Cardiology Flashcards
What pathophysiologically causes the 4th heart sound?
Atrial contraction into a non-compliant or hypertrophied ventricle
Note: Atrial contraction is not normally heard - but if you do it is a ‘low pitched sound’
What are the aetiological causes of a 4th heart sound? (4)
- Heart failure
- Myocardial infarction
- Cardiomyopathy
- Hypertension (pressure overload)
(Note: these all cause a non-compliant 4th ventricle)
Describe the sound of 4th heart sound?
Le Lub …….Dub
it is low pitched
Which added sound can be a normal finding and when?
3rd heart sound - in children and young adults up to 30 yo
4th heart sound is always abnormal
What pathophysiologically causes the 3rd heart sound?
It is caused by a sudden deceleration of blood into the left ventricle from the left atrium and this is because the ventricle reaches its elastic limit suddenly
What are the aetiological causes of a 4th heart sound? (6)
- Heart failure
- Myocardial Infarction
- Cardiomyopathy
- Hypertension
- Mitral and Aortic regurgitation (volume overload)
- Constrictive pericarditis
What are the causes of constrictive pericarditis? (6)
- TB (developing countries)
- Renal failure
- Inflammatory: SLE, sarcoidosis, scleroderma,
- Myocardial infarction
- Dressler’s syndrome
- Drugs: doxorubicin , cyclophosphaimde, phenytoin
Describe the effects of volume overload vs pressure overload on the apex beat
Volume overload: the apex beat = displaced and not powerful
Pressure overload: the apex beat = not displaced and powerful
AR and MR can cause volume overload, therefore what is a late sign/severe of AR and MR?
a displaced apex beat
What are the 3 causes of splinter haemorrhages/?
- micro- trauma to the nail (most common)
- infective endocarditis
- vasculitis
What are the signs of infective endocarditis? 2 in the hands 1 in the heart 2 in the abdomen plue the rarities
2 in the hands: splinters and clubbing 1 in the heart: changing murmurs 2 in the abdomen: splenomegaly microscopic haematuria rare: janeway lesions, oslers nodes, roth spots
What are the stages of clubbing? (4)
Stage 1. Increased fluctuancy of the nail bed
Stage 2. Loss of the angle
Stage 3. Increased curvature of the nail
Stage 4. Expansion of the terminal phalynx
What is the name of the window test for clubbing?
Schamroth’s window test
If you spot clubbing - how should you state it as a finding?
Evidence of digital clubbing
Where should you be looking during collapsing pulse?
In the neck! It can be often be seen there (Corrigan’s sign)
Note: the pulse in the arm is called Corrigan’s pulsation - both detect Aortic regurgitation
Why does the neck need to be relaxed when looking forJVP?
Because the JVP is behind the sternocleiodomastoid
so the muscle needs to be relaxed
Where should you positionally look for JVP?
From the front and the side
How can you tell the difference between the arterial pulse and the JVP?
Jugular venous pulsation is a ‘double pulsation’ whereas arterial pulse is a flickering
If the JVP is raised, what should you check for?
Sacral or Ankle oedema
JVP stands for jugular venous pulsation - it is the pulsation of which vein?
the INTERNAL jugular vein
What does the JVP indicate?
The pressure of the right atrium (internal jugular vein –> SVC –> right atrium)
Why is it bad if the examiner says examine the heart?
Because it could be the cardiovascular system or the praecordium
- always ask them to clarify
How do you perform the manoeuvre for mitral stenosis?
Patient rolls to the left side + listen with the bell
How do you perform the manoeuvre for aortic regurgitation?
Patient sits forward, at the end of EXpiration + listen with the diaphragm
What 2 things can a midline sternotomy indicate?
- Coronary artery bypass graft
2. Valve replacement
If you see a midline sternotomy - how can you tell which of the 2 surgerys it was for?
Check the legs for evidence of ‘vein harvesting’
What are the 3 big causes of atrial fibrillation?
- Ischaemic heart disease
- Rheumatic heart disease
- Thyrotoxicosis
What are the other causes of atrial fibrillation?
- Infective: Pneumonia, Sepsis
- Endocrine: hyperthyroidism
- Alcoholic heart disease
- Pulmonary emboli
- Cardiomyopathy
What are the 2 differentials for an irregularly irregular pulse?
Atrial fibrillation
Ventricular ectopics
How do you distinguish between the two causes of irregularly irregular pulse and why?
Exercise - during exercise the ectopic beats will disappear as they only have a chance to occur in diastole and during exercise it is diastole which is shortens in order to increase the heart rate, so there is less chance for the ectopic to occur
How do you asses whether atrial fibrillation is well controlled? (2)
- Time the apical rate and the radial pulse - if AF is well controlled they should be the same
- <80bpm apical heart rate at rest = good control
Explain why there is sometimes a difference between the pulse rate and the heart rate timed at the apex and state the term
Pulse deficit-
AF causes the ventricular rate to increase, shortening the diastolic filling time - some impulses are so near to each other that not enough blood enters the heart to produce a cardiac output (hence no palpable pulse for that beat), but there is just enough blood flow to go through the valves therefore heart sounds are heard and the apical pulse is still there
This is what causes an irregularly irregular pulse
AF management - what is the 1st line rate control?
beta-blocker e.g. bisoprolol
AF management - what is the 2nd line rate control? (2)
- diltiazem if the patient is active
2. Digoxin if the patient is sedentary
AF management - what is 3rd line rate control?
Dual therapy with two of these drugs e.g. bisoprolol + digoxin
What are the indications for rhythm control in AF ? (6)
- New onset within last 48 hours
- LVF primarily due to AF
- Reversible cause e.g. thyrotoxicosis
- Clinically indicated e.g. if pt = young
- Symptoms despite attempted rate control
- Acutely unwell
What are the two options for rhythm control?
Electrical DC cardioversion
or
Chemical cardioversion
Which drugs can be used for chemical cardioversion?
Flecanide (if no structural heart disease)
Amiodarone (if structural heart disease)
What are the 3 elements of AF management?
Rate control
Rhythm control
Stroke prevention
How is the need for stroke prevention assessed?
CHA2DS2-VASc score
What does CHA2DS2-VASc stand for?
C = Congestive Heart failure H = Hypertension A = Age >75(2 points) D = Diabetes S = previous stroke or TIA (2 points)
V = Vascular disease (e.g. peripheral arterial disease or Ischaemic heart disease) A = Age 65-74 S = Sex (female)
How is the CHA2DS2-VASc score interpreted?
Score 0 = may not require anticoagulation
Score 1 = consider anticoagulation in men
Score 2 = consider anticoagulation in men and women
What anticoagulation can be used in AF management?
- Apixaban
- Dabigatran etexilate
- Rivaroxaban
- Vitamin K antagonist (Warfarin)
What is important to consider before anticoagulating in AF?
The risk of bleeding
How do you assess the risk of bleeding in AF?
HAS-BLED score
What does HAS-BLED stand for?
H = Hypertension A = Abnormal renal function/ Abnormal liver function S = Stroke
B = Bleeding tendency or predisposition L = Labile INR E = Elderly >65yo D = Drugs (concomitant aspirin or NSAIDs) or alcohol Each is worth 1 point
In HAS-BLED, what is considered abnormal renal function? (3)
- Creatinine >200 umol/L
- Transplant
- Dialysis
In HAS-BLED, what is considered abnormal liver function? (3)
- Cirrhosis
- Bilirubin >2x normal
- AST/ALT/ALP >3x normal
How is HAS-BLED interpreted?
Score = 0 - low risk of bleeding, anticoagulation should be strongly considered
Score = 1-2 - low-moderate risk of bleeding, anticoagulation should be considered
Score > or equal to 3 - high risk of major bleeding, alternatives to anticoagulation should be considered
If a person is not on anticoagulation due to bleeding risk, what would they need?
This should be reviewed annually
When should digoxin in AF only be considered?
Only in NON-paroxysmal AF in a sedentary patient