Cardiology (Antiplatelets and murmurs) Flashcards
antiplatelet drugs
Antiplatelet drugs decrease platelet aggregation and inhibit the formation of thrombi in the arterial circulation.
e.g. arterial clots such as MI
anticoagulation
Venous and intracardiac thrombosis driven largely by coagulation cascade and fibrin compared to arterial thrombus - mainly platelet rich
Antiplatelets: Acute coronary syndrome (ACS) treated medically
First line Lifelong aspirin + 12 months ticagrelor
Second line If aspirin is contraindicated, give lifelong clopidogrel
Antiplatelets: Acute coronary syndrome (ACS) treated with PCI
First line Lifelong aspirin + 12 months prasugrel or ticagrelor
Second line If aspirin is contraindicated, give lifelong clopidogrel
Antiplatelets: PAD
First line Lifelong clopidogrel
Second line Aspirin
Antiplatelet: ischaemic attack
Start aspirin 300mg daily immediatley
Prevention
First line Lifelong clopidogrel
Second line Aspirin + lifelong modified-release dipyridamole
Antiplatelet: Stroke
Start aspirin 300mg daily immediatley for 2 weeks
Prevention
First line Lifelong clopidogrel
Second line Aspirin + lifelong modified-release dipyridamole
normal heart sounds are
S1 (first heart sound) and S2 (second heart sound).
I + II + 0
S1
the closure of the mitral and triscuspid valve
S2
due to the closure of the aortic and pulmonary valves
heart murmurs basics
Heart murmurs are additional sounds as a result of turbulent blood flow.
- Ideally, blood flow should be laminar and silent.
- A thrill is a murmur significant enough to be palpable.
- Systolic murmurs are mostly pathological but can be benign in children or pregnant women.
- Diastolic murmurs are always pathological.
ejection systolic murmus
- Aortic stenosis (louder on expiration)
- Pulmonary stenosis (louder on inspiration)
- Coarctation of the aorta
late systolic murmur
- Coarctation of the aorta – loudest below the left scapula
- Mitral valve prolapse
Pansystolic murmur
- Mitral regurgitation (louder on expiration)
- Tricuspid regurgitation (Louder on inspiration)
- Ventricular septal defect – loudest at the left lower sternal border
early diastolic murmur
- aortic regurgitation (expiration)
- pulmonary regurgitation
(inspiration)
.
mid-late diastolic murmur
- Mitral stenosis
- Severe aortic regurgitation
Continuous machinery murmur in the left upper sternal border:
patent ductus arteriosus
Pulsus paradoxus
Pulsus paradoxus describes an abnormally large decrease in systolic blood pressure (>10 mmHg) and a decrease in pulse strength during inspiration. It is seen in cardiac tamponade and severe asthma.
Collapsing pulse
Also known as Corrigan’s pulse, a collapsing pulse is a sign of aortic regurgitation characterised by a pulse that is bounding and forceful that rapidly increases then collapses. This is felt by raising the patient’s arm vertically upwards and holding the patient’s forearm. Gravity causes an increased flow of blood to the arm and a resultant collapsing pulse.
De Musset’s sign
De Musset’s sign describes rhythmic bobbing of the head in sync with the heart and is a sign of aortic regurgitation. The nodding occurs due to an increase in pulse pressure as a result of aortic insufficiency.
Quincke’s sign
Quincke’s sign describes pulsations of the capillaries in the nailbeds that occur with each heart beat. This is a sign of aortic regurgitation.
Roth’s spots
These are red spots with white centres seen on the retina due to haemorrhage of retinal capillaries. This is a sign of infective endocarditis.
Janeway lesions
Janeway lesions are erythematous, non-tender, macular lesions on the palms and soles of the hands associated with infective endocarditis. They occur due to immune complex deposition.
Osler’s nodes
Osler’s nodes are painful, erythematous, and raised lesions on the hands and feet associated with infective endocarditis. They occur due to immune complex deposition.
Beck’s triad
This is a sign of cardiac tamponade.
- Hypotension
- Muffled/quiet heart sounds
- Elevated jugular venous pressure
Jugular venous pressure
The jugular venous pressure (JVP) is assessed by looking at the jugular vein and can be used to assess cardiorespiratory disorders. It can be difficult to differentiate the JVP from the carotid artery. Some distinguishing features include:
- The JVP is biphasic (‘beats twice’) whereas the carotid artery beats once
- The JVP is non-palpable. If a pulse is felt, it is the carotid artery
- The JVP is occludable. Lightly pressing on it occludes the jugular vein which then fills from above the occlusion.
An elevated JVP suggests venous
congestion (such as heart failure).
Parasternal heaves
Heaves are palpable heart impulses felt when the hand is rested just lateral to the left sternal edge. This is a sign of right ventricular hypertrophy.
Thrills
Thrills are palpable heart murmurs that are felt over the areas on the chest corresponding to the valves of the heart. They feel like a cat purring under the hand.
define syncope
Syncope describes a transient loss of consciousness due to a decrease in blood flow to the brain. This is rapid in onset, lasts for a short period of time (mostly up to around 30 seconds), and people resolve spontaneously and completely recover.
This definition excludes other causes of a loss of consciousness, such as epilepsy, which may last longer and have a post-ictal period and more prolonged recovery.
classification of syncope
- Reflex
- Orthostatic
- Cardiac
reflex syncope
- Vasovagal
- Situational
- Carotid sinus syncope
vasovagal syncope
‘fainting’
* Exposure to blood or unpleasant sight
* Strong emotion
* Pain
* Stress
Situational syncope
syncope caused by specific behaviours:
* Coughing
* Urination
* Defecation
* Vomiting
* Swallowing
Carotid sinus syncope:
Pressure on the carotid sinus can cause syncope in some individuals
Orthostatic syncope
This is syncope that occurs due to an excessive drop in blood pressure when standing up from sitting or lying down. Its causes include:
- Primary autonomic failure: causes include Parkinson’s disease, dementia with Lewy bodies, multiple system atrophy, other Parkinson’s plus syndromes
- Secondary autonomic failure: causes include diabetes mellitus, uraemia, spinal cord injuries, amyloidosis
- Drug-induced orthostatic hypotension: causes include diuretics, vasodilators, alcohol, antidepressants
- Volume depletion: causes include haemorrhage, diarrhoea, vomiting
cardiac syncope
Cardiac syncope occurs due to arrhythmia, valvular heart disease, muscular heart disease, or vascular heart disease.
cardiac syncope: arrhtmia
Bradycardia:
* Sinus node dysfunction
* Atrioventricular (AV) conduction disorders
* Implanted device malfunction
Tachycardia:
* Supraventricular
* Ventricular
cardiac syncope: structural disease
Causes include: valvular disease, myocardial ischaemia/infarction, hypertrophic cardiomyopathy, cardiac masses (e.g. myxomas or other tumours), pericardial disease and cardiac tamponade, congenital heart disease, prosthetic valve dysfunction
