cardiology Flashcards
describe aortic stenosis
ejection systolic murmur radiating to carotids
describe aortic regurgitation
high pitch early diastolic murmur best heard with patient sitting forward and breath held at expiration.
describe mitral stenosis
low pitched mid diastolic murmur best heard with patient lying on left
describe mitral regurgitation
pansystolic murmur radiating to the axilla
classic triad of aortic stenosis
angina
HF
syncope
causes of Aortic regurg.
connective tissue disease
infective endocarditis
ascending aortic dissection
causes of aortic stenosis
bicuspid valve
calcification
RHD
presentations of mitral stenosis
fatigue
AF
pulmonary hypertension resulting in dyspnoea and haemoptysis,
which murmurs are associated with LV heave and RV heave respectively
aortic stenosis and mitral regurgitation
Management of STEMI
morphine
oxygen
nitrate
aspirin + ticagrelor + unfractionated heparin
PCI within 120 mins, (alteplase within 12 hours if unable)
what makes up the tetralogy of fallot
ventricular septal defect
right ventricular outflow obstruction
overriding aorta
right ventricular hypertrophy
what is a tet spell
an acute hypoxic episode in someone with TOF
how does a tet spell present
abrubt onset of rapid shallow breathing agitation increasing cyanosis LoC loss of/decreased intensity of murmur
Presentation of TOF
cyanosis dyspnoea poor somatic growth finger clubbing ejection systolic murmur at upper left sternal border tet spells
investigations for Tetralogy of fallot
Transthoracic ECHO - RVH, overriding aorta, VSD
colour doppler ECHO - assesses degree of RV obstruction
CXR - boot shaped heart
ECG - right axis deviation
management of tet spells
manoeuvres that increase venous return (knee to chest, in mothers arms)
oxygen
propranolol
phenylephrine - increases venous resistance -> increases blood to the lungs
bicarbonate if acidotic
management of tetralogy of fallot
alprostadil - maintains patency of ductus arteriosus
BT shunt
ECMO
Definitive treatment = complete surgical repair
presentation of transposition of the great arteries
cyanosis tachypnoea clubbing poor weight gain/difficulty feeding failure to thrive
investigations of transposition of the great arteries
in utero via ultrasound
Transthoracic ECHO
CXR - ‘egg on a string’
management of transposition of great arteries
prostaglandins to maintain ductus arteriosus to allow time for surgery
surgery = arterial switch or atrial switch
presentation of patent ductus arteriosus
tachypnoea/apnoea widened pulse pressure gibson murmur (machine like, under left clavicle) bounding femoral pulse failure to thrive
management of patent ductus arteriosus
IV indomethacin/ibuprofen - COX inibitors inhibit prostaglandins
surgical ligation
percutaneous catheter device closure
presentation of coarctation or aorta
neonates - low Cardiac output, shock, collapse, weak/absent femoral pulses
older children - HTN at young age, UL BP > LL BP, radio-radial delay, radio-femoral delay, systolic ejection murmur
associated risk factors for congenital heart disease
TOF - Digoerge, Down’s
ASD - maternal alcohol, down’s
VSD - Down’s
patent ductus arteriosus - maternal rubella infection, prematurity
coarctation of aorta - turner’s, DiGeorge’s, bicuspid aortic valve
define aortic dissection
a separation of the aortic wall causing blood to flow into the new false channel composed of the inner and outer layers of the media
presentation of aortic dissection
typically men over 50 (younger in those with predisposing factors such as marfan’s, ehlers danlos)
sudden tearing chest pain radiating through to the back
hemiplegia
unequal arm BP
acute limb ischaemia
investigation for aortic dissection
CT CAP - shows flap of the intima
CXR - exclude pneumothorax
ECG - exclude MI
Hb/G&S/x match
management of aortic dissection
noradrenalin
oxygen
fluids
inotropes
labetalol - aim for SBP 100-110 (as the walls are already thinned, prevents further dissection and rupture)
Add IV nitrates if BB insufficient
opioid analgesia
endovascular/open stent-graft repair
cause of pericarditis
viral infection (coxsackie, HIV, VZV) bacterial (pneumonia, TB) MI drugs (penicillin, isoniazid) RA, SLE malignancy
presentation of pericarditis
central chest pain worse on inspiration and lying flat, relived by sitting forward
pericardial rub
pericardial effusion
symptoms/signs of pericardial effusions
dyspnoea
raised JVP
bronchial breathing at left base
investigations for pericarditis
ECG - concave ST elevation, PR depression
FBC, CRP, ESR, troponin, blood cultures, viral serology, TFTs
CXR - enlarged globular heart if effusion
ECHO - identifies effusion
pericardiocentesis if effusion ( culture, ZN stain of TB, cytology)
management of pericarditis
pericardiocentesis if large symptomatic effusion/suspicious of tamponade, infection or neoplasia
NSAIDs, colchicine
define cardiac tamponade
the accumulation of pericardial fluid, blood, pus, or air within the pericardial space that creates an increase in intra-pericardial pressure, restricting cardiac filling and decreasing cardiac output
becks triad
triad of falling BP, raised JVP, muffled heart sounds found in cardiac tamponade
presentation of a cardiac tamponade
becks triad
tachycardia
pulsus paradoxus
dyspnoea
treatment of cardiac tamponade
pericardiocentesis
define constrictive pericarditis
heart becomes encase in a rigid pericardium impeding diastolic filling
features of constrictive pericarditis
RHF (raised JVP, hepatomegaly, ascites, peripheral oedema)
quite heart sounds
CXR - small heart, pericardial calcifications
what are the 4 subtypes of cardiomyopathy
hypertrophic
dilated
restrictive
arrhythmogenic right ventricular
define hypertrophic cardiomyopathy
LV outflow tract obstruction due to asymmetrical septal hypertrophy
presentation of hypertrophic cardiomyopathy
angina, dyspnoea, palpitations
jerky pulse, double apex beat, harsh systolic ejection murmur
ECG - AF, VT, deep q waves
management if hypertrophic cardiomyopathy
beta blockers/CCB amiodarone (AF, VT) anticoagulation if AF surgical myomectomy implantable defibrillator
define dilated cardiomyopathy
dilated ventricles results in a weak heart
presentation of dilated cardiomyopathy
fatigue dyspnoea pulmonary oedeme RVF AF, VT
management of dilated cardiomyopathy
diuretics b-blockers ACEI anticoagulation biventricular pacing/implantable cardioverter transplant
define restrictive cardiomyopathy
the walls of the heart are rigid (but not thickened) leading to it being unable to stretch and fills poorly
presentation of restrictive cardiomyopathy
chest pain
dyspnoea
palpitations
RVF - raised JVP, hepatomegaly, ascites, oedema
management of restrictive cardiomyopathy
diuretics
treat underlying cause (amyloidosis, haemochromatosis, sarcoidosis)
define arrhythmogenic RV cardiomyopathy
progressive replacement of myocardium with fibro-fatty tissue.
presentation of arrhythmogenic RV cardiomyopathy
palpitations
syncope
RVF - oedema, fatigue
LVF - dyspnoea, orthopnoea
management of arrhythmogenic RV cardiomyopathy
sotalol - BB with class 3 antiarrhythmic properties catheter ablation implantable cardioverter defibrillator
presentation of right heart failure
peripheral oedema ascites hepatomegaly raised JVP GI tract congestion (anorexia, GI upset, wt loss)
presentation of left heart failure
activity intolerance cyanosis dyspnoea, orthopnoea, PND cough with frothy sputum third heart sound
investigations of HF
elevated BNP ECHO CXR ECG U&Es, LFTs, TFTs, lipids, glucose
signs on CXR for HF
Alveolar shadowing kerly b lines cardiomegaly upper lobe diversions effusion
management of acute heart failure
oxygen
furosemide
IV GTN
inotropes if hypotensive (adrenaline, dopamine)
pharmacological management of chronic heart failure
beta blocker + ACEI
MRA (spironolactone)
replace ACEI with sacubitril
consider Ivabradine , hydralazine or digoxin
Device therapy for HF
if LVEF < 35%
implantable cardioverter defibrillator
cardiac resynchronisation therapy - biventricular pacing
others
intra-aortic balloon pump
ventricular assist devices (LAD)
ECMO (used will waiting for transplant/implantation of LAD)
presentation of AF
palpitations irregularly irregular pulse dizziness dyspnoea murmurs - ?underlying valve disease
ECG findings in AF
absent p waves
varying fibrillatory waves
irregularly irregular QRS complexes
investigations for AF
ECG TFTs CXR - HF, pneumonia ECHO - valve disease troponin - MI
management of AF
rate control (bisoprolol or verapamil) anticoagulation (enoxaparin + warfarin) rhythm control ( flecainide, amiodarone)
risk factors for AF
valve disease heart failure hypertension hyperthyroidism COPD AKI/dehydration pneumonia
ECG of paroxysmal supraventricular tachycardia (AVNRT)
absent p waves
narrow complex tachycardia
rate usually >180
Management of PSVT
vagal manoeuvres
adenosine (up to three boluses) - verapamil if contraindicated (asthma)
DC cardiovert if adverse features (shock, syncope, ischaemia, HF)
ECG of ventricular tachycardia
broad complex tachycardia
regular rhythm
usually > 120bpm
management of VT
amiodarone if stable
if not synchronised DC cardioversion
causes of VT
post MI
cardiomyopathy
myocarditis
congenital heart disease
ECG of torsades de pointes
varying amplitudes/shape of QRS complexes
HR around 200bpm
management of torsades de pointes
IV magnesium
synchronised DC cardioversion
describe second degree heart block mobitz type 1
Gradually prolonged PR interval before dropping QRS complex
describe second degree heart block mobitz type 2
prolonged but regular PR intervals followed by a random dropped beat
describe first degree heart block
prolonged PR interval (>200ms)
describe 3rd degree heart block
complete dissociation between p waves and QRS complexes
management of fist degree heart block
monitor
withhold causative medications if possible
management of mobitz type 1
IV atropine
management of mobitz type 2
implanted pacemaker
management of complete heart block
IV atropine - can repeat up to 3 times
inotropic support - IV adrenaline
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