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Cardiology Flashcards

1
Q

Define Aortic stenosis

A

Commonest murmur

Narrow aortic valve

ESM

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2
Q

Pulses in Aortic stenosis

A

slow-rising pulse

peripherally (as valve stenosed)

narrow pulse pressure (<30mmHg)

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3
Q

O/E precordium in Aortic Stenosis

4 points

A

pacemaker
aortic THRILL (horizontal)
forceful apex beat
ESM +/- S4 HS

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4
Q

Murmur in Aortic stenosis

A 
Ejection systolic murmur 
loudest right 2nd ICS
sitting forward on expiration
radiates to carotids
\+/- S4 (aortic contraction against stiff LV)
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5
Q

Rule out if suspected Aortic stenosis

A

Significant -ves are

Infective endocarditis
LVF
Severe AS

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6
Q

Signs of severe aortic stenosis

A

S4
Narrow pulse pressure
decompensation - LVF
slow-rising pulse

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7
Q

DDx Aortic stenosis

A 
aortic sclerosis (no radiation, normal radial pulse)
MR
HOCM 
PS
TR
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8
Q

3 Causes aortic stenosis

A

Senile calcification
Rheumatic heart disease
Bicuspid aortic valve

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9
Q

Clinical Sx severe aortic stenosis

A

Angina
Syncope
Dyspnoea

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10
Q

5 Ix for Aortic Stenosis

A

Bloods: FBC, U+E, NT-proBNP, lipids, glucose
ECG: LVH, arrhythmia

CXR: calcified AS, LVH, pulmonary oedema
Echo and doppler: assess severity, look cause, assess LV function

Cardiac catheterisation: valve gradient, assess coronary arteries if surgery planned

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11
Q

Echo features in severe AS

A

Valve area <1cm^2
pressure gradient >40mmHg
jet velocity >4m/s

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12
Q

Mx of aortic stenosis

A

MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurse

Conservative: (optimise CV risk) diet, exercise, smoking
Medical: (optimise CV risk) statins, anti HTN, DM, anti plt
Surgical:
- valve replacement +/- CABG
- TAVI (transcatheter aortic valve implantation)
- balloon valvuloplasty
- regular f/up and echo

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13
Q

Indications for surgery in Aortic stenosis

A

Symptomatic AS
Severe asymptomatic AS with EF <50%
Severe AS undergoing CABG or other valve Op

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14
Q

Mortality in surgical valve replacement for AS

A

3-5% depending on pt

EuroSCORE

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15
Q

Presentation of Aortic Stenosis

A

Systolic murmur commonly associated with AS or MR
Other DDx include HOCM, ASD, VSD
Evidence that it is AS include:
1) PULSE (narrow pulse pressure, slow-rising pulse)
2) SCAR (pacemaker)
3) PALPATION (forceful apex beat, aortic thrill)
4) MURMUR (aortic area loudest, radiates to carotids, grade 3?, high pitch, ESM, heard loudest leaning forward on end expiration) +/- S4 heart sound

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16
Q

Define Mitral Regurgitation

A

Pan-systolic murmur

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17
Q

4 Causes of Mitral Regurgitation

A

Functional (LV dilatation (idiopathic or 2 to HTN)
Rheumatic heart diease
Mitral valve prolapse
Annular calcification -> contraction of valve

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18
Q

Pulse in Mitral Regurgitation

A

Can have atrial fibrillation

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19
Q

O/E Precordium in Mitral Regurgitation

4 points

A

left parasternal heave (RVH as increased preload)
Displaced apex (ventricle pump extra preload)
HS: soft S1, loud P2 if PTH
Murmure: PSM

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20
Q

Murmur in Mitral Regurgitation

A 
PSM 
blowing 
Apex
left lateral position in end expiration
radiates to axilla
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21
Q

2 clinical signs severe Mitral Regurgitation

A

LVF (LV pumps Sv plus regurgitant volume)

AF

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22
Q

Significant negatives in Mitral Regurgitation

A

Infective endocarditis !!

Severe MR

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23
Q

DDx of Mitral Regurgitation

A

Aortic stenosis
VSD
TR

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24
Q

Ix for Mitral Regurgitation

A

Bloods: FBC, U+E, NT-proBNP, lipids, glucose
ECG: LVH, AF, p-mitrale

CXR: LA or LV hypertrophy, mitral valve calcification, pulmonary oedema
Echo and doppler: assess severity, assess LV function

Cardiac catheterisation: assess coronary arteries if surgery planned

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25
Echo features in severe Mitral Regurgitation
Jet width >0.6cm systolic pulmonary flow reversal regurgitant volume >60ml
26
Mx for Mitral Regurgitation
MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurse Conservative: (optimise CV risk) diet, exercise, smoking Medical: (optimise CV risk) statins, anti HTN, DM, anti plt Surgical: - valve replacement or repair if SYMPTOMATIC Specific AF - rate control and anticoagulate emboli - anticoagulate decrease afterload - ACEi or BB, diuretics
27
Prognosis of Mitral Regurgitation
Asymptomatic for >10 years | symptomatic 25% mortality at 5 years
28
Definition of Infective Endocarditis
Colonisation of endocardium 2 to bacteraemia | Typically valvular surfaces
29
Subtypes of Infective Endocarditis
Acute - Sx Days - weeks Spiking fever, tachy,fatigue, damage cardiac surfaces -ve Janeway/Oslers Often septic emboli sx - stroke, septic joint, splenic infarct Subacute Sx Weeks -months Consitutional Sx (fever + FLAWS +ve for Janeway/Oslers
30
Organisms of acute IE
Staphylococcus aureus | Streptococcus pyogenes
31
Organisms of subacute IE
Streptococcus viridans Staphylococcus epidermidis HACEK, Coxiella, Mycoplasma
32
Murmur/ organism of IE + IVDU
Right sided valves Staph aureus
33
Risk factors of IE LIFESTYLE MEDICAL SURGICAL
``` LIFESTYLE • IVDU • Poor dental hygiene MEDICAL • PMH of IE • Immunosuppression: chronic renal failure, DM • Congenital heart disease • Soft tissue infection SURGICAL • Dental surgery Cardiac surgery e.g. prosthetic valve ```
34
Murmur in IE
New murmur + fever | Usually mitral/aortic valve MR/AR (unless IVDU)
35
Immune phenomena in IE
Oslers nodes Roth spots Haematuria
36
Thromboembolic phenomena in IE
Janeway lesions | Splinter haemorrhages
37
O/E hands in IE 4 points
* Clubbing * Splinter haemorrhages (on nails) * Janeway lesions -painless * Oslers -painful
38
O/E cardiac in IE
new murmur | MR> AR
39
7 Ix in IE
``` • FBC - anaemia, raised ESR • U+Es - baseline • Urinalysis - haematuria • Blood cultures • ECG - e.g. increasing PR interval Echo Fundoscopy ```
40
Diagnostic criteria for IE
Duke's criteria 2 MAJOR 1 MAJOR + 3 MINOR 5 MINOR
41
Major Duke's Criteria for IE
Positive blood culture of typical IE organisms or 2 +ve >12 hrs apart Vegetation/abscess on echo or new regurgitant murmur
42
Minor Duke's Criteria for IE
• Risk factor e.g. IVDU, congenital abnormality, prosthetic valve • Fever >38 • Thromboembolic phenomena • immune phenomena • +ve blood culture not meeting major criteria (NB HACEK are culture -ve)
43
Mx of Infective endocarditis
Broad spectrum antibiotics as blood cultures taken Then treat according to sensitivity + trust guidelines • Acute: Flucloxacillin if MSSA, IV Vanc + Met if MRSA • Subacute: IV Benpen + Gent or Vancomycin for 4 wk NB prophylactic Abx for IE not recommended
44
DDx of IE
rheumatic fever atrial myxoma
45
Define rheumatic fever
T2 hypersensitivity reaction / Molecular mimicry - cell mediated immunity + Ab to Strep Ag - cross-react with myocardial Ags (myosin/SM cells)
46
Peak age of Rheumatic fever
5-15 years
47
Pathophysiology of Rheumatic fever
Aschoff bodies Anitschkow myocytes
48
Criteria for Rheumatic fever
Jones Criteria 2 major or 1 major + 2 minor
49
Onset of Rheumatic fever Sx
2-4 weeks after strep throat infection
50
Evidence of Group A Strep in Rheumatic fever | 4
+ve throat culture Rapid strep Ag test high ASOT (blood) recent scarlett fever
51
Systems affected in Rheumatic Fever
Heart Joints Skin CNS
52
Sx of Rheumatic fever HEART JOINTS SKIN CNS
``` HEART pancarditis, valve disease (regurg -> stenosis) JOINTS arthritis, synovitis SKIN erythema marginatum, subcutaneous nodules CNS encephalopathy, Sydenham's chorea ```
53
Jones' Major Criteria JONES
``` Joint-arthritis Pancarditis Nodules subcut Erythema marginatum Sydenham's chorea ```
54
Jones Minor Criteria
``` fever high ESR/CRP arthralgia prolonged PR interval previous rheumatic fever ```
55
Ix for Rheumatic fever
Bloods - FBC, ESR, ASOT ECG ECHO
56
Murmur in Rheumatic fever
Mitral Regurg (PSM) is commonest M>A >T >P REGURG -> STENOSIS
57
Ms Rheumatic fever
Bed rest until CRP normal Benpen 0.6-1.2mg IM for 10 days Erythromycin if penicillin allergic Analgesia for carditis/arthritis- NSAID/aspirin Oral Pred if: CCF, cardiomegaly Chorea- Haldol Prevent recurrence - Pen V 250mg/12h PO for 5-10yrs
58
Prognosis in Rheumatic fever
attacks approx 3m long | if carditis more likely to have chronic rheumatic heart disease
59
Factors increase risk recurrent rheumatic fever
further strep infection pregnancy OCP
60
Classify causes of chest pain
``` Cardiac Respiratory Chest Wall Gastrointestinal Psychiatric ```
61
Causes of Cardiac CP
``` IHD/ACS (STEMI, NSTEMI, unstable angina) Aortic dissection Unstable or crescendo angina Decubitus angina Prinzmetal or variant angina Syndrome X St Vincents angina ```
62
Features of ACS/IHD
CP = tight, heavy, non-specific precipitated by exercise relieved by rest/GTN
63
Features MI
sweating/diaphoresis nausea vomiting
64
Features aortic dissection
Tearing CP | mediastinal widening on CXR
65
Features of silent MI
sweating feel scared no other features (i.e. no CP) in OLD, DM pts (rare as have to lose nerve supply to heart_
66
Features unstable angina
CP at rest may be trop -ve treat as increased risk NSTEM - i.e. be bound + ACS protocol
67
Features crescendo angina
decreased exercise tolerance + CP BETTER at rest may be trop -ve
68
Features decibitus angina
old man with aortic regurg | CP worse on lying down
69
Features Prinzmetal/variant angina
transient ST elevation due to coronary vasospasm Females age 20-50 Tx = daltiezam (nitrates, CCBs)
70
Features Syndrome X
= microvascular angina ST depression (ischaemia) on exercise ECG NORMAL angiogram cannot stent but high risk MI, give meds
71
What is St Vincent's angina
``` pharyngitis Tropherema Pharentii (Brazil) ```
72
Features Tietze's
costochondral tendereness | recreated by palpating chest
73
Features Bornholm's
epidemic myalgia primary school teachers raised CRP + pleuritic CP muscle tenderness due to Coxsackie B + Echovirus

Year 6 (9 decks)

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