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Year 4 > Cardiology and Cardiothoracic surgery > Flashcards

Cardiology and Cardiothoracic surgery Flashcards

1
Q

What are the differential diagnoses of chest pain?

A
  • Cardiac:
    • MI/Angina - most common
    • myocarditis
    • pericarditis/Dressler’s syndrome
    • cardiac tamponade
  • Pulmonary:
    • Pneumonia - most common
    • PE
    • pneumothorax/haemothorax/tension pneumothorax
    • empyema
    • pulmonary neoplasm
    • bronchiectasis
    • TB
  • GI:
    • oesophageal: spasm, GORD, oesophagitis, ulceration, achalasia, neoplasm, Mallory-Weiss tears, oesophageal rupture
    • PUD
    • gastritis
    • pancreatitis
    • biliary colic
  • mediastinal:
    • lymphoma
    • thymoma
  • Vascular:
    • dissecting aortic aneurysm
    • aortic rupture
  • Surface structures
    • Costochondritis
    • rib fracture
    • skin (brusing, herpes zoster)
    • breast
  • Anxiety/psychosomatic
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2
Q

DDx for loss of consciousness?

A
  • Hypovolaemia - most common
  • Cardiac:
    • structural or obstructive causes:
      • ACS
      • AS
      • HCM
      • cardiac tamonade, constrictive pericarditis
    • Arrhythmias
  • respiratory:
    • massive PE
    • pulmonary HTN
    • hypoxia
    • hypercapnia
  • Neurologic:
    • Stroke/TIA (esp. vertebrobasilar insufficiency)
    • migraine
    • seizure
  • metabolic
    • anaemia
    • hypoglycaemia - most common
  • Drugs:
    • antihypertensives
    • antiarrhythmics
    • diuretics
  • Vasovagal
  • Autonomic dysfunction
    • Diabetic neuropathy
  • psychiatric:
    • panic attack
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3
Q

DDx for local oedema.

A
  • Inflammation/infection
  • venous or lymphatic obstruction:
    • thrombophlebitis/DVT
    • venous insufficiency
    • chronic lymphangitis
    • lymphatic tumour unfiltration
    • filariasis - parasitic disease
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4
Q

DDx for generalised oedema.

A
  • Increased hydrostatic pressure/fluid overload:
    • heart failure - most common
    • pregnancy
    • drugs (e.g. CCBs)
    • iatrogenics (e.g. IV fluids) - most comon
  • Decreased oncotic pressure/hypoalbuminaemia
    • nephrotic syndrome
    • Liver cirrhosis
    • malnutrition
  • increased capillaru permeability:
    • severe sepsis
  • hormonal
    • hypothyroidism
    • exogenous steroids
    • pregnancy
    • oestrogens
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5
Q

DDx for palpitations.

A
  • Cardiac:
    • arrhythmias (PAC, PVC, SVT, VT)
    • valvular heart disease - most common
    • HCM
  • endocrine
    • thyrotoxicosis - most common
    • pheochromocytoma
    • hypoglycaemia
  • systemic
    • fever
    • anaemia- most common
  • drugs
    • stimulants and anticholinergics
  • psychiatric
    • panic attack
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6
Q

DDx for dyspnea.

A
  • Cardiovascular
    • Acute MI
    • CHF/ LV failure
    • aortic/mitral stenosis
    • aortic/mitral regurgitation
    • arrythmic
    • cardiac tamponade
    • constrictive pericarditis
    • left-sided obstructive lesions (e.g. left atrial myxoma)
    • elevated pulmonary venous pressure
  • respiratory:
    • airway disease
      • asthma- most common
      • COPD exacerbation
      • upper airway obstruction (anaphylaxis, foreign body, mucus plugging)
    • parenchymal lung disease
      • ARDS
      • pneumonia
      • interstitial lung disease
    • pulmonary vascular disease
      • PE
      • pulmonary HTN
      • pulmonary vasculitis
    • Pleural disease
      • pneumothorax
      • pleural effusion
  • Neuromusclar and chest wall disorders?
    • C-spine injury
    • polymositis, myasthenia gravis, Guillain-Barre syndrome
    • kyphoscoliosis
  • anxiety/psychosomatic
  • haemological/metabolic
    • anaemia, acidosis, hypercapnia
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7
Q

Define what is, what causes and what the treatment is for?

Sinus bradycardia

A
  • P axis normal (P waves positive in I and aVF)
  • rate <60 bpm
  • marked sinus bradycardia (<50 bpm) may be seen in normal adults, particularly athletes, and in elderly individuals
  • caused by
    • increased vagal tone or vagal stimulation
    • vomiting
    • episodes of myocardial ischemia or infarction (inferior MI)
    • sick sinus syndrome
    • increased intracranial pressure
    • hypothyroidism
    • hypothermia
    • drugs (β-blockers, calcium channel blockers, etc.)
  • treatment: if symptomatic, atropine during acute episodes; pacing for sick sinus syndrome; if drug-induced, reduction or withdrawal of drugs
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8
Q

Define what is, what causes and what the treatment is for?

Sick sinus syndrome

A
  • characterized by sinus node dysfunction (marked bradycardia, sinus pause/arrest, sinoatrial block), mainly in the elderly
    • when symptomatic, electronic pacemaker is indicated
  • frequently associated with episodes of atrial tachyarrhythmias (“tachy-brady syndrome”)
  • usually require a combination of a pacemaker for bradycardia and medications (β-blocker, calcium channel blocker, and/or digoxin, initiated after pacemaker insertion) for tachycardia
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9
Q

Define what is, what causes and the treatment for?

First degree AV block

A
  • prolonged PR interval (>200 msec)
  • frequently found among otherwise healthy adults
  • no treatment required
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10
Q

Define what is, what causes and the treatment for?

Second degree AV block

A
  • can describe block by ratio of number of P waves to number of QRS (e.g. 2:1, 3:1, 4:1 increases in severity)
  • second degree AV block is further subdivided into Type I and Type II block:
    • Type I (Mobitz I) second degree AV block
      • a gradual prolongation of the PR interval precedes the failure of conduction of a P wave (Wenckebach phenomenon)
      • AV block is usually in AV node (proximal)
        • triggers (usually reversible): increased vagal tone (e.g. following surgery), RCA-mediated ischemia
        • not an indication for temporary or permanent pacing
    • Type II (Mobitz II) second degree AV block
      • the PR interval is constant; there is an abrupt failure of conduction of a P wave
      • AV block is usually distal to the AV node (i.e. bundle of His)
      • increased risk of high grade or 3rd degree AV block
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11
Q

Define what is, what causes and the treatment for?

Third degree AV block

A
  • complete failure of conduction of the supraventricular impulses to the ventricles
  • ventricular depolarization initiated by an escape pacemaker distal to the block
  • QRS can be narrow or wide (junctional vs. ventricular escape rhythm)
  • P-P and R-R intervals are constant, variable PR intervals
  • no relationship between P waves and QRS complexes (P waves “marching through”)
  • management: electrical pacing
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12
Q

Describe which leads correspond to which areas of the heart on and ECG.

A
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13
Q

Describe the following anatomy.

A
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14
Q

Define systolic heart failure.

A

This type is also known as heart failure due to left ventricular systolic dysfunction or heart failure due to reduced ejection fraction (HFrEF). This type of heart failure occurs when the ejection fraction is less than 40%.

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15
Q

Define diastolic heart failure.

A

This type is also known as heart failure with preserved ejection fraction. This type of heart failure occurs when the heart muscle contracts well but the ventricle does not fill with blood well in the relaxation phase.

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16
Q

What are the causes of systolic dysfunction?

A
  • Coronary artery disease (ischaemic cardiomyopathy)
  • Dilated cardiomyopathy
  • Valvular heart disease
  • Viral cardiomyopathy
  • Post-chemotherapy cardiomyopathy
  • Congenital heart disease
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17
Q

What are the causes of diastolic dysfunction?

A
  • Hypertensive heart disease
  • Ischaemic heart disease
  • AF
  • Hypertorphic cardiomyopathy
  • Infiltrative cardiomyopathy
  • Constricitve pericarditis/ pericardial disease
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18
Q

What are the signs and symptoms of both right and left heart failure?

A
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19
Q

What Ix are used to assess heart failure?

A
  • identify and assess precipitating factors and treatable causes of CHF
  • blood work: FBC, UEC, CMP, fasting blood glucose, HbA1c, lipid profile,LFT, serum TSH, ± ferritin, BNP, uric acid
  • ECG: look for chamber enlargement, arrhythmia, ischemia/infarction
  • CXR: cardiomegaly, pleural effusion, redistribution, Kerley B lines, bronchiolar-alveolar cuffing
  • echo: LVEF, cardiac dimensions, wall motion abnormalities, valvular disease, pericardial effusion
  • radionuclide angiography (aka gated blood pool scanning): LVEF
  • MRI
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20
Q

How is acute pulmonary oedema Rx?

A
  • treat acute precipitating factors (e.g. ischemia, arrhythmias)
  • L – Lasix® (furosemide) 40-500 mg IV
  • M – morphine 2-4 mg IV: decreases anxiety and preload (venodilation)
  • N – nitroglycerin: topical/IV/SL
  • O – oxygen: in hypoxemic patients
  • P – positive airway pressure (CPAP/BiPAP): decreases preload and need for ventilation when appropriate
  • P – position: sit patient up with legs hanging down unless patient is hypotensive
  • IF this fails ICU admit
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21
Q

What are the conservative and non-pharmcological management for CHF?

A
  • Conservative Measures
    • symptomatic measures: oxygen in hospital, bedrest, elevate the head of bed
    • lifestyle measures: diet, exercise, DM control, smoking cessation, decrease alcohol consumption, patient education, sodium and fluid restriction
    • multidisciplinary heart failure clinics: for management of individuals at higher risk, or with recent hospitalization
  • Non-Pharmcological Management
    • cardiac rehabilitation: participation in a structured exercise program for NYHA class I-III after clinical status assessment to improve quality of life
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22
Q

What are the pharmacolgical Rx for CHF?

A
  • Vasodilators
    • ACEI: standard of care – slows progression of LV dysfunction and improves survival
      • all symptomatic patients functional class II-IV
      • all asymptomatic patients with LVEF <40%
      • post-MI
    • angiotensin II receptor blockers
      • second-line to ACEI if not tolerated, or as adjunct to ACEI if β-blockers not tolerated – hydralazine and nitrates
      • second-line to ACEI, decrease in mortality not as great as with ACEI
      • may consider in acute renal failure until creatinine stabilizes
  • β-blockers: slow progression and improve survival
    • class I-III with LVEF <40%
    • stable class IV patients
    • note: should be used cautiously, titrate slowly because may initially worsen CHF
  • Diuretics: symptom control, management of fluid overload
    • furosemide (40-500 mg daily) for potent diuresis
    • metolazone may be used with furosemide to increase diuresis
    • furosemide, metolazone, and thiazides oppose the hyperkalemia that can be induced by β-blockers, ACEI, ARBs, and aldosterone antagonists
  • Mineralocorticoid receptor (aldosterone) antagonists: mortality benefit in symptomatic heart failure and severely depressed ejection fraction
    • spironolactone for class IIIb and IV CHF already on ACEI and loop diuretic
    • eplerenone may be considered if intolerable endocrine side effects
    • note: potential for life threatening hyperkalemia
      • monitor K+ after initiation and avoid if Cr >2.9 mg/dL or K+ >5.2 mEq/L
  • Digoxin and cardiac glycosides: digoxin improves symptoms and decreases hospitalizations, no effect on mortality
    • indications: patient in sinus rhythm and symptomatic on ACEI, or CHF and AF
    • patients on digitalis glycosides may worsen if these are withdrawn
  • Antiarrhythmic drugs: for use in CHF with arrhythmia
    • can use amiodarone, β-blocker, or digoxin
  • Anticoagulants: warfarin for prevention of thromboembolic events
    • prior thromboembolic event or AFib, presence of LV thrombus on echo
    • possible benefit in other patients with LVEF <30% (controversial)
23
Q

What are the surgical options for CHF?

A
  • resynchronization therapy: symptomatic improvement with biventricular pacemaker
    • consider if QRS >130 msec, LVEF <35%, and severe symptoms despite optimal therapy
    • greatest benefit likely with marked LV enlargement, mitral regurgitation, QRS >150 msec, high diuretic requirement
  • ICD: mortality benefit in 1° prevention of sudden cardiac death
    • prior MI, optimal medical therapy, LVEF <30%, clinically stable
    • prior MI, non-sustained VT, LVEF 30-40%, EPS inducible VT
  • LVAD/RVAD - ventricular assist device
  • cardiac transplantation
  • valve repair if patient is surgical candidate and has significant valve disease contributing to CHF
24
Q

Harsh ejection (crescendo and decrescendo) murmur right of the sternum radiation to the carotids?

A

Aortic stenosis

25
Q

Prominant first heart sound and a ‘rumbling’ mid diastolic murmur?

A

Mitral stenosis

26
Q

Describe the following anatomy

A
27
Q

Pansystolic murmur, loud S3, soft or absent S1, maximal at apex, radiates to axilla. Louder on expiration and isometric hnad grip.

A

Mitral regurgitation.

28
Q

What are the rules of thumb with regards to murmurs getting louder?

A
  • Right sided murmurs become louder on INspiration
  • Left sided murmurs become louder on EXpiration
  • The only murmurs louder with Valsalva are HOCM and mitral prolapse
29
Q

Timing of murmurs within the cardiac cycle.
Not really a question but I like the visual representation of this.

A
30
Q

Which murmurs are best heard with the bell of the stethoscope?

A

Generally speaking, low pitched sounds are meant to be auscultated with the bell.

  • Mitral stenosis
  • third heart sound
31
Q

Which murmurs are louder on inspiration (increased preload)?

A

Right-sided murmurs are usually louder with inspiration; left sided murmurs are usually softer (this is one way of distinguishing between them)

  • Tricuspid regurgitation
  • Tricuspid stenosis
  • Pulmonic regurgitation
  • Pulmonic stenosis
32
Q

Which murmurs are louder on expiration (decreased preload)

A

Left sided murmurs are usually louder with expiration. Right-sided ones are quieter.

  • Aortic regurgitation
  • Aortic stenosis
  • Mitral regurgitation
  • Mitral stenosis
33
Q

Which murmurs are louder on leaning forward with deep expiration?

A

This manoeuvre brings the left side of the heart closer to the chest.

  • Aortic regurgitation and stenosis are heard best in this position
  • Pericardial friction rub is also most audible in this way
34
Q

Which murmurs are louder with the valsalva manoeuvre (decreased preload)?

A

One could write an entire monograph on the four phases of the Valsalva manoeuvre. Let us limit ourselves to discussing what happens in Phase 2 (during “straining”) with decreased preload the prevalent condition.

  • The systolic murmur of hypertrophic cardiomyopathy (HOCM) becomes louder
  • Mitral prolapse murmurs get louder
  • All other murmurs become quieter because less blood is available in the heart
35
Q

Which murmurs are quieter with squatting (increased preload)?

A

Suddenly squatting from a standing position increased preload and afterload; the increased blood in the chambers increases the loudness of all murmurs, except…

  • The systolic murmur of hypertrophic cardiomyopathy (HOCM) becomes quieter
  • All other murmurs become louder because more blood is available in the heart
36
Q

Which murmurs are louder with the isometric hand grip (increased afterload)?

A
  • All murmurs become louder EXCEPT aortic stenosis and HOCM
37
Q

Mid-diastolic rumble at apex, loudest at apex, best heard with bell in left lateral decubitus position, loud S1, Opening snap. Louder on expiration.

A

Mitral stenosis

38
Q

Quiet S1, No opening snap, Collapsing pulse, diatolic murmur louder on expiration.

A

Aortic regurgitation

39
Q

Systolic murmur, radiates to carotids, ejection systolic plateau pulse, quieter with isometric hand grip. Quiter with valsalva. Louder on expiration?

A

Aortic stenosis

40
Q

What are the casues of mitral regurgitation?

A
  • Mitral valve prolapse
  • Age-associated
  • Rheumatic heart disease
  • Infective endocarditis
  • Papillary muscle failure due to ischaemia
  • Dilated cardiomyopathy
  • Marfan’s syndrome
  • Rheumatoid arthritis
  • Ankylosing spondylitis
41
Q

What are the causes of aortic regurgitation?

A
  • Rheumatic heart disease
  • bicuspid valve
  • seronegative arthropathy, eg. ankylosing spondylitis;
  • Marfan’s syndrome
  • Aortitis (e.g. syphilis, rheumatoid arthritis,
  • dissecting aneurysm
  • infective endocarditis
42
Q

What are the causes of mitral stenosis?

A
  • Rheumatic heart disease
  • Congenital parachute valve
43
Q

What are the causes of aortic stenosis?

A
  • Degenerative calcification
  • Congenital bicuspid valve
  • Rheumatic heart disease
44
Q

What are the causes of tricuspid regurgitation?

A
  • Rheumatic heart disease
  • Infective endocarditis
  • RV papillary muscle infarction
  • Trauma (steering wheel injury)
  • Ebstein’s anomaly
45
Q

Heart murmur.

Tapping apex, loud first heart sound and an apical rumbling mid-diastolic murmur.

A

Mitral stenosis

46
Q

Heart murmur.
O/E has a high arched palate, an arm span greater than her height. soft first heart soound, a mid-systolic cick and an apical blowing late systolic murmur radiating to the axilla.

A

Mitral valve prolapse

47
Q

Heart murmur.

Slow rising carotid pulse and a loud ejection systolic murmur at the upper right sternal edge, radiating to the carotids.

A

Aortic stenosis

48
Q

Heart murmur.

Early diastolic murmur at the aortic area. It is loudest with the patient sitting forward in expiration.

A

Aortic regurgitation

49
Q

Heart murmur

6 month old, continuous machinery murmur at the upper left apex during routine examination at baby clinic.

A

Patent ductus arteriosus

50
Q

What are the absolute contraindications to exercise stress testing?

A
  • Acute myocardial infarction (within two days)
  • Unstable angina
  • Uncontrolled cardiac arrhythmias
  • Symptomatic severe aortic stenosis
  • Uncontrolled heart failure
  • Acute pulmonary embolism or pulmonary infarction
  • Acute myocarditis or pericarditis
  • Acute aortic dissection.
51
Q

What are the relative contraindications to exercise stress testing?

A
  • Left main coronary stenosis
  • Moderate stenotic valvular heart disease
  • Electrolyte abnormalities
  • Severe arterial hypertension
  • Tachyarrhythmias or bradyarrhythmias
  • Hypertrophic cardiomyopathy
  • Mental or physical impairment leading to an inability to exercise adequately
  • High-degree atrioventricular (AV) block.
52
Q

Heart failure is associated with which type of pulse?

A

is associated with pulse waves of differing amplitude and/or intensity and hence pulsus alternans.

53
Q

Rheumatic fever and mitral stenosis is associated with which type of pulse?

A

is associated with a low volume pulse, atrial fibrillation (irregularly irregular)

54
Q

What are the five poor prognostic markers that are predictive of sudden cardiac death in HOCM?

A
  • Syncope
  • Family history of HCM and sudden cardiac death
  • Maximum left ventricular wall thickness greater than 3 cm
  • Blood pressure drop during peak exercise on stress testing, and
  • Documented runs of non-sustained VT on 24 hour tape

Year 4 (25 decks)

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