Cardiology Flashcards
What is unstable angina?
Chest pain which occurs at rest and is >10 mins duration
Severe and new onset
Crescendo pattern: episodes are worse than those previously
What is hypertrophic cardiomyopathy?
Due to mutations (inherited or spontaneous) in genes encoding myocyte contractile filament proteins
Ventricular hyper trophy with systolic dysfunction
Cause of sudden death in young people
What is rheumatic heart disease?
Results from acute rheumatic fever often precipitated by strep pyogenes
Streptococcal antigens cross react with myocardial antigens, resulting in an autoimmune response against heart valves, most often mitral and aortic valves
What is dilated cardiomyopathy?
Dilation of all 4 chambers of the heart and thinning of ventricle wall
Caused by: viral infections, endocrine disease, chronic alcohol use, severe protein malnutrition
What is pancarditis?
Triad of endocarditis, myocarditis and pericarditis
A 24 year old man has been admitted to a surgical ward for treatment of an abscess on his back. He is due to for theatre tomorrow and his pre operative ECG shows ST elevation. What is the most appropriate management of this patient?
Organise ECHO as an outpatient
Changes are that of an athletic heart with mild ST elevation and prominent T waves
What is Wolff Parkinson white syndrome?
Abnormal accessory electrical conduction pathway between atria and ventricles called bundle of Kent
This may stimulate ventricles to contract prematurely, resulting in supraventricular tachycardia
What prophylaxis should be given for DVT?
Once daily low molecular weight heparin
How is DVT most reliably diagnosed?
Venography
In what proportion of patients is DVT clinically apparent?
70% of cases
Which organs can cause central chest pain?
Heart Lungs Thoracic wall Great vessels Stomach Pancreas
What are the cardiac causes of central chest pain?
Acute coronary syndrome Myocardial infarction Pericarditis Arrhythmias Cardiac failure Dissection
What features of a history would support a theory of a cardiac cause for central chest pain?
Central / L-sided
Sudden, on exertion
Crushing, heaviness, sharp
Classically into L arm/neck, may be none
Sweating, SOB, fever, palpitations, associated risk factors
Constant, worsening, periodic on exertion or at rest
Exacerbating: exertion (MI), inspiration/lying flat (Pericarditis)
Alleviating: GTN (MI), leaning forward (Pericarditis)
Severity – 0 -10
For cardiac causes of central chest pain, what would you look for on examination?
Around the bed: GTN spray
End of the bed: comfortable/uncomfortable, sweating
Pulse: regular/irregular, character, rate
BP: may be high if in pain, worrying if low
JVP: may be raised if constrictive pericarditis or cardiac
tamponade
Cardiac examination: may be normal (MI, ACS); pericardial friction rub (Pericarditis); Evidence of valvular disease (Arrhythmias)
Peripheral oedema
What would expect in history/examination of a patient with aortic dissection?
History: very acute, sharp, tearing, radiating into the back, associated with hemiplegia/paraplegia or acute limb ischaemia as dissection progresses
Examination: Unequal pulses/BP between arms, may be hemiplegia / paraplegia
What are the respiratory causes of central chest pain?
Pneumonia
Pneumothorax
PE
What factors in the history would make you suspect a respiratory cause of central chest pain?
Central or L/R sided
Sudden (PE/Pneumothorax), gradual (Pneumonia)
Sharp
SOB, fever, cough (productive/non-productive), haemoptysis, associated risk factors
Constant (PE/Pneumothorax) or intermittent
Exacerbating: inspiration, coughing
Severity – 0 -10
What might you expect to find on examination for a respiratory cause of central chest pain?
Around the bed: sputum pot, inhalers
End of the bed: comfortable/ uncomfortable, visibly short of breath
Hands: cyanosis
BP: worrying if low
Mouth: cyanosis
Chest: Pneumonia – bronchial breathing, creps, dull percussion note (assoc effusion), use of accessory muscles
- Pneumothorax – deviated trachea, absent breath sounds,
hyperresonant percussion note
- PE – may be normal apart from raised respiratory rate
What are thoracic wall causes for central chest pain?
Costochondritis
Rib fractures
Herpes zoster
What features in a history and examination would make you suspect Costochondritis as a cause of chest pain?
Usually L or R sided, sharp, worse on inspiration, may have recently had cough/pneumonia
Evidence of pneumonia, chest pain is reproducible on palpation, usually at costosternal junction
What features in the history and examination would make you suspect rib fractures as a cause of chest pain?
Usually L or R sided, sharp, worse on inspiration, history of trauma
Evidence of trauma elsewhere, overlying bruising or visible flail segment, localised tenderness, significant shortness of breath
What features in the history and examination would make you suspect herpes zoster as a cause for chest pain?
Dermatomal pattern, vesicular lesions visible within a single dermatome, may be normal examination
What are some abdominal causes of central chest pain?
Perforated peptic ulcer
Pancreatitis
GORD
Cholecystitis
What features from a history and examination would make you think of a ruptured peptic ulcer as a cause of chest pain?
Sudden onset, sharp, associated with vomiting/abdominal pain/sweating, risk factors (alcohol excess,previous GORD or ulcer) will look uncomfortable, may be tachycardic and hypotensive, cold peripheries, chest examination may well be normal apart from raised RR, abdominal examination – epigastric tenderness, guarding, rebound
What features in the history and examination would make you suspect pancreatitis as a cause for central chest pain?
Gradual but worsening, dull, radiation to back, associated with vomiting/abdominal pain, risk factors (alcohol excess,previous gallstones or pancreatitis)
Look uncomfortable, tachycardic and hypotensive, cold peripheries, chest examination may well be normal apart from raised RR,
abdominal examination – epigastric tenderness, guarding,
rebound
Grey-Turner’s sign or Cullen’s sign
What features in the history and examination would make you suspect GORD as a cause for central chest pain?
Intermittent, burning, radiation into throat, associated with certain foods, may be worse on lying flat
Examination will be largely normal
What is buergers test?
Assesses arterial circulation of lower limb
Raise patients leg and observe angle at which there is blanching. After one minute, lower legs so dependent with feet on floor
If reactive hyperaemia is observed - arterial insufficiency present
How do you differentiate between an anterior MI and pericarditis on an ECG?
Anterior MI: convex, upwards, gravestone sign ST elevation in leads V1-5
Pericarditis: concave, downwards ST elevation
What would a posterior MI look like on an ECG?
Dominant R wave in lead V1 and posterior leads V5-8 revealing ST elevation
What does a PE look like on an ECG?
SI QIII TIII acute cor pulmonale, right heart strain
A 55 year old male presents with weight gain and shortness of breath, he has a long history of chronic airway disease. On examination he has a raised JVP with prominent v waves and auscultation of the heart reveals a soft systolic murmur. What is the likely cardiological defect?
Tricuspid regurgitation
Elevated right sided pressures following pulmonary hypertension
A 22 year old female presents with a six month history of deteriorating shortness of breath. She has turners syndrome. On examination she has a blood pressure of 162/88 and has a harsh ejection systolic murmur over the aortic and pulmonary areas. What is the likely cardiological defect?
Coarctation of the aorta
Hypertension and ejection systolic murmur
A man in his 30s presents with cadiac type chest pain and has had an MI. On further investigation he is found to have familial Hypercholesterolaemia but normal triglycerides. Biochemically what is the underlying abnormality?
Defective LDL receptors
What is Flecainide?
Class 1c sodium channel blocker that is used for paroxysmal atrial fibrillation
What class of anti arrhythmic is atenolol?
Class II
What is Amiodarone?
Class III anti arrhythmic drug that prolongs the action potential by blocking K channels
What is digoxin? What is it used for as an anti arrhythmic?
Positive Inotrope that increases vagal activity
Used in atrial fib and flutter
What is the mechanism of adenosine as an anti arrhythmic drug?
Causes hyperpolarisation when bound to its receptor therefore decreases the pacemaker potential slope
In which patients might a silent MI occur?
Elderly
Hypertensive
Diabetes
What dose of aspirin should be given in an acute MI?
300mg PO immediately reduces mortality
What condition typically has a pericardial rub on auscultation?
Pericarditis
What could result from inappropriate thrombolysis of pericarditis?
Haemopericardium
What are some absolute contraindications for thrombolysis?
Active internal bleeding
Suspected aortic dissection
Recent head trauma/intracranial neoplasm
Previous haemorrhagic stroke at any time
Previous ischaemic stroke in the past year
Previous allergic reaction to fibrinolytic agent
Trauma/surgery within 2 weeks at risk of bleeding
What is a gallop rhythm?
Presence of S3 and S4 at a rate making it impossible to accurately distinguish the two
What is the acute management for an MI?
High flow oxygen 300mg aspirin chewed 5mg IV morphine 300mg clopidogrel GTN spray
What is the acute management for left ventricular heart failure?
High flow oxygen
2.5-5mg diamorphine IV
40mg furosemide IV
Two puffs GTN spray
What are the risk factors assessed for in the CHA2DS2 VASc
C: congestive heart failure H: hypertension A: age >75 (2) D: diabetes S: stroke or Tia history (2) V: vascular disease history A: age 65-74 S: female
What are the Ts and Hs which are major contributing factors to pulseless arrest?
Hypovolaemia Hypoxia Hydrogen ions (acidosis) Hyper/hypokalaemia Hypoglycaemia Hypothermia Toxins Tamponade Tension pneumothorax Thrombosis Trauma
What 4 things should be done in the acute management of an MI?
Morphine
Oxygen
Nitrates
Aspirin
What is PCI?
Percutaneous coronary intervention
Revascularisation technique
Non surgical widening of the coronary artery using a balloon catheter. A stent is placed after dilation
What is the target door to balloon time in a STEMI patient needing PCI?
90 minutes
What drugs are required post PCI procedure?
Dual anti platelet therapy: aspirin and clopidogrel
What are possible complications of PCI?
Stent thrombosis: acute MI with high mortality
Restenosis: excessive healing of vessel wall, angina symptoms
What are the main contraindications to thrombolysis?
Bleeding disorder History of recent haemorrhage Trauma Surgery Acute cerebrovascular event
What should be given to patients presenting with ACS 12 hours after onset of symptoms where reperfusion therapy is not possible?
Aspirin
Clopidogrel
Anti thrombin agent: heparin, enoxaparin or fondaparinux
What factors determine whether PCI or CABG is used in an MI patient?
PCI: Short, non calcified lesion on straight unbranched artery. Single or 2 vessel disease
CABG: longer, calcified lesions in tortuous vessels, involving major bifurcations, chronic occlusions, left anterior descending involvement, patients with diabetes, LV dysfunction or strongly positive exercise test
What are possible complications of CABG?
MI AKI Ventricular arrhythmia Stroke Low output state requiring supportive measures
What long term medications should a patient be on after an MI?
Antiplatelet: low dose aspirin, clopidogrel
Beta blocker
ACE inhibitor
Cholesterol lowering agent
What are common and rare causes of atrial fibrillation?
Mitral valve disease Hypertension Myocardial ischaemia Hyperthyroidism Alcohol Rarer: Endocarditis Constrictive pericarditis Pneumonia
What investigations are useful for AF?
ECG FBC: anaemia can complicate TFTs Echo 24 hour ECG tape U&Es
If an apex beat is described as heaving, what is the underlying mumur?
Aortic stenosis
Left ventricular hypertrophy
If an apex beat is in the sixth intercostal space and is thrusting in nature. What is the underlying murmur?
Aortic regurgitation
Volume overload
If an apex beat is described as tapping in nature, what is the underlying murmur?
Mitral stenosis
Opening snap
Which drug is considered first line to treat AF with rate control?
B blocker
What is the embryological origin of the diaphragm?
Mesoderm of second pharyngeal arch
What is the embryological origin of the cardiac muscle?
Splanchnic mesoderm
A 35 year old man diagnosed with HTN. He has visible pulsation a suprasternal notch, heaving apex beat and a continuous bruit best heard over back. What pulse abnormality would you expect to feel?
Radio femoral delay
HTN in young with abnormal pulse think of coarctation of aorta
A 65 year old female with a tapping apex best, loud first heart sound, opening snap and rumbling mid diastolic murmur best heard medial to apex beat. No pre systolic accentuation of the murmur. What pulse abnormality would you expect to feel?
Irregular pulse
she has mitral stenosis
Patient is likely to develop AF
A 68 year old man with a heaving apex beat, soft single second heart sound and harsh ejection systolic murmur radiating to neck, what pulse abnormality would you expect to find?
Anacrotic
He has systolic overload - aortic stenosis or severe systemic HTN. Soft second heart sound and neck radiation suggests AS
Character of pulse is small volume and slow rising - anacrotic
When does pulsus paradoxus occur?
Severe obstructive airway disease
Decreased venous return to left atrium that normally occurs is exaggerated
When does pulsus alternans occur?
Left ventricular failure
When do you hear a soft first heart sound?
Mitral regurgitation
Poor apposition of mitral valves prior to systole
When would you expect to hear a gallop rhythm with a third heart sound?
Congestive cardiac failure
Stretching of the ventricles during diastolic filling, restriction to the stretch causes a jarring noise
What is corrigans sign?
Rapid upstroke and collapse of the carotid pulse associated with a decrescendo diastolic murmur
Associated with aortic regurgitation, water hammer pulse best felt in the carotids
What is kussmauls sign?
Elevated jvp which rises on inspiration and has a knock on auscultation of the heart
Constrictive pericarditis/ pericardial effusion
What are some risk factors for atrial fibrillation?
COPD IHD/MI Thyrotoxicosis Mitral stenosis Pneumonia PE Sepsis
What causes an s3 gallop?
Heart failure
What are causes of complete heart block?
MI
Cardiac operations
Rheumatic disease
Drugs
50 year old female with worsening SOB on exertion and orthopnoea. On examination, tapping apex, loud first heart sound and apical rumbling mid diastolic murmur. What is it?
Mitral stenosis
What are common causes of mitral stenosis?
Rheumatic fever
Congenital
SLE/RA
What are some complications of mitral stenosis?
Atrial fibrillation
Embolism
Infective endocarditis
30 year old female with palpitations, SOB on exertion. On examination she has a high arched palate, arm span greater than her height. Soft first heart sound, mid systolic click and apical blowing late systolic murmur radiating to axilla. What is it? And what does she have?
Mitral valve prolapse
Marfans syndrome
Name some causes of mitral valve prolapse
Connective tissue disorders: Marfans, ehlers danlos DMD Fragile X syndrome Congenital heart disease Ebstein anomaly Ischaemic heart disease
80 year old man presents with exertional syncope. On examination he has slow rising carotid pulse and loud ejection systolic murmur at the upper right sternal edge, radiating to carotids. What is it?
Aortic stenosis
What are some causes of aortic stenosis?
Congenital bicuspid valve
Rheumatic fever
Senile calcification
What is the classical triad of symptoms for aortic stenosis?
Chest pain
Heart failure
Syncope
55 year oral female presets with ankle swelling. On examination, early diastolic murmur at aortic area. Loudest with the patient sitting forward in expiration. What is it?
Aortic regurgitation
What are some causes for aortic regurgitation?
Rheumatic fever Infective endocarditis Trauma Aortic dissection Marfans Ankylosing spondylitis RA SLE HTN
An otherwise healthy female of 6 months is found to have a continuous machinery murmur at the upper left apex during routine examination at baby clinic. What is it?
Patent ductus arteriosus
What might a child with patent ductus arteriosus have a history of?
Premature birth Perinatal distress Born at extreme altitude Failure to thrive Low birth weight
What can be used to close a patent ductus arteriosus if there are no other heart abnormalities?
Indomethacin
On auscultation there is a soft first heart sound, what is this?
Mitral regurgitation: poor apposition of mitral valves prior to systole
On auscultation there is a gallop rhythm with a third heart sound. What is this?
Congestive cadiac failure: stretching of the ventricles during diastolic filling being restricted, creating a jarring noise
On auscultation there is a loud first heart sound and an opening snap heard in diastole, what is it?
Mitral stenosis: close proximity of tethered valves, high velocity closure of leaflets - loud first heart sound
Opening snap - rapid opening of a pliable valve, as it becomes more calcified this may disappear
List some causes of atrial fibrillation
Thyrotoxicosis Mitral valve disease Congenital heart disease Cardiac surgery Pericarditis Ischaemic heart disease Pulmonary embolism Pneumonia Sepsis Alcohol Excess caffeine Cardiomyopathy Sleep apnoea
What are the 3 main modifiable risk factors for cardiovascular disease?
Hyperlipidaemia
Smoking
Hypertension
An 84 year old patient is incidentally found to have an ejection systolic murmur loudest over the second right intercostal space. The patient is asymptomatic and an echo reported no pressure gradient across the valve. What is the most likely diagnosis?
Aortic sclerosis
An 84 year old patient is incidentally found to have an ejection systolic murmur loudest over the second right intercostal space. The patient is asymptomatic and an echo reported no pressure gradient across the valve. What is the most likely diagnosis?
Aortic sclerosis
In a patient newly diagnosed with HTN who is 50 and Caucasian, what is the first line therapy?
ACE inhibitor
Under 55 and Caucasian
Name some drugs which may cause Hyperkalaemia as a side effect?
ACE inhibitors Heparin Ciclosporin Amiloride Spironolactone Angiotensin II receptor blockers
Where does the right coronary artery originate?
Right aortic sinus
Where does the diagonal artery originate?
Anterior descending artery
Where does the right atrioventricular nodal artery originate?
Right coronary artery near its termination
Where does the left marginal artery originate?
Circumflex artery
Describe the branches of the right coronary artery
60% individuals SA nodal artery
Right marginal
Posterior descending
AV nodal
Describe the branches of the left coronary artery
40% individuals SA nodal
Left anterior descending, branches to give diagonal
Circumflex, branches to give left marginal
A 56 year old male with a five year history of HTN attends ED complaining of severe chest pain which radiates to the back. He describes it as tearing in nature. He is tachycardic and hypertensive with a BP of 185/95 and a soft early diastolic murmur. The ECG shows st elevation of 2mm in inferior leads and there is a small left sided pleural effusion on chest X-ray. What is the likely diagnosis?
Aortic dissection
Murmur is aortic regurgitation
What examination findings might there be in a patient with pericardial constriction or effusion?
Dyspnoea Raised JVP Pulsus paradoxus Pericardial knock Pericardial rub Kussmauls sign
What is the definition of orthostatic hypotension?
Fall in systolic BP of at least 20mmHg (30 in HTN), or diastolic of 10mmHg within 3 mins of standing
How is perfusion rhythm maintained in complete heart block? What happens if this doesn’t occur?
Junctional or ventricular escape rhythm
Or ventricular standstill leading to syncope or sudden cardiac death
What causes orthopnoea?
Left heart can’t cope with increased venous return when recumbent
What causes PND?
Inability to cope with increased volume return when recumbent along with interstitial pulmonary oedema leading to increased airway resistance
What are the categories of the chads2 VASc score?
Congestive heart failure Hypertension Age over 75 Diabetes Stroke Vascular disease Age 65-74 Sex
How do you manage a haemodynamically stable patient with SMVT? What if they are pulseless?
IV arrhythmic: amiodarone, procaineamide, lidocaine
DC cardio version and CPR
What are causes of aortic stenosis?
Bicuspid aortic valve
Age related calcification
Rheumatic fever
What are signs and symptoms of aortic stenosis?
Syncope Angina Dyspnoea Slow rising pulse Left ventricular hypertrophy Micro angiopathic haemolytic anaemia Systolic ejection murmur
What are some causes of aortic regurgitation?
Tertiary syphilis
Connective tissue disorders
Endocarditis
Rheumatic fever
What are signs and symptoms of aortic regurgitation?
Fatigue Syncope SOB Palpitations Widened pulse pressure Left ventricle dilation S3 heart sound Displaced apex beat Early diastolic murmur
What are 3 mechanisms for arrythmogenesis?
Accelerated automaticity
Triggered activity
Re entry
What is sick sinus syndrome and what can cause it?
Fibrosis of sinus node Idiopathic Ischaemic heart disease Cardiomyopathy Myocarditis
What are potential side effects of IV adenosine?
Bronchospasm Flushing Chest pain Heaviness of limbs Sense of impending doom
A 68 year old male presents with breathlessness and weight loss. He is a smoker of 10 cigarettes a day. On examination he has a raised JVP, two finger breadth pulsatile hepatomegaly and ankle oedema. What is the likely diagnosis?
Congestive heart failure
Secondary to COPD
What heart abnormality is pulsatile hepatomegaly a sign of?
Tricuspid regurgitation
A 55 year old male presents with weight gain and SOB. He has a long hx of chronic airway disease. On examination he has a raised jvp with prominent v waves. Auscultation of the heart reveals a soft systolic murmur. What is the likely diagnosis?
Tricuspid regurgitation
60 year old man with chest pain, NSTEMI changes on ecg, pulse 66, BP 130/82 and sats 98%. What is the most appropriate immediate management?
Aspirin Nitrates Morphine Clopidogrel Calculate GRACE score
70 year old man with chest pain, STEMI changes on ECG, pulse 102, BP 160/90, sats 93%. What is the most appropriate immediate management?
Aspirin Nitrates Morphine Oxygen Prasugrel Arrange immediate percutaneous coronary intervention
What are absolute contraindications for thrombolysis?
Active internal bleeding
Suspected aortic dissection
Recent head trauma or intracranial neoplasm
Previous haemorrhagic stroke at any point
Previous ishchaemic stroke in past year
Previous allergic reaction to fibrinolytic agent
Trauma or surgery in past 2 weeks at risk of bleeding
What are causes of a collapsing pulse?
Aortic regurgitation
Patent ductus arteriosus
What can cause an ejection systolic mumur?
Aortic stenosis Pulmonary stenosis Hypertrophic obstructive cardiomyopathy Tetralogy of fallot Atrial septal defect
