Cardiology Flashcards
MI infarction suspected
Ischeami results in myocardial necrosis
Myocardial necrosis releases proteins (troponins, myoglobin, creatine kinase, etc.)
Ischaemic symptoms
• Development of pathological Q waves on the ECG
• ECG changes indicative of ischaemia (ST segment elevation or depression)
• Coronary artery intervention, for example coronary angioplasty-
( coronary angioplasty/ percatenous transluminal coronary angioplasty ( PTCA)using a balloon to stretch open a narrowed artery.
Nowadays a stent is used and is left there permanently to improve blood flow.
Combination of stent + coronary angioplasty is percatenous coronary intervention (PCI)
Features that indicate increased chance of Acute myocardial infarction ?
Described as a pressure
Associated with nausea
Associated with diaphoresis
Radiation to either or both arms
Worse than previous angina
Features that indicate decreased likelihood/ chance of Acute myocardial infarction ?
Described as sharp
Described as positional
Reproducible with palpation
Inframammary location
Not associated with exertion
What are the classic presenting symptoms of ACS.
ACS - acute coronary symptoms
ACS - a group of conditions which result in ischaemia ( reduced blood flow to heart e.g myocardial infarction . Even none of MI - still very dangerous as associated with increased risk of heart attack.
Heavy, aching or tight
Centre or left side of chest
Not related to respiration or movement
May radiate to one or both arms, neck or jaw
What ECG changes are indicative of myocardial ischaemia that may progress to AMI
T wave inversion and ST segment depression may progress to AMI
What is infective endocarditis ?
Infection of : 0 endocardial surface of heart incuding: - Valvular structures - Chordae tendineae - sites of septal defects - or mural endocardium ( lining of heart chamber walls)
SIGNS/ SYMPTOMS
- Fever / chills (most common)
- Cardiac murmurs
Non specific symptoms present :
0 Night sweats 0 Malaise 0 Fatigue 0 Anorexia 0 Weight loss 0 myalgias
- Weakness (systemic emboli should be suspected in pl with asymmetric weakness consistent with stroke)
- Arthralgias
- Headache
- SOB
Uncommon signs
- Splinter Haemorrhages
(found on nails of hand & feet - longitudinal, red-brown haemorrhage under a nail and looks like a wood splinter) - Osler nodes - (Osler’s nodes are painful, red, raised lesions found on the hands and feet.)
- Janeway lesions - (Haemorrhagic, macular, painless plaques with a predilection for the palms and soles.)
Oslers , janeway - are skin manifestations of endocarditis.
Roth spots - Haemorrhages in the retina - oval , pale lesions.
Cutaneous infarcts
(if want more info look on BMJ)
RISK FACTORS
- Hx of IE
- artifical prosthetic heart valve
- some types of Congenital heart types
(including surgically corrected - prosethic materials) - Post heart transplant —-> may develop cardiac valvulopathy (increased risk of IE)
- IV Drug use.
weaker
- Intravascular Catheters or Implanted electronic devices
- Mitral valve prolaspe wirh regurgitation
- ## Hypertrophic cardiomyopathy
Diagnosis of IE ?
Blood cultures ( 3 sets from different venepuncture sites at 30 min interval before starting antibiotic therapy) * if SEPSIS SUSPECTED DO NOT WAIT TO START ANTIBIOTIC THERAPY.
- Echocardiogram - Transthoracic Echo done ——————–> if it does not show vegetations but IE still suspected transesophageal is done.
(First are the main ones used to diagnose - DUKE criteria)
- FBC - anaemia , leukocytosis
- CRP - elevated
- ECG
- Serum U & E , glucose
- LFTS (normal or elevated)
- Urinalysis - blood in urine may indicate septic emboli ( complication of IE)
- Active sediment in urinalysis - means blood found.
CAN CONSIDER:
- Rheuamtoid factors (positive result is a minor criteria for diagnosis of endocarditis ) - some places use ANA , anti - CCP etc.
- complement levels ( e.g C3 , C4 ETC)
- ESR - elevated
- MRI
- CT
What is the Duke Criteria ?
- just for knowlegde (dont have to memorise)
The Duke criteria are a set of clinical criteria set forward for the diagnosis of infective endocarditis
For diagnosis the requirement is:
0 2 major and 1 minor criteria or
0 1 major and 3 minor criteria or
0 5 minor criteria
For adequate diagnostic sensitivity, transoesophageal echocardiography is the preferred modality used in patients designated “high-risk” or those in whom transthoracic echocardiography would likely be difficult. Examples of high-risk patients are those with 3:
past medical history of endocarditis congenital heart disease physical exam significant for: signs of heart failure a new heart murmur stigmata of infective endocarditis history of prosthetic heart valve implantation
Major criteria
0 positive blood cultures for infective endocarditis
0 typical microorganism for infective endocarditis from 2 separate blood cultures :
- Viridans streptococci, Streptococcus bovis, and HACEK group
or
- community-acquired Staphylococcus aureus or enterococci in the absence of a primary focus
or
persistently positive blood cultures, defined as recovery of a microorganism consistent with infective endocarditis from:
2 blood cultures drawn 12 hours apart or all of 3 or most of 4 or more separate blood cultures, with first and last drawn at least 1 hour apart.
- evidence of endocardial involvement
positive echocardiogram for infective endocarditis - oscillating intracardiac mass on valve or supporting structures or in the path of regurgitant jets
or
- on implanted material in the absence of an alternative anatomical explanation
- abscess
- new partial dehiscence of prosthetic valve - new valvular regurgitation
MINOR CRITERIA
- predisposing heart condition
- intravenous drug use
- fever: 38°C
- vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, and Janeway lesions
- immunologic phenomena: glomerulonephritis Osler nodes Roth spots rheumatoid factor
- microbiologic evidence: positive blood culture but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis
- echocardiography findings consistent with infective endocarditis but not meeting major criterion as noted previously
Capsule version of Duke criteria
Major diagnostic criteria include more than one positive blood culture (typical organism in 2 separate cultures or presistently positive blood cultures), or positive echocardiogram findings of vegetation, abscess or abscess prosthetic valve.
Minor criteria include:
predisposition (cardiac lesion, IV drug abuse);
fever over 38 °C;
vascular signs, e.g. mycotic emboli, Janeway lesions (painless palmar/plantar macules);
immunological signs e.g. Oslers nodes (painful swelling fingers/toes), positive RhF, glomerulonephritis
microbiological evidence not fitting major criteria.
Diagnosis is made on 2 major, 1 major/3minor or >5 minor criteria.
Treatment of IE ?
Suspected IE
1ST LINE
- Supportive care (ABC) + Empirical brooad spectrum antibiotics
Consider surgery :
- Acute heart failure - emergency surgery or cardiogenic shock despite medical therapy.
(Give IV diuretics to manage pulmonary oedema before surgery)
CONFIRMED IE - targeted antibiotic therapy
consider surgery - Indications for surgery include:[7]
Heart failure: for example, aortic or mitral valve (prosthetic or native) endocarditis with severe acute regurgitation, obstruction or fistula causing persistent pulmonary oedema or cardiogenic shock despite medical therapy
Uncontrolled infection such as:
Abscess, false aneurysm, fistula, or enlarging vegetation
Prosthetic valve endocarditis caused by staphylococci or non-HACEK gram-negative bacteria
Fungal or multidrug-resistant organism endocarditis
Prevention of embolism: for example, aortic or mitral valve (prosthetic or native) endocarditis with persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy.
ONGOING - high risk of IE
1ST LINE
Advice + antibiotic prophylaxis.
What heart valve is most affected by IV drug users ?
Tricuspid
Injection into venous circulation will impact tricupsid valve most ( valve after right atrium - where venous blood enters from IVC )
Complications of IE ?
Septic emboli ——————> Infarction ( heart block etc) OR TIA
- Acute kidney injury
- Heart failure
- Veterbral osteomylelitis .
Some causes of bradycardia?
- Hypothermia
- Hypothyroidism
- Aerobic training (athletes)
- Myocardial infarction
- (not sure about this - nothing is support capsule info) Legionnaire’s disease / Legionalla pneumonia (Lung infection caused inhalation of aerolised bacteria e.g from air condition or hot tubs , contaminated drinking water , taps / showers that havent been use often etc
What is pericarditis ?
Pericarditis - Inflammation of the pericardium.
Acute - if less than 4-6 weeks.
Can be :
- Dry (Fibrinous)
or
- Effusive - with purulent , serous , Haemorrhagic exudate.
CHARACTERISTICS
Traid of main symptoms :
- Sharp , pleuritic (on breathing) - can also be stabbing or aching.
(*sharp , severe , retrosternal (behind breast bone , sternum) worst with inspiration , supine (lying down ) )- sitting down or leaning forward makes it better) - Pericardial rub (TYPICAL OF PERICARDITIS)
(grating , to - and fro sound produced by friction of the heart against the inflammed pericardium) - can be heard loudest at expiration
- if large pericardial effusion present - pericardial rub may be absent as pericardium is seperated so cannot rub against each other.
- Pleural rub vs pericardial rub - ask patient to hold breath , pericardial rub stilll heard & occurs at every heart beat.
3. Serial electrocardiographic changes.
RISK FACTORS
- Male
- Age - 20 -50 years
- Transmural Myocardial infarction
- transmural - involves full thickness of myocardium.
- Cardiac surgery
- Neoplasm
- Recent histoy of viral or bacterial infections
- ureamia or dialysis
(ureamia - uric acid in blood / if dialysis is not working -
metabollic toxins are accumulating in blood due to kidney failure and irritating pericardium) - systemic autoimmune disease e.g Rh Athritis , SLE.
WEAK
- pericardial injury ( can occur weeks - months after)
- mediastinal radiation.
COMPLICATIONS
Cardiac Tamponade
- Constrictive Pericarditis —————–> prevents ventricular filling ————————> Heart failure.
- pain can mimic Myocardial ischemia / infarction
(usually describe more as pressure - like , heavy squeezing pain vs sharp & pleurituc
or pulmonary embolism - need to be careful of PE because its treatemnt of anticooagulation can be life threatening in pericardtitis - cause bleeding into pericardial space ————> Cardiac tamponade.
Diagnosis of Pericarditis ?
ECG -
Changes seen -
0 Global upwardly concave ST-segment (J-point) elevations with PR-segment depressions in most leads
0 J-point depression and PR elevation in leads aVR and V1.
- Serum Troponin - elevation (indicates pericarditis myopericarditis (myocardial involvement) (or other aetiologies e.g ACS)
0 Echocardiograpgy - do for all those suspected - if Cardiac Tamponade (do urgently at bedside) - normal does exclude diagnosis.
0 Pericardiocentesis - done if :
Cardiac tamponade (urgently needed)
- Suspected purulent pericarditis
or large / symptomatic pericardial effusion
or High suspicion of neoplastic pericarditis
- can send fluid for analysis (bacteria , fungi , autoimmune , TB causes)
- CRP
- Serum U & E - elevated urea indicates ureamic pericarditis
- FBC
- LFTs - elevated with liver congestation occuring developing cardiac tamponade.
- CXR
CONSIDER
- Blood cultures
(if purulent P suspected or signs of sepsis) - infective cause. - autoimmune screen - if autoimmune P suspected
- Viral screen - if viral cause of pericarditis suspected .
- Creatine Kinase (suggest myocardial injury)
- ESR
- Chest CT , or cardiac MRI - if complicated P suspected or atypical presented.
- pericardial biopsy ( rarely done - Cardiac MRI prefered)
Treatment of Pericarditis ?
Idopathic or viral
and criteria for admission to hospital.
SUSPECTED PERICARDITIS
1ST LINE
- Triage & consider hospital admission
Admit to hospital if :
Any of the following high-risk features
- High fever (i.e., >38°C [>100.4°F])
- Subacute course (i.e., symptoms over several days without a clear-cut acute onset)
- Evidence of a large pericardial effusion
- Cardiac tamponade
- Failure to respond within 7 days to a non-steroidal anti-inflammatory drug
Minor risk factors (based on expert opinion and literature review)
- Pericarditis associated with myocarditis (myopericarditis; associated with a rise in troponin)
- Immunosuppression
- Trauma
- Oral anticoagulant therapy.
if none of the high risk features of clinical features that suggest an underlying aeitology that requires inpatient management———————————————> STart empirical anti-inflammatories and arrange 1 week follow up.
Consider Pericardiocentesis - if cardiac tamponade suspected.
ACUTE
Idiopathic or viral (non-purulent)
1ST LINE
0 high dose NSAIDS
(Aspirin or Ibu)
(* aspirin prefered for those recovering from and, other NSAIDS can adversely affect healing & associated with increased risk of cardiac events. )
+ PPI (omeprazole)
+ Colchicine (for 3 months )(Crucial to prevent recurrance)
+ Exercise restriction
(avoid strenous actvitity unitl symptoms resolve & CRP normalised.
Consider -
Corticosteriods - (PRED oral) if NSAIDS , Colchicine is contrainidcated & infectious cause is excluded ( do not use in viral P as there is a risk of re - activation of viral infection & inflammation)
also if there is a indication for use e.g. presence of autoimmune condition - Colchicine is used in combination with steriods in this situation) - IMPORTANT.
Treatment of pericarditis ?
not idiopathic of viral (non - purulent)
Not idiopathic - means that there is a known cause of the pericarditis so treat underlying cause.
1ST LINE
- Treat underlying cause
+ NSAIDS (Aspirin or Ibu) + PPI
+ Colchicine (unless TB pericarditis )
+ Excercise restriction
Consider : Corticosteriod.
Treatment of Pululent Pericarditis ?
1ST LINE
- IV empirical antibiotic therapy
( then tailor antibitiocs after results of blood cultures etc.)
+ Specialist management e.g Pericardiocentesis or surgical pericardial intervention
Treatment of Recurrent pericarditis ?
1ST LINE
NSAIDS + PPI + Colchicine (not TB P) + excercise restriction + treatment of underlying cause
Consider :
Corticosteriods
- IV Immunosuppressant
(Azathiopine , anakinra , normal immunoglobulin human) - only started by rheumatologist
Pericardectomy - if persistent & symptomatic or not improving or declining &
TB P with recurrent effusions and evidence of constrictive physiology despite therapy.
Colchicine - side feffects & cautions
Before starting - do a baseline FBC - as it can cause bone myelosupression & neutropenia.
Warn the patient that colchicine may cause gastrointestinal side effects such as diarrhoea. Consider reducing the dose if the patient is unable to tolerate the drug at full initial dose
Causes / types of Pericarditis ?
- Tuberculosis (a common cause in the developing world)
- Secondary immune processes (e.g., rheumatic fever, post-cardiotomy syndrome,
&
*post-myocardial infarction syndrome (POST - MI) - IMPORTANT ( Dressler’s syndrome (autoimmune reaction to damaged cardiac tissue)) - Metabolic disorders (e.g., uraemia, myxoedema), radiotherapy
- Cardiac surgery
- Percutaneous cardiac interventions
- Systemic autoimmune disorders (e.g., rheumatoid arthritis, systemic sclerosis, reactive arthritis, familial Mediterranean fever, systemic vasculitides, inflammatory bowel disease)
- Bacterial/fungal/parasitic infections
(some of these are purulent - produce Pus)
(ex - influenza , mumps , Coxackie B , varicella) - Viral
- Trauma
- Certain drugs (e.g., hydralazine, antineoplastic drugs, clozapine, tumour necrosis factor-alpha inhibitors, phenytoin)[1]
- Neoplasms.
