dresslers post-MI
both saddle shaped
PEricarditis is more acute i.e. - 48hrs
Dresslers = 2-6 weeks = A.I.
Dressler shave mild temp/ESR/effusion
Mx - NSAIDs
Reinfarction - cardiac marker
use CK-MB - as returns to nprmal much quicker
Indications for temproary pacing
Anterior MI –> Mobitz type 2 or complete HB
Trifasicular block - prior to surgeyr
Symptomatic/decompensated bradycardia - not responding to Atroopine
note - Complete HB after POSTERIOR MI is VVVV COMMON –> Doesnt require temporary pacing
Ivabradine
Works as antiangival by reducing HR
acts on SAN –> Funny current
S.e:
- HEartblock
- Visual phenomena - bright spots
- headache
Aortic dissection
Tear in tunica intima
Assoc: HTN Trauma Bicuspid valve Collagen disorders Turners and noonans Pregnancy Syphillis
Ft:
Chest pain
Aortic regurgitate
Htn
Specific ft of ischaemia to distal supply
Classification
Stanford type A - ascending sort
Stanford type B - descending
Inx —> CT with IV contrast
Mx
- ascending —> IV labetolol and surgery
- descending —> IV labetolol
Heart failure drugs with improved mortality
Beta blocker
Ace inhibitiors
Spironolactone
Nitrates and hydralazine
Stable angina and suspect CAD Inx
Contrast CT Angio
Anticoags
Heparin - activates anti-thrombin 3
Clo-P-idogrel - P2Y12 inhibitor
A-b-ciximab - glycoproteins IIb/IIIa inhibitor
D-abigatran - D irect thrombin inhibito
Rivaroxaban - Factor X inhibitor
PE anticoagulation length
Eovokd - 3/12
unprovoked 6/12
Ca - 6/12 of LMWH
Prosthetic heart valves antithrombotic therapy
Biprosthetic - ASA
Mexhanical - ASA + warfarin
Pinzmental
Angina mx
Dihydropyridine CCB
Second heart sound
Loud - HTN
soft - AS
Fixed split - ASD
Reversed - LBBB
S4
S4 is seen in aortic stenosis
Associated with atrial contract against stiff ventricle
Associated with P wave
Flutter definitive management
Radio frequency ablation of tricuspid valve isthmus
Infective endocarditis Mx
Blind treatment:
- Native - amoxicillin (+/-gent)
- Pen allerg - Vanc + low dose gent
- Prosthetic - Vanc+ rifamp + ld-GEnt
Staph A:
- Native - Fluclox
- NAtiv + Pen - Vanc + rifamp
- Prosthetic - FLuclox + rifamp + ld-gent
- PRosthetic + pen allergic - Vanc + rifamp + gent
Strep:
- Fully sensitive (Viridans) - Benzylpenicillin
- pen allergy - Vanc + gent
- low sens - Benzpen + gent
SVT prophylaxis in pregnancy
Used metoprolol
Adenosine and verapamil - decreases uterine Bf
Amiodarone - teratogenic
Flecainide only specialist
Hyperlipidaemi xanthomata
Palmar - remnant hyperlipidaemi
Tendon/tuberous - familial hypercholesterolaemia
Eruptive xanthoma - familial hyperTG.
Mx Surgical excision Topical trichloroacetjc acid Laser therapy Electrodessication
Congenital Heart dx:
Acynatoc vs Cyanotic
Acyanotic:
- shunt - VSD/ASD/PDA/Aortic coarctation
- No shunt - Aortic coarctation/ congenital AS
Cyanotic:
- Shunt = TOF/ Transposition/Ebsteins anomaly.
- w/o shunt = Tricuspid atresia/pulm stenosis/pulm atresia/ hypoplastic L heart
ASD
2types - primum and secundum
secundum most common
most common congenital heart dxin adults
Features:
- ESM and fixed S2 split
- paradoxical embolus
secundum:
- assoc w/ holt-oram syndrome - triphalangeal thumbs
- ECG - RBBB + RAD
Primum
- px earlier
- ECG: RBBB + LAD + increased PR
- assoc abnormal AV valves.
ASD - indications for surgery
Worsening dyspnoea increased R heart pressure Chamber dilatation sig L --> R shunt Systemic emboli.
VSD
Most common congenital heart disease
50% sponatneosuly close
assoc with patau/Edwards/Downs syndrome
Ft:
- pansystolic murmur - louder with smaller defects
Assoc:
- Aortic regurg
- Eissenmengers
- I.E.
- RHFx
- Pulm HTN
VSD - indications for closure
Sig L--R shunt Pulm HTN/ Right heart pressure Other cardiac abnormalities Endocarditis Membranous VSD --> A.R.
PDA
Common in:
- Prmeature babies
- high alt
- Rubella infection in 3rd trimester
Ft:
- Left Subclavian thrill
- L heart enlarged + heave
- Machinary murmer
- Wide pulse P + Bounding pulse
Mx:
- Indometacin
Coarctation
Life threatening in early life –> Use PG to maintain PDA
- HFx / Metabolic acidosis
Ft:
- Heart failure in infancy
- HTN in adulthood
- Radio-femorla delay
- leg cramping
- Aortic click and apex
- Mid systolic murmur - loudest at back
- Notchinf of inferior ribs - CXR
- Post stenoit c dilatation –> Oesophageal compression –> Dysphagia.
Assoc:
- Turners
- Bicuspid Aortic Valve
- berry aneurysms
- Neurofibromatosis
Atrial fib - Types
1) First episode
2) paroxysmal or persistent (<7days or >7days)
3) Permanent - persistent and not cardivertable.
A fib management
1st line is rate control on:
- <65 yrs
- 1st episode
- HFx
- Reversible cause
Rate control@
- Beta-blocker and rate limting -CCB (diltiazem)
2nd line - 2of:
- Betablocker
- CCB
- Dig
AF - Cardioversion
If HD unstable or <65/HFx/1st episode/reversible
Pharmacological - Flecainide or amiodarone (structural)
Onset <48 hrs:
- Herparines
- DC or pharmacological
Onset >48hrs:
- Anticoag for 4/52 or TOE to exclude thrombus
Prev fx of cardioversion or recurrence –> 4/52 of amiodarone or sotalol before reattempts.
CHADVASC and HASBLED
CHADVASC:
- > 1 and male - consider
- > 2 - anticoag.
HASBLED:
- HTN/abnormal RFX or LFT cr>200 or Transaminas >3x/ stroke hx/ bleed risk/Labile INR/Elderly >65/ drugs (NSAIDS/ASA etx.) or EtOH
- 1 for each
- > 3 is high risk
Indication for pacing in CHFx
NYHA 3 - 4
QRS >120
LVEF >35% with dilated ventricle and pt on optimum medical mx.
Biventriuclar pacing.
Angina - types
Decubitus - Worse on lying down
Pinzmental - Coronary A spasm - Transient ST elevation
Syndrome X: - Middle aged female - ST depression on exercise.
Angina grades
1 - strnouous exercise
2 - 2 flights of stairs
3 - one block on level ground
4 - at rest
Angina - Mx
1st line:
- GTN + ASA + STATIN + Beta block or RL-CCB
2nd - increase mac dose of mon
3rd - Try other monotherapy
4th - can tolerate combo-> combo
4th - cant tolerate - LA nitrates/Ivabradine/ Nicorandil/ranolazine
5th - + 3rd drug from above list - only if WAITING PC
Angina 1st line of Inx - if ?CAD
CT Angiogram
S.E. of anti-anginals
CCB:
- Headache
- Flushing
- ankle oedema
Beta-blocker:
- Bronchospasm
- fatigue
- cold peripheries
- sleep disturbance
Nitrates:
- headache
- Postural drop
- Tachy
Nicorandil
- Headache
- flushing
- Anal ulceration
NSTEMI Mx
MONAC
LT ASA and 12 motnh of ticagrelor/prasugrel=(preferred of PCI)
if angiography >24 hrs or not at all - Fondaparinux
Angiography <24 hr - unfrac hep
High risk of bleed and Andiography < 96hrs - IV tirofiban
Causes of raised BNP
LVH ischemia tachy RV overload low PO2 Stress/sepsis COPD Low GFR
Primary cardiomyopathies - Genetic
HOCM:
- AD = beta myosin heavy chain
- MR
- Septal hypertrophy
- Poor prognosis : BP change during ex/Young age/ Syncope/ FHx/ non sustained VT.
- Tc = A + B + C + D + E
- Avoid nitrates/inotropes/ACEI
Arrythmogenic RV dysplasia:
- RV myocardium replace with fatty fibrous tissue.
- ECG - V1-V2 T wave inversion + Epsilon wave
- MRI
- Mx = Sotalol
Primary cardiomyopathies - mixed
Dilated:
- EtoH
- Coxsackie
- beri beri
- Doxorubicin
Restrictive
- Amyloidosis
- Post-RT
- Lefflers
primary cardiomyopathies - Acquired
Peripartum Cardiomyopathy
- Last 1/12 preg –> 5/12 post partum
- RF - Inc Age, parity and gestation #
Takotsubo Cardiomyopathy
- stress/broken heart syndrome
- Octopus pot
- Transient - Mx = supportive.
Secondary Cardiomyopathy
Infective - Coxsackie Infiltrative - Amyloidosis Storage - haemochromatosis Toxicity - Doxyrubicin Inflamm: - Sarcoidosis Endocrine - DB/Acromegaly/Thryotoxicosis Neuromuscular - muscular dystrophies/dystrophies/myotonic dystrophies Nutritional - Thiamine --> Beri Beri A.I. - SLE
Restrictive cardiomyopathy vs Constrictive pericarditis.
cardiomyopathy > pericarditis.
- Prominent apical pulse
- Cardiomegaly
- ECG changes - Q wave LBBB
- Don’t get pericaridial calc on CXR
Pericarditis
Chest pain relief on sitting forward
Flu like sx
ECG - widespread saddle shaped ST elevation & PR DEPRESSION (most spec)
Causes:
- Viral / TB / uraemia. Dresslers / trauma. hypothyroid/ malignancy
Inx - ECG + Echo
Mx : tx causes + NSAID
Constrictive pericarditis
primarily caused by TB
Ft
- SOB
- HFx
- Raised JVP - prominent X + Y descent
- Loud S3 = pericardial knock
- Kussmauls sign
inx - CXR
Contrictive pericarditis vs tamponade
Pericarditis > Tamponade:
- Increased X + Y descent
- Kusmaulls sign
- CXR - pericardial calc
Tamponade = Becks triad & ECG = electrical alternans + pulsus paradoxus.
Pericardial effusion
Can develop 2L
Pulsus pardoxus + pulsus alternans
CXR –> globular cardiac enlargemnent
Causes:
- pericarditis causes
- aortic dissection
- iatrogenic
- IHD –> ventricular wall rupture
myocarditis
viral - Coxsakie/HIV bacteria - Diptheria/Clostridia Spirochetes - Lyme dx protozoa - Chagas/lyme AI Doxyrubicin
Px - young pt w/ acute chest pain + dyspnoea
Inx:
- increased inflamm markers
- ECG St elevation/ Twave inversion
Rheumatic fever
2-6/52 after strep pyogenes infection
IgG + IgM –> CD4 T cell
X reaction w/ M protein
Get aschoff bodies
Diagnosis = Evidence of recent infection + (2 Maj) or (1 major + 2minor)
Recent infection:
+ throat swab
+ strep antibodies
+ Group A strep antigen
Major: Erythema Marginatum Sydenhams chorea Polyarthritis Subcut nodules cardits/valvulitis
Minor: Raisesd ESR/CRP Temp Arthritis High PR
Cardiac tumours
Atrial mycoma most common
75% in LA - Fossa ovalis
Female>Male
Ft:
- systemic
- Emboli
AF
MID DIAS MURMUR WITH TUMOUR PLOP
who gets statin
Anyone with secondary for prevention for - CVD/CBVdx/PAD
Primary:
- any pt with 10 year CV risk >10%
- DB1 with QRISK
- DB 2 who >10 yrs / >40 ye old / DB nephropathy
stopping statin
Transaminases >3x ULN = PERSISTS
SVT w/ Aberrant conduction vs VT
VT>SVT - Concordant QRS - capture + fusion beats RBB w/ LAD - CRS > 140 - Hx IHD - Vent rate <170
Hypothermia - ECG changes
Prolonged PR J wave Long QT Bradycardia Arrythmias.
Bradycardia management
Give six doses of atropine —:> fx –> External pacing or isoprenaline/adrenaline
Multifocal atrial tachycardia
Tachy cardic - narrow complex - caused by at least 3 different sites
different P wave morphologies
Mx:
- short electrolytes and hypoxia
- Rate limiting CCB
Cardiac syndrome X
Angina ike chest pain on exertion
ST Depression n exercise ECG
Normal coronaries
Mx: Nitrates
When to start anti HTN
ABPI > 135/85 and end organ damage, DB2, Renal dx, CVD or Q risk >10%
ABPI 150/95 anyone
BP Targets
<80 - <140/90 or 135/85
> 80 - 150/90 or 145/85
PRe-eclampsia RF
Obesity smoking twins nulliparity DB
PE anticoagulation length
Eovokd - 3/12
unprovoked >3/12
Ca >6/12
Hydralazine
increase cc-GMP –> relaxation of SM of Arterioles>veins
BEst cardiac scans
Structural - Cardiac MRI
CAD - Cardiac CT
PErfusion etc. - nuclear imaging - SPECT
Warfarin and bleeding
Major bleeding - IV Vit K 5 mg + PTTC
INR>8.0 + minor bleed - IV vit K 1-3m - rpt Vit K at 24hr
INR >8 no bleed - PO vit K 1-5mg - rpt Vit K
INR 5 –> 8 w/ minor bleed - IV Vit K 1-3mg
INR 5 - 8 no bleed - just withold two doses
with all- restart warfarin when INR
Complete HB with narrow QRS
lower risk than wde QRS for asystole
Post thrombolysis aim for resolution
if <50% –. PCI
Infective endocarditis Mx
Blind treatment:
- Native - amoxicillin (+/-gent)
- Pen allerg - Vanc + low dose gent
- Prosthetic - Vanc+ rifamp + ld-GEnt
Staph A:
- Native - Fluclox
- NAtiv + Pen - Vanc + rifamp
- Prosthetic - FLuclox + rifamp + ld-gent
- PRosthetic + pen allergic - Vanc + rifamp + gent
AF with heart failure and reduced EF
AVOID BEtablocker and rl-CCB –> negatively inotropic
use Dig
Statin monitoring
BAseline –> 3/12 —> 12/12
Remember AST/ALT >3x ULN and PERSISTENT - stop
What med in articular makes clopi less effective
PPIs
Dypiridamole MOA
Inhibit phosphodiesterase –> elevate platelet cGMP –> reduce intracellular Ca
also it:
- Thromboxane inhib
- reduced cellular uptake of adenosine
Centrally acting anti-HTN
MEthyldopa - used in preg induced HTN
Moxonidine - USed in essential HTN when other fail
Clonidine - stim alpha-2 adrenoreceptocepter in vasomotor centre
ACEI first dose side effect
first dose hypotensio
ACS common meds MOA
Aspirin - Antiplatelet - inhibit production of thromboxane
Clopi - Inhibit ADP binding site of platelets
Enoxaparin - activates antithrombin 3 –> potentiate facto Xa
Fondaparinux - activates antithrombin 3 –> potentiate factor Xa
Bivalarudin - Direct thrombin inhib
Abciximab, eptifibatide, tirofiban - glycoprotein 3a/2b recepto antagonist
Amiodarone
MOA - Blocks K+ channels
prior to tx - TFT/LFT/U+E/CXR
TFT/LFT - 6/12
Hyperkalaemia
K+ >6 –> Stop ACEI
Switch for another
What medication if ? SVT with aberrant conduction over VT
Amiodarone
Adenosine interactions
Blocked by theophyllines
increased by dipyradimole
Post anaphylaxis monitoring length
8 hours
Most important prognostic factor pst STEMI
LV ejection fraction
Statin + clarithromycin/erthromycin
Myalgia and rise in CK
RF for statin induced myopathy
Age
Female
low BMI
multisystem dx
Catecholaminergic polymorphic VT
AD
Mutation i gene for ryanodine receptor which is found in SR
Ex –> polymorphic VT
Syncope
Sudden death
Sx bf age of 20
Mx:
Beta block
ICD
VTE and when to start IVC filter
If recurrent despite:
- increasing therapeutic range to 3-4
- USing LWH –> still get
Myotonic dystrophy cardiac manifestations
PROLONGEED PR - most common
cardiomyopathy
Most prothrombotic factor in anti-phospholipid syndrome
Lupus Anticoagulant
other factors:
- Anticardiolipin
- beta - 2- glycoprotein 1
Brugada syndrome ecg changes
ST elevation in V1 - V3 and partial RBBB
Poor prognostic indicators in ACS
ST deviation Heart failure PVD Age Fall in SBP Elevated cardiac markers Cardiac arrest on admisipn raised Cr Killip clas
Ivabradine indications for use
Angina in HR >70 if 1st lines havent worked and pt cannot tolerate combo f CCB/betablocker
CHFx:
- in addition to standard tehrapy if HR >75
Causes of raised BNP
LVH Ischameia Tachy RV overload sepsis CKD Liver cirrgosis Hypoxaemia COPD DB Age >70
Which organism has the highest mortality in I.E.
Staph
ICD insertion and group 2
permanent Bar
Who gets ticagrelor in NSTEMI patient
a
ALL PATIENTS
Adenosine
GPCR agonist of adenosine type 1 receptor in avn
This leads to decreased cAMP
Management of long QT
Bisoprolol is goof for immediate managemenr.
Conventional anti-arryrhmics (amiodarone and flecainide) can lengthen QT
Causes of secondary hypertension
ABCDE
A - Apnoea (OSA), Aldosteronism, Accuracy of measure
B - Renal A Bruits (Stenosis), Bad Kidneys (Renal dx)
c - Cushings, Coarctation, Catecholamines
D - Diet, Drugs
E - Endocrine - phaeo/hypothyroid/hyperPTH/Excess EPO
Most common cause of viral myocardtis
PARVOVIRS B19 _ HHV6
pre-test scores of Coronary artery disease
<30% - CT Ca Score
30-60% - Mycoradial perfusion scitography
> 60% - Invasive coronary angio
NSTEMI and LT management
MAny still use GRACE score
<1.5% - Aspirin 12 months
1.3 - 3% - Aspirn + Clopi 12 months & OP perfusion/stress imaging
> 3%
- glycoprotein inhibitor (Tirofiban) and angiography in 96hrs
