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Cardiology Flashcards

1
Q

What additional clues might point you towards the indication for a midline sternotomy scar?

A 
Metallic click - metallic valve
Murumr - tissue valve/valvotomy
Leg scar - CABG
Old scar young patient - congenital heart disease
Immunosuppression - transplant
Nil else - trauma, tissue valve, CABG
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2
Q

What are the cardiac causes of clubbing?

A

Atrial myxoma
infective endocarditis
Congenital heart disease

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3
Q

What might cause a collapsing pulse?

A

Aortic regurgitation
Thyrotoxicosis
Anaemia

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4
Q

What might cause an impalpable apex beat?

A

COPD

COPD
Obesity
Pericardial effusion
Dextracardia

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5
Q

What are the features of pulmonary hypertension?

A 
Raised JVP
Peripheral oedema
Left psternal heave
Pulsatile hepatomegaly
Loud P2 and PSM of TR
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6
Q

What are the examination findings of aortic stenosis?

A

Pulse - slow rising, narrow pulse pressure

Precordium:
Pacemaker
Forceful non-displaced apex
ESM in R 2nd ICS radiating to carotids

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7
Q

What are some cauess of aortic stenosis?

A

Senile calcification
Bicuspid valve
Rheumatic fever

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8
Q

What might be some differentials for aortic stenosis?

A

Sclerosis
MR
HOCM
PS

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9
Q

What are the clinical features of severe AS?

A

Angina
Dyspnoea
Syncope

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10
Q

How would you investigate AS?

A

ECG - LVH, arrhythmias
Bloods - FBC, UnE, BNP, Lipids, glucose
CXR - Calcification, LVH, pulmonary oedema
Echo - LV function, underlying cause

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11
Q

What is the management of AS?

A

Gen - MDT, CV risk, monitor
Surgical - Valve replacement +-CABG if symptomatic
Also - TAVI, balloon valvuloplasty

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12
Q

How would you accentuate the murmur heard in AS?

A

Sat forward in end expiration

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13
Q

What are the examination findings in MR?

A

Pulse - AF
Displaced apex
Soft S1 loud S2
Blowing PSM loudest in apex radiating to axilla

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14
Q

How would you accentuate the murmur heard in MR?

A

Left lateral position in end expiration

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15
Q

What differentials might you give for MR?

A

AS

VSD

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16
Q

What are the common causes of MR?

A

LV dilatation
Calcification
Rheumatic heart disease
Mitral valve prolapse

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17
Q

What investigations would you do for MR?

A

ECG - LVH, arrhythmia, p-mitrale (bifid)
Bloods - FBC, UnE, BNP, lipids, glucose
CXR - Cardiomegaly, calcification, pulm oedema
Echo- assess function

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18
Q

What is the treatment for MR?

A

Gen - MDT, CV risk, monitor
Med - AF rate control and anticoagulate
Surg - Valve replacement if symptomatic

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19
Q

What eponymous signs might you see in AR?

A 
Quincke's - capillary pulsation in nailbed
De Musset's - head nodding
Corrigans - vigorous carotid pulsation
Traube's - pistol shot femorals
Mueller's - systolic uvular pulsations
Rosenbach's - pulsatile liver
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20
Q

What other findings are seen in AR?

A 
Collapsing pulse 
Wide pulse pressure
Displaced apex
S3
High pitched EDM loudest at LLSE
May also have ESM
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21
Q

How would you accentuate the murmur heard in AR?

A

Sitting forward end expiration

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22
Q

What are the common causes of AR?

A

Bicuspid aortic valve
Rheumatic disease
Ankspo/RA
CTD e.g. Ehlers Danlos, Marfan’s

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23
Q

What investigations would you do for AR?

A

ECG - LVH/strain
Standard bloods
CXR - Cardiomegaly, pulmonary oedema
Echo

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24
Q

What is the management of AR?

A

Gen - MDT, CV risk, monitor
Reduce afterload - ACEi/Bblockade/Diuretics
Surg - valve replacement if symptomatic

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25
What examination findings might you find in a patient with MS?
Face - Malar flush Pulse - AF Precordium - Left heave, tapping non displaced apex, MDM in apex radiating ot axilla
26
How would you accentuate the murmur heard in MS?
Left lateral position in end expiration - listen with the bell
27
What are some causes of MS?
Rheumatic fever by far commonest Also prosthetic/congenital valves
28
What investigations might you do for MS?
ECG - AF, p-mitrale Usual bloods CXR - LA hypertrophy, calcification, pulm oedema Echo
29
What is the management of MS?
Gen - MDT, CV risk, monitor Consider RhFever prophylaxis (PenV) AF rate and anticoagulate Surgery - Valve replacement/balloon plasty
30
What is the pathophysiology of rheumatic fever?
Ab cross reactivity with myosin following Strep pyogenes infection. Aschoff bodies
31
What criteria must be met for diagnosis of RhF?
Revised Jones Evidence of GAS infection + 2maj OR 1 maj + 2 min
32
What are major Jones criteria?
JONES ``` Joints - polyarthritis O - pancarditis N - subcutaneous nodules E - erythema marginatum S - Sydenham's chorea ```
33
What are the minor Jones criteria?
Arthalgia Fever PR prolongation Raised inflamm markers
34
What is the treatment of rheumatic fever?
``` Bedrest Benpen Analhgesia Oral pred if CCF Haldol for chorea ```
35
What are the risk factors and organisms associated with acute and subacute infective endocarditis?
Acute RFs - IVDU, immunosuppression, wounds Acute bugs - s. aureus, s. epidermis Subacute RFs - Valve prostheses, MR Subacute bugs - S. viridans, s. bovis
36
What are the clinical features of subacute infective endocarditis?
``` Hands - Splinter haemorrhages Osler's nodes Janeway lesions Clubbing ``` ``` Other - Roth spots Fever Splenomegaly Haematuria ``` Cardiac - New/changing murmur
37
What diagnostic criteria must be met for a diagnosis of infective endocarditis?
Dukes criteria 2 major OR 1 major 3 minor OR 5 minor
38
What are the Dukes major criteria?
+ve blood culture in 2 separate cultures | Endocardial involvement
39
What are the Dukes minor criteria?
``` Fever Predisposition (cardiac lesion, IVDU) Emboli Immune Fx 1 +ve blood culture ```
40
What is the management of IE?
Fluclox + gent Or | BenPen + Gent
41
What might a left lateral inferior thoracotomy scar indicate?
MV repair/valvotomy
42
Aortic vs mitral valve replacement on auscultation?
Aortic - Lub click | Mitral - Click lub
43
What are the key differences between and when would you use a mechanical valve and when a biological valve?
Mechanical valves last longer and require lifelong anticoagulation, so are used on younger patients and on those already on anticoagulants (e.g. AF) Biological valves are less durable and only require aspirin not warfarin. They are used in older patients and women of child bearing age.
44
What are the possible complications of having a valve replacement?
``` Surgical mortality Thromboembolism Anaemia (warfarin and haemolysis) IE Bleeding Failure ```
45
What are some common causes of AF?
``` MS Thyrotoxicosis IHD Rh Fever HTN Pneumonia Hypokalaemia PE ```
46
What investigations would you do in a patient with AF?
ECG - irreg irreg, no p waves Bloods - FBC, (pneumonia), UnE (lowK), TFT, Trop, D-Dimer CXR - oedema, calcification, pneumonia Echo - valve dysfunction
47
What is the management of acute AF?
``` If haemodynamically unstable ->cardiovert If stable -> Rate control with B blocker Start LMWH Chem cardiovert (flec or amiodarone) ```
48
What is the management of longstanding AF?
Use CHADSVASC score to assess stroke risk then (if necessary) anticoagulate with Apixaban etc or Warfarin Rate control with beta blocker or CCB
49
What are the components of the CHA2DS2VASc score?
``` CCF HTN Age >75- 2 points DM Stroke/TIA- 2 points Vascular disease Age 65-74 Sex female ```
50
What rare the result cut offs for CHADVASC?
0- Aspirin | Not 0 - Warfarin/DOAC
51
What are some contraindications to warfarin therapy?
``` Coagulopathy Compliance issues Fall risk PUD Pregnancy ```
52
What are the possible complications of warfarin therapy?
Bleeding | Osteoporosis
53
Give some indications for permanent pacing
``` Complete AVA block Mobitz type 2 Symptomatic bradycardia Drug resistant tachyarrhythmias CCF ```
54
What are the different types of pacemakers?
Single lead Dual lead Biventricular Implantable defibrillator
55
What are some complications of pacemaker insertion?
Insertion - bleeding, arrhythmia Post insertion - Erosion, lead migration, infection, malfunction
56
What are some common causes of left heart failure/
1. IHD 2. Idiopathic dilated cardiomyopathy 3. Systemic HTN 4. Mitral/aortic valve disease
57
What are some common causes of right heart failure?
Left heart failure Pulmonary hypertension Tric/pulm valve disease
58
What are the signs and symptoms of left heart failure?
``` Signs: Cyanosis AF Cardiomegaly w displaced apex S3 gallop tachy Wheeze Creps ``` ``` Symptoms: Dyspnoea on exertion fatigue Orthopnoea + PND Nocturnal cough ```
59
What are the signs and symptoms of right heart failure?
``` Raised JVP Pulsatile hepatomegaly Pitting oedema Ascites Anorexia& nausea ```
60
What are the Xray features of chronic heart failure?
ABCDEF ``` Alveolar shadowing Kerley B lines Cardiomegaly Diversion to upper lobes Effusions Fluid ```
61
What is the management of chronic heart failure?
Gen: MDT, CV risk, monitor SPecific: 1. ACEi + BBlocker + furosemide 2. Add spiro 3. Digoxin 4. Resynchronisation therary Surgery LVAD (external) Transplant
62
Which leads and vessels supply the inferior view of the heart?
Leads: II, III, aVF Vessel: RCA
63
Which leads and vessels supply the anterolateral view of the heart?
Leads: I, aVL, V5, V6 Vessel: L circumflex
64
Which leads and vessels supply the anteroseptal view of the heart?
Leads: V2-4 Vessel: LAD
65
Which leads and vessels supply the anterior view of the heart?
Leads: V2-6 Vessel: Left main stem
66
Which leads and vessels supply the posterior view of the heart?
Leads: V1-3 (recip) Vessel: RCA
67
What might cause broad QRS complexes?
Ventricular initiation Conduction deficit WPW
68
What are some causes of QT prolongation?
TIMME ``` Toxins - Macrolides, antiarrhythmics, TCAs, antihistamines Ischaemia Mitral valve prolapse Myocarditis Electrolytes (any) ```
69
What are some causes of T wave inversion?
``` Strain Ischaemia Ventricular hypertrophy BBB Digoxin ```
70
What are U waves
Occur after T waves in hypokalaemia
71
What are J waves
Occur between QRS and ST due to: Hypothermia SAH HyperCa
72
What causes left and right BBB?
LBBB: Inferior MI Congenitals RVH ``` RBBB: Fibrosis LVH Inf MI Coronary HD ```
73
Name and describe some narrow complex tachycardias (SVTs)
``` Sinus tachy AVNRT - absent p waves, normal QRS AVRT - p waves present, normal/broad QRS Atrial flutter - Saw toothed baseline with ratio AF- irreg irreg ```
74
Name and describe some broad complex tachys
VT - no ps, regular wide QRS, no Ts VF - completely shapeless (V frantic) Torsades - AM
75
What are and what causes p pulmonale and p mitrale?
P pulmonale - peaked P wave caused by pulmonary HTN, tric sten P mitrale - bifid p wave caused by MS
76
RVH vs LVH on ECG?
RVH - Tall R in V1 and Deep S in V6 LVH - Deep S in V1 and Tall R in V6
77
What are the ECG findings of Wolf Parkinson White?
Delta wave - slurred upstroke before QURS
78
What is S1Q3T3?
Deep S wave in lead 1 Pathological Q wave in lead 3 T wave inversion in lead 3
79
How do hyper and hypokalaemia affect ECG/
HyperK: Tented T waves Broad QRS Absent p waves ``` HypoK: Flattened T waves ST depression QT prolongation U waves ```
80
When and how would you treat a bradycardia?
Treat when symptomatic 1. Manage underlying cause 2. IV Atropine 3. External pacing May receive permanent pacing if problem recurs
81
How do you manage an SVT?
1. O2 and IV access 2. Assess rhythm 2a. Regular rhythm - Continue trace, vagal manouvres, Adenosine 6mg IV bolus Reasess; If no adverse signs (low BP, HF, LoC, tachy) then digoxin/amiodarone infusion. If adverse signs then sedate followed by DC cardioversion or Amiodarone infusion 2b. Treat as AF - Rate control with B blockade Consider cardioversion w amiodarone if <48 hrs, consider anticoag
82
How do you manage a VT?
1. Assess pulse a. No pulse -> CPR b. Pulse -> O and IV access 2. Assess adverse signs (hypo, tachy, HF, CP, LoC) a. Yes -> Sedate, DC, Amiodarone b. No -> Correct electrolyte abnormality and reassess
83
What are the risk factors for ACS?
``` Modifiable: HTN Smoking Obesity DM Cholesterol ``` ``` Non-modifiable Age Ethnicity FHx Gender ```
84
What is the progression of ECG changes in STEMI?
``` Normal ST elevation and hyperacute T waves Q waves (full thickness) ST normalisation T wave inversion ```
85
What is the timing of troponin rise in STEMI?
Elevated from 3-12 hours Peaks at 24 hours 2 high readings required for confirmation
86
What investigation results point to an NSTEMI over a STEMI?
Positive trop with typical symptoms but no ST elevation
87
What is the management of STEMI and NSTEMI?
STEMI: PCI or thrombolysis NSTEMI: Angio +- PCI/CABG
88
What are the complications of an MI?
Death Passing PRAED st Death Pump fa ilure ``` Pericarditis (early, fever, positional, saddle STelev) Rupture: LV wall -> tamponade Chordae -> MR w. PSM Septum -> PSM, JVP, HF ``` Arrhythmias (Tachy or brady) and Aneurysm Embolism - 3/12 warfarin Dressler's -> Pneumopericarditis at 2-6 weeks
89
What is the management pathway of a STEMI?
1. ECG 2. Target SpO2 94-98% 3. IV access + bloods 4. Brief Hx + exam 5. 300 Asp 300 Clopi 6. Analgesia - MnM 7. GTN & B-blockade 8. LMWH 9. CCU for monitoring 10. PCI or thrombolysis
90
What should be done regarding secondary prevention of MI?
ABCDS + lifestyle ``` ACEi B-blocker Cardiac rehab group DVT prophylaxis till movile Statin (atorva 80) ``` Stop smoking, diet, exercise etc. Clopi continue for 1 month, aspirin is lifelong
91
What are some non atheromatous causes of angina?
Anaemia AS Tachyarrhythmia Arteritis
92
What are the different types of angina/
``` Stable - exertional Unstable - constant Decubitus - on lying Prinzmetal - vasospasm during rest Syndrome X - Angina and ST elevation on exercise but no evidence of atherosclerosis ```
93
What secondary prevention is given to patients with angina/
Aspirin 75 OD ACEi Statins (simva 40) Antihypertensives
94
What symptomatic relieve can be given to angina patients?
GTN spray + either BB or CCB
95
What is the management of treatment resistant angina?
PCI or CABG
96
Complications of CABG?
``` MI Stroke Tamponade Postperfusion syndrome (neurocognitive imp) AF Sternum nonunion Graft stenosis ```
97
What is the management algorithm for severe pulmonary oedema?
1. Sit pt up 2. 15L non rebreathe O2 3. IV access, bloods, ECG 4. MnM 5. 40mg IV furosemide 6. GTN 7. Hx, CXR, ?echo 8. Start nitrate infusion if SBP >100 (aim for >90) 9. Consider CPAP, furosemide, nitrates, haemofiltration 10. If SBP <100 consider inotropes
98
What are the causes of flash pulmonary oedema/
Cardiogenic - MI Arrhythmia Fluid overload Non-cardiogeniic ARDS Upper airway obstruction Neurogenic
99
What is Beck's triad and when would you see it?
Hypotension Raised JVP Muffled heart sounds Seen in cardiac tamponade
100
What is the treatment algorithm for hypertension/
<55 1. ACEi 2. ACEi +CCB 3. ACEi + CCB + Thiazide >55 or black 1. CCB 2. CCB + ARB 3. CCB + ARB + Thiazide
101
What are the causes of a mitral valve prolapse?
Primary myxomatous degeneration frequently in young women MI CTD Turner's
102
What are the signs of an MV prolapse?
Mid systolic click +- a late systolic murmur
103
What are the complications of an MV prolapse?
MR Stroke Arrhythmia
104
What are the causes of tricuspid regurg?
RV dilatation RhFever IE Carcinoid
105
What are the signs of TR?
``` Raised JVP Ascites/oedema PSM at LLSE on inspiration Pulsatile hepatomegaly Jaundice ```
106
What are the features of tricuspid stenosis?
Fatigue, ascites oedema, Opening snap EDM at LLSE on inspiration
107
What are the featuers of pulmonary stenosis?
Dyspnoea, ascites, oedema Ejection click ESM at ULSE on inspiration
108
What are the causes of acute pericarditis?
Viral, bacterial, fungal MI (Dressler's) Drugs - penicillin, isoniazid Other - uraemia, RA, SLE, sarcoid
109
WHat is a classic (and other) sign(s) of constrictive pericarditis?
Kussmaul's sign - Raised JVP on inspiration RHF Hepsplenomegaly Fluid
110
What is a classic feature of a pericardial effusion?
Ewart's sign - large effusion compressing lower lobe causing bronchial breathing at the left lung base
111
Which three signs are seen in cardiac tamponade?
Kussmaul Beck's triad Pulsus paradoxus (pulse fades on inspiration)
112
What are the causes of acute myocarditis?
Idiopathic in 50% Any infection Drugs - cyclophosphamide, carbamazepine, phenytoin Autoimmune - GCA, SLE
113
What are the clinical featuers of acute myocarditis?
``` Flu like prodrome Dyspnoea, fatigue Chest pain Arrhythmia/palps S4 gallop ```
114
What are the investigations and treatment for myocarditis?
ECG - ST elev/dep T inv +ve trop, CK elevation Treat the cause
115
What is the pathophysiology and inheritance pattern of HOCM?
LVOT obstruction due to septal hypertrophy AD inheritance - ask re family Hx of sudden death
116
What are the clinical features of HOCM?
``` Angina Dyspnoea Palps Exertional syncope Double apex beat ESM @ LLSE ```
117
What is the management of HOCM?
Med - -ve inotropes (BBlock/verapamil) Amiodarone for arrhythmia Anticoagulate if AF Non-med - septal myomectomy if severe
118
What are the causes of dilated cardiomyopathy?
DILATE ``` Dystorphy Infection Late pregnancy Autoimmune - SLE Toxins (ETOH) Eosinophilia Neoplasia (Carcinoid) ```
119
What are the clinical and investigation findings in DCM?
``` Clin - Displaced apex Massive JVP S3 gallop Hypotension MR/TR ``` CXR - c-megaly, oedema ECG - T inversion Echo - dilation and hypokinesis
120
What is the management of DCM?
Bed rest Diuretics, ACEi, digoxin, anticoagulate Biventricular pacing Transplant
121
What are the complications and features of an ASD?
Eismenger's syndrome (R->L shunt) due to raised RA pressure ``` Dyspnoea Pulm HTN Arrhythmia Chest pain AF JVP ESM ```
122
How do you diagnose and manage an ASD?
Echo Transcatheter closure
123
What are the features of coarctation of the aorta?
RF delay w weak femorals HTN Systolic murmur
124
What how does a VSD commonly present?
Severe HF in infancy or incidentally later in life with harsh PSM at LLSE
125
What are the components of Tetralogy of Fallot/
VSD Pulmonary stenosis Overriding aorta RVH
126
How does Marfan's present?
Cardiac - Aortic aneurysm/dissection Aortic root dilatation -> AR MV prolapse Ocular - Upper lens dislocation ``` MSK - High arched palate Pes planus Arachnodactyly Scoliosis Pectus excavatus Hypermobility ```
127
What hat might you see on CXR of a Marfan's pt?
Widened mediastinum Scoliosis Pneumothorax
128
What are the features of Ehler's Danlos?
Hyperelastic skin Hypermobility Cardiac - valves and aneurysms Fragile vessels and poor healing.

Scott's Notes (21 decks)

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