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
Which medication should not be used for long term rate control?
Amiodarone
What is paraoxysmal AF?
Intermittent AF which terminates spontaneously or with which terminated with intervention in less than 7 days
What is meant by ‘pill in pocket’ and what are the indications?
Flecanide 50mg bd if no other her heart disease and infrequent episodes (Normal pulse and BP)
Used for paraoxismal AF - rather than taking medication daily, you instead take this if you have an episode of AF
What are the indications for using Warfarin rather than a DOAC? (2)
Mitral stenosis
Metal valve
In a patient with AF taking warfarin what INR would you aim for?
2-3
If a patient has a mechanical prosthetic mitral valve and was on Warfarin, what INR would you aim for?
3-4 (depending on the model of the device)
What is a good way to differentiate between ejection systolic and pansystolic murmurs based on heart sounds? (but what is the catch?)
You hear 2nd heart sound in ejection systolic, you do not hear 2nd heart sound in pansystolic
In severe stenosis, the 2nd heart sound may be quiet
What are the causes of pressure overload of the left ventricle?
- Aortic stenosis
- Hypertension
- Coarctation of the aorta
- Hypertrophic cardiomyopathy (with LV outflow tract obstruction ‘subvalvular stenosis’)
What is coarctation of the aorta?
A birth defect, where you have a narrowing in the aorta - this increases the afterload
If a younger person presents with aortic stenosis what cause will you consider?
Bicuspid aortic valve
Aortic stenosis causes ____ overload
Aortic regurgitation causes ____ overload
AS –> pressure overload
AR –> volume overload
What symptoms of Aortic stenosis are a good guide to severity?
S = syncope A = angina D = dyspnoea
What is the definitive treatment of aortic stenosis?
Valve replacement
In which patients are TAVIs good for? (2)
- Those unfit for cardiopulmonary bypass (note: sutureless valve replacement reduces cardiopulmonary bypass time)
- Fit patients who are >85yo
What is cardiopulmonary bypass?
A machine which temporarily takes over the function of your heart and lungs
What os the difference between aortic sclerosis and aortic stenosis?
Aortic sclerosis = a thickening of the valve leaflets but no narrowing
Aortic stenosis = a narrowing of the valve orifice (there is fusing of the commissures restricting valve opening)
How do the signs of aortic stenosis and aortic sclerosis differ?
Aortic stenosis - murmur + all the other features e.g. slow rising pulse, radiation to the carotid etc
Aortic sclerosis, you only get the murmur without the other signs
What are the 3 categories for causes of mitral regurgitation?
- Leaflet
- Papillary muscle and chordae
- Annular dilatation
What are the leaflet causes of mitral regurgitation? (3)
- Congenital
- Endocartitis
- Degenerative
What are the papillary muscle and chordae causes of mitral regurgitation? (3)
- Mitral valve prolapse
- Acute coronary syndrome
- Marfan’s
What are the Annular dilatation causes of mitral regurgitation? (2)
- Cardiomyopathy
2. Ischaemic heart disease with heart failure
What are the signs of mitral regurgitation?
- Apex beat usually displaced (volume overload)
- Quiet first heart sound
- Pansystolic murmur radiates LOUDLY to axilla
- Second heart sound not heard separately (as pansystolic)
What is the song description of mitral regurgitation murmur?
Burrrrrr (add picture)
What is the treatment of mild mitral regurgitation?
medical treatment with 1. ACE inhibitors
2. Diuretics +/- anticoagulants
What is the treatment of severe mitral regurgitation?
Valve repair
What are the signs of aortic stenosis?
- Slow rising pulse
- Low volume pulse with low pulse pressure
- JVP not elevated
- Apex beat forceful but not displaced (pressure overload)
- Ejection systolic murmur
What are the causes of aortic stenosis? (3)
- Degenerative calcific aortic stenosis
- Congenitally bicuspid valve with degenerative changes
- Rheumatic heart disease
What is the pathophysiology of Rheumatic heart disease and diastolic murmurs?
- Bacterial tonsillitis (throat infection)
- 2-4 weeks later acute rheumatic fever - the antibodies to strep ‘M’ protein cross reacts (molecular mimicry) with the heart
- 10-20 years later chronic rheumatic heart disease (mitral stenosis/aortic regurgitation)
What bacteria is specifically implicated in the bacterial tonsillitis involved in rheumatic fever?
Group A beta haemolytic streptococcus (strep pyogenes)
When the antibodies cross react- they don’t only cross react with the heart - which other parts of the body do they cross react with? (2)
- Joints
2. Brain
In chronic rheumatic heart disease what specific changes occur at the leaflets? (2)
- Leaflet thickening
2. Fusion of commissures
What are the signs of mitral stenosis?
- Malar flush
- Atrial fibrillation
- JVP not raised until late
- Apex beat not displaced
- Loud first heard sound
Why is there a loud first heart sound in mitral stenosis?
The valve does not open much, meaning the atrial pressure is increased, therefore the ventricular pressure needs to get higher than usual in order to close the mitral valve against the higher pressure in the atrium and so the valve is open for longer but then the leaflets slam/snap shut
What is the cause of malar flush in mitral stenosis?
Pulmonary artery hypertension
How does Mitral stenosis lead to right heart failure?
Add picture
What is the treatment for mild mitral stenosis?
Medical treatment:
- anticoagulants
- diuretics
- rate control of atrial fibrilation
What is the treatment of moderate mitral stenosis?
? Trans-septal valvuloplasty
? valve replacement
Why might a patient with mitral stenosis wear a medic alert bracelet?
In case they are on warfarin - remember mitral stenosis and metal valve are the two indicators for warfarin
What is the different terms for a circular opacity in the CXR?
- coin lesions
- cavity
- cannon balls (metastases)
What is a transeptal valvuloplasty
Inflating a balloon in the mitral valve to expand it but without actually replacing the valve
What are the signs of aortic regurgitation? (5)
- Collapsing pulse (Corrigan’s pulse)
- Collapsing pulse in the neck (Corrigan’s sign)
- JVP not raised
- Apex beat displaced
- Diastolic murmur follows second sound
What is the song description of aortic regurgitation?
Lub taaaaarr
What is the pneumonic for the causes of aortic regurgitation?
REALM R - Rheumatic heart disease E - Endocarditis A - Ankylosing spondylitis L- Luetic (syphillis) heart disease M - Marfans
If you detect aortic regurgitation - what can you do to try and detect the cause?
Look for the signs of endocarditis
Look for the signs of Marfan’s - high-arched palate, arachnodactyly (long spidery fingers)
What is the treatment for aortic regurgitation?
Valve replacement if significant regurgitation present
What is the pneumonic for complications of valve replacement?
POSH Valuve P - Paravalvular leak O - Obstruction (by thrombus) S - Subacute bacterial endocarditis H - Haemolysis due to turbulance Valve failure
2 out of which 3 factors are required to diagnose ACS?
- ECG changes
- Troponin positive
- Cardiac chest pain
What are the 5 ECG changes consistent with ACS?
- T wave inversion
- ST depression
- ST elevation
- Q waves
- New onset LBBB
How do you differentiate between Unstable angina and Myocardial Infarction?
Unstable angina - troponin negative
MI - troponin positive
What are the characteristics of cardiac chest pain? (3)
- Central, retrosternal, band-like constriction
- Non -pleuritic (not sharp or worse on inhalation)
- With radiation to neck/jaw/shoulder/arm
Which 6 features of pain should make you suspect ACS?
- Lasts more than 15 minutes
- Occurs at rest (unstable angina)
- Increasing in frequency (crescendo angina)
- Severe
- Associated with Nausea, vomiting or sweating
- Non-resolving with nitrates
What are the independent risk factors of ACS? (6)
- Smoking
- Diabetes
- Hyperlipidaemia
- Family History
- Hypertension
- Chronic Kidney Disease
What initial bloods do you want to obtain in suspected ACS? (6)
- FBC
- Urea and electrolytes
- LFTs
- Lipids
- Serial Troponin
- Glucose
Why is FBC useful in suspected ACS?
Anaemia can cause cardiac ischaemia
Why are urea and electrolytes (inc creatinine) useful in suspected ACS? (2)
- Impaired renal function can cause false positive elevation of troponin
- Hypokalaemia and Hyperkalaemia are both associated with arrhythmias
Why is Glucose useful in suspected ACS?
To check if they are ?diabetic - you want to aim for physiological levels 4-11 mmo/L
Why is LFTs useful in suspected ACS? (2)
- For baseline prior to statins
2. Hepatic impairment = a relative contraindication to ticagrelor
Why are serial troponins useful in suspected ACS?
As a measure of myocardial damage
In ACS, what do Q waves suggest?
Full thickness transmural infarct
Without Q waves = subendocardial
What is the initial management of ACS?
Morphine & Metoclopramide
Oxygen (if desaturating)
Nitrates sublingually
Aspirin 300mg STAT
What is the management of STEMI?
Primary PCI (percutaneous coronary intervention)
How long do you have to do PCI in STEMI?
Up to 12 hours from onset
What is the long term management of STEMI?
A- ACE-inhibitor B - Beta - blocker C- Cholesterol lowering D- Dual antiplatelet E- Echo to assess LV
Name 3 drugs inhibiting platelet ADP pathways
Clopidogrel
Ticagrelor
Prasugrel
What is the typical antiplatelet regimen for STEMI?
- Aspirin 300mg stat in ambulance
- Loading dose of Prasugrel (in cathlab before stent)
- Continue the Prasugrel with Aspirin (DAPT) for at least 1 year
- Aspirin 75mg continue indefinitely
What is the official definition of ST elevation?
> 1mm in limb leads or 2mm in two adjacent chest leads
What features are there on an ECG for a posterior MI?
ST depression in R waves and in V1 and V2
What is the way to remember the complication of MI?
Sudden death on PRAED street
What are the complications of MI?
Sudden death
P - Pump failure (HR) R - Rupture of papillary muscle or septum A - Aneurysm and Arrhythmias E - Embolism D - Dressler's syndrome
What are the 6 qualities of pericardial pain?
pericardial pain = pericarditis pain
2 qualities like pleurisy: sharp and worse on inspiration
2 qualities like angina: retrosternal and radiates to left (shoulder not arm)
2 qualities of its own: worse lying flat, eased by sitting up
During PCI what is the recommendation now regarding multivessel disease?
If they are haemodynamically stable and you see disease in more than one vessel- you can do PCI for the other vessels also
What question is useful to ask to discriminate for acute early pericarditis?
Has your pain changed?
Pericarditis pain does not respond to opioids e.g.morphine
therefore their pain wont have changed even after morphine
What is the treatment of pericarditis?
Ibuprofen
If it continues more than 14 days - you may give colchicine
If pain is severe and not settling with ibuprofen and colchicine, you can then give steroids
What might you notice on inspection of someone with acute LVF? (5)
- Patient looks acutely unwell - pale and grey
- Cold clammy peripheries ? cyanosis
- Frothy blood stained sputum
- Orthopnoeic using accessory muscles
- May have wheeze (cardiac asthma)
What is the cause of the wheeze in acute HF?
Build up of fluid in the lungs and airway
What are the signs of acute LVH?
- Sinus tachycardia or atrial fibrillation
- Systolic hypotension
- Signs of cardiomegaly (displaced apex beat, signs of valve disease)
- Third and Fourth heart sounds
- Right sided or bilateral pleural effusions
What are the radiological changes in heart failure? (6)
- Cardiomegaly
- Upper lobe diversion
- Diffuse mottling of lung fields
- Prominent hilar shadows- bat’s wings
- Small pleural effusions
- Fluid in fissures
