Cardiology Flashcards
Symptoms and signs of heart failure?
Poor feeding, breathlessness, faltering growth, excessive sweating, recurrent chest infections.
Signs - tachycardia, cool peripheries, tachypnoea, hepatomegaly. Third heart sound, murmur, abnormal pulses.
Causes of heart failure?
Neonates - duct dependent: Requires PDA until definitive treatment. - Hypoplastic left heart syndrome - Critical aortic valve stenosis - Severe coarctation of the aorta
Infants:
- Large ventricular septal defect
- Atrioventricular septal defect
- Large PDA
Older children and adolescents:
- Eisenmenger syndrome
- Rheumatic disease
- Cardiomyopathy
Investigations for heart failure?
Echo is diagnostic
CXR
ECG - may show hypertrophy
Management of heart failure?
Treat underlying cause.
Diuretics - ACE-i
Nutritional support for poor feeding.
Causes of blue baby?
Hypoventilation Right-to-left intracardiac shunting V-Q mismatch Diffusion impairment ToF Truncus arteriosus Transposition of great arteries Respiratory distress syndrome Transient tachypnoea of newborn Aspiration (meconium, blood, milk) can give rise to atelectasis or chemical pneumonitis Pneumonia Pulmonary haemorrhage Pulmonary oedema Pneumothorax Pleural effusion Polycythaemia
How do oxygen sats rise in healthy babies in first 10 minutes of life?
Rise to >90 by 10 minutes of age.
How to treat blue baby?
A-E
15L 100% oxygen - if doesn’t;t help, means its cardiovascular cyanosis so won’t help.
Fluids and vasopressors for hypotension and shock
Abx if evidence of sepsis or pneumonia
Alprostadil (prostaglandin E1) infusion to maintain latency of ductus arteriosus if suspected ductal-dependent congenital cardiac conditions.
What are the hallmarks of an innocent murmur?
Asymptomatic Soft blowing murmur Systolic murmur only Heard on left sternal edge No radiation
Name Genetic disorders and associated congenital heart disease?
Down syndrome - AV septal defect
Turner syndrome - coarctation of aorta, bicuspid aortic valve.
DiGeorge syndrome - ToF, Truncus arteriosus, interrupted aortic arch
Noonan syndrome - Pulmonary stenosis
Name acyanotic congenital heart defects? Which direction are the shunts?
Ventricular septal defect
Atrial septal defect
Patent ductus arteriosus
Coarctation of aorta
Left to right shunts
What are the causes or association with ventricular septal defect?
Down’s, Edwards, Patau’s.
Most common CHD
Features of ventricular septal defect?
Small VSD - asymptomatic
Large VSD - symptoms of heart failure (breathlessness, fluid overload, sweating when feeding, fatigue, poor feeding).
Pansystolic murmur at lower left sternal edge.
Management of ventricular septal defect?
Complications?
Spontaneous improvement occurs in most children with small defect.
Operate in severe cases to repair hole.
Eisenmengers syndrome - irreversible and life-threatening.
Right heart failure
Aortic regurgitation
Infective endocarditis.
What are the two types of atrial septal defect?
Ostium secundum Ostium primum (common in Down's)
Features of atrial septal defect?
Asymptomatic if small
May have paradoxical embolus - embolus usually travels from RA to RV to lungs - PE.
In ASD it may travel from RA to LA to LV to aorta to aortic branches - stroke.
Usually doesn’t occur as L pressure is greater.
Ejection systolic murmur in left upper sternal edge with split S2.
Diagnosis and management of atrial septal defect?
Echocardiogram
ECG - right ventricular hypertrophy
Small defects often close spontaneously after a few years.
Larger defects will need cardiac catheterisation to close to hole.
Features and risk factors of Patent Ductus Arteriosus?
Most common CHD in premature infants, born at high altitude or maternal rubella infection in first trimester.
PDA occurs if reduced oxygen levels or if there are increased prostaglandins.
Continuous machinery murmur in left upper sternal edge (radiate to back)
Left sub-clavicular thrill
Wide pulse pressure
Bounding, collapsing pulses
Heaving apex beat.
Increased work of breathing, poor weight gain, signs of congestive heart failure/LVHF
Risk factors - prematurity, Down’s syndrome, high altitude, maternal rubella.
Management of PDA?
Ibuprofen - inhibits prostaglandin synthesis - closes connection.
Cardiac catheterisation or ligation can also be done.
Features of coarctation of aorta?
Narrowing of aorta Mid-systolic murmur, maximal over back. Heart failure in infancy Radio-femoral delay Apical click from aortic valve.
What are examples of cyanotic CHD? Which direction is the shunt?
ToF
Cyanotic Spells
Transposition of Great Arteries
Features of ToF?
Presents at 1-2 months.
Pulmonary stenosis, RV hypertrophy, overriding aorta, VSD.
Severity of pulmonary stenosis determines degree of cyanosis.
Signs: Cyanosis Ejection systolic murmur due to pulmonary stenosis Dyspnoea Tachycardia Poor weight gain Clubbing Irritability Poor exercise tolerance.
Investigations and management of ToF?
Chest X-ray - RVH
ECG - RV hypertrophy
ECHO
Surgical repair often undertaken in two parts
Cyanotic episodes may be helped by beta-blockers to reduce infundibular system.
What are cyanotic spells?
Life-threatening, acute cyanosis due to sudden increase in pulmonary resistance, making it more difficult to oxygenate blood.
Occurs when ill or dehydrated.
Features of cyanotic spells?
Cyanosis
Severe chest pain
SOB
Tachycardia
Management of cyanotic spells?
Squatting and holding breath can help increase venous return (vagal manoeuvres)
Oxygen
Fluids (increases venous return)
Analgesia
Beta-blockers to reduce infundibular spasms (stabilises venous return)
What is transposition of great arteries?
Aorta connected to RV, pulmonary artery connected to LV.
Two seperate circuits - deoxy blood and oxy blood.
Features of transposition of great arteries?
Babies usually present at about 4 days when PDA starts to close and creates symptoms. If they have VSD, baby will stay alive for longer.
Cyanosis in first day of life
Heart failure - tachypnoea, laboured breathing, tachycardia, cool/clammy skin
Diagnosis of transposition of great arteries?
Murmur Echo ECG CXR - egg on side appearance Cardiac catheterisation
Initial and surgical treatment of transposition of great arteries?
ICU admission
IV prostaglandin E1 given to keep PDA open
Cardiac catheterisation is diagnostic and therapeutic.
Balloon atrial septostomy guided through foramen vale to open atrial septum and create ASD.
Surgery:
Aorta moved from RV to LV
Pulmonary artery moved from LV to RV
Coronary arteries moved
What causes rheumatic fever?
Strep pyogenes
How to diagnose rheumatic fever?
Evidence of recent strep infection plus 2 major OR
1 major with 2 minor
Major - erythema marginatum, sydenham’s chorea, polyarthritis, carditis, valvulitis, SC nodules.
Minor - Raised ESR or CRP, pyrexia, arthralgia, prolonged PR interval
Evidence of recent strep infection - raised or rising strep abs, positive throat swab, positive rapid group A strep antigen test.
How do you manage rheumatic fever?
Benzylpenicillin.
Causes of infective endocarditis?
Staph aureus most common Staph epidermidis - most common following prosthetic valvular surgery Strep viridans (20%) Strep bovis - colorectal cancer SLE Malignancy Bartonella Brucella HACEK - Haemophillus, actinobacillus, cardiobacterium, eikenella, kingella
Features and diagnosis of infective endocarditis?
Modified duke criteria Diagnosis if: - pathological criteria positive - 2 major criteria - 1 major and 3 minor criteria OR - 5 minor criteria
Pathological - positive histology or microbiology
Major - Positive blood cultures, evidence of endocardial involvement
Minor - predisposing heart condition or IV drug use
Microbiological evidence does not meet major criteria
Fever >38 degrees
Vascular problem
Management of infective endocarditis?
Indications for surgery?
Initial blind therapy:
Native valve - amoxicillin (Vanc + low dose gent)
Prosthetic valve - Vanc + rifampicin + low dose gent
Native caused by staph:
Flucloxacillin (Vanc + rifampicin)
Prosthetic caused by staph:
Flucloxacillin + rifampicin + low dose gent
Caused by fully sensitive strep:
Benzylpenicillin (vanc + low dose gent)
Caused by less sensitive strep:
Benzylpenicillin + low dose gent (Vanc + low dose gent)
Indications for surgery -
Severe valvular incompetence
Aortic abscess
Infections resistent to abx/fungal infections
Cardiac failure refractory to standard medical treatment
Recurrent emboli after abx therapy.
What is Kawasaki disease and features?
Vasculitis that is predominantly seen in children
High grade fever lasting >5 days Fever resistant to antipyretics Conjunctival infection Bright red, cracked lips Strawberry tongue Cervical lymphadenopathy Red palms of hands and soles of feet which later peel
Management of Kawasaki disease? Complications?
High dose aspirin
IV immunoglobulin
Coronary artery aneurysm
Reye’s syndrome due to use of aspirin in children
What is Ebstein’s Anomaly?
What is it associated with?
What causes it?
Congenital heart defect - low insertion of tricuspid valve resulting in large atrium and small right ventricle.
Associated with WPW syndrome and tricuspid incompetence (pan-systolic murmur, giant V waves in JVP)
Can be caused by exposure to lithium in-utero.
