Cardiology & Cardiac Surgery Flashcards
Recite what the CHA2DS2-VASc Score represent
Management for CHA2DS20-VASc Score:
0
1
2 or greater
0 - do not require anticoagulant
1 - low-moderate risk, should consider antiplatelet or anticoagulant
2 or greater - moderate-high risk, anticoagulant (warfarin!)
When do you suspect aortic dissection?
- Sudden onset of thoracic or abdominal pain + sharp, tearing and/or ripping character
- Widened mediastinum or aorta on CXR
- Pulse or blood pressure variation
Aortic Dissection patient with ECG showing acute MI, thrombolyse or not?
Best treatment?
Absolutely NOT due to high risk of bleeding.
Morphine, BB and urgent TOE to confirm diagnosis.
CTA if TOE not available.
Besides acute MI or MI, what else can a dissection that involved the ascending aorta induce?
- Acute aortic valve regurgitation (diastolic decrescendo murmur)
- Acute MI or MI
- Cardiac tamponade and sudden death due to ruction
- SBP variation (>20mmHg) between arms
- Neurologic deficits (stoke/decreased consciousness)
- Horner syndrome (if there is compression of cervical sympathetic ganglion)
- Vocal cord paralysis and hoarseness (compression to left RLNerve)
Dressler’s Syndrome features and best treatment
KEY:
- usually develops 2-3 weeks after acute MI or heart surgery
- patient would suffer from: recurrent fever + chest pain with pleural/pericardial rub
Best treatment: regular aspirin (or steroids if allergic)
In early stages, pleurocentesis and pericardiocentesis are not required yet.
ECG: all T waves, broad QRS complex and prolonged PR interval
Next step?
Hyperkalemia
Next step: IV calcium carbonate 10% 10mL, infused over 2-3 minutes with cardiac monitoring.
Effect lasts for 30-60 minutes
Causes of high troponin levels that is not due to ACS?
Most common:
Renal failure
Myocarditis
AF
Pulmonary thromboembolism
Antibiotic regimen for native valve IE due to streptococci?
Combination of beta-lactam antibiotic + gentamicin
Duration: 2 weeks (uncomplicated) to 6 weeks (enterococcal IE)
Staphylococcal IE antibiotic regimen
Combination of beta-lactam antibiotic + gentamicin + RIFAMPICIN
Signs of constrictive pericarditis
- Paradoxical JVP/Kussmaul’s sign (pulsatile)
- Massive hepatosplenomegaly
- Ascites
- Peripheral oedema
Raised JVP ~ right heart failure
DDX
Superior vena cava obstruction - JVP raised, but no pulsation; no peripheral ankle oedema and ascites.
Budd Chiari syndrome - clot - RUQ pain + mild jaundice + tender hepatomegaly and ascites.
How long should a patient who has received intracoronary drug-eluting stent be on antiplatelet therapy for?
Dual antiplatelet therapy for 12 months.
Aspirin + Ticagrelor/Prasugrel/Clopidogrel
How to confirm hypertrophic cardiomyopathy?
Symptoms?
ECHO
Asymptomatic
Fatigue
Weakness
Chest Pain
Syncope
Midsystolic ejection murmur or LV lift
Commonly cause arrhythmias or death in young athletes
All-first degree relatives of an affected individual be clinically screened for HCM
- physical exam by cardiologist, ECG, TTE
- commercial genetic testing
In which group in Prolong QT syndrome commonly seen?
Syncopal episodes commonly seen in late childhood or adolescence.
During syncope, arrhythmias (VF, Torsades de Pointes) can be noted
May result in death
Congenital Heart Block is related to what disease?
Neonatal Lupus
- rare manifestation of transferred maternal IgG auto-Ab.
- most will self-resolve, but can be permanent in some requiring pacing
Other symptoms: thrombocytopenia, neutropenia, rash, liver dysfunction and congenital HB.
When to refer a child to Paediatric Cardiology for Congestive Heart Failure?
Weak, diaphoretic, poor weight gain, tachypnoeic with retractions.
Lung: crackles, wheezes or both
Cause: congenital heart disease, Kawasaki, metabolic cardiomyopathies, arrhythmias, viral myocarditis
Most effective lifestyle intervention for preventing cardiovascular disease and premature deaths?
Smoking cessation
Ideal Lipid Profile?
Total Cholesterol: < 5-5.5
LDL: < 4
TGL: < 2
HDL: > 1
How often should the absolute CVD risk assessment be done?
Every 2 years in adults aged > 45 y/o OR to be clinically determined high risk
If SBP > 180mmHg or total cholesterol > 7.5, should be considered clinically high risk.
First line investigations in any patient with erectile dysfunction
- Blood glucose
- Free testosterone
- TFT
- Prolactin
- Luteinising
Cardiac Catheterisation as a general term includes…
angioplasty, PCI, balloon angioplasty
Unstable Angina
Low Risk vs High Risk
CK?
Troponin?
ECG?
Low Risk Unstable Angina:
CK normal
Troponin not detectable
ECG normal
High Risk Unstable Angina:
CK normal
Troponin detectable
ECG ST depression
Should be referred to cardiologist for URGENT STRESS ECHO to confirm diagnosis.
If confirmed, to do angiography.
Biomarkers for Heart Failure
That helps predict prognosis
Eg. B-type natriuretic peptide, troponin, ST2, gal-3
What are the initial evaluation of suspected syncope?
- History
- Physical examination (careful carotid sinus massage in older patients)
- Review ECG
- Transthoracic Echocardiogram (TTE) - to evaluate presence or severity of structural heart disease
Once determined, then establish diagnosis.
Usually start by ruling out cardiac causes first, followed by neuro.
Best indicator of myocardial re-infarction?
CK-MB
- short half-life of 12 hours
NSTEMI
CK?
Troponin?
ECG?
CK elevated
Troponin detectable
ECG ST depression, no Q wave
Is anticoagulant required for planned electrical cardioversion?
Yes! If not the risk of embolic event and stroke is very high.
Warfarin for 4 weeks before and maintain therapeutic INR for 4 weeks after the electrical cardioversion.
~ 8 weeks in total!
Managment of Acute Coronary Syndrome (ACS)
STEMI
NSTEMI
UA
Fibrates lowers which component of the lipid profile?
Statins?
Fibrates (fenofibrate or gemfibrozil) - Triglyceride
Fish oil is second line
Statins - LDL or TC
Other lipid-lowering drugs in the market:
Nicotinic acid, bile acid resins (isolated cholesterolaemia), ezetimibe inhibitors, fish oil
When to stop statins?
Transaminase is persistently x3 above upper limit
CK is x 10 the upper limit
Persistent unexplained muscle pain
How often should the following groups repeat their lipids?
Low Risk: ?
Moderate Risk: ?
High Risk: ?
Low Risk: every 5 years
Moderate Risk: every 2 years
High Risk: every year
Most common cause of pericarditis in Australia?
Viral or idiopathic
First line treatment: NSAIDS (7-10 days) + Colchicine (3 months)
Diagnosis of Prosthetic Valve Endocarditis (like IE)
Clinical manifestations
Blood cultures (or other microbiological data)
ECHO - vegetation
Modified Duke’s Criteria
First line treatment for hypertriglyceridemia
- Diet rich in mono- and poly-unsaturated fat
- Diet low in glycaemic index carbohydrates food
- Weight loss by caloric restriction and exercise
- Consider marine omega 3 fatty acids (fish oil) and fibrates
Aim for TG < 1.5 mmol/L
Is antiplatelet therapy recommended for stroke prevention in patient with AF?
NO.
Follow CHA2DS2-VASc Score.
Thrombolytic to avoid in aboriginal?
Streptokinase
Many have high levels of anti-streptokinase IgG level
Resistant to streptokinase reperfusion therapy
Suspected PE with background of renal failure
Investigation?
V/Q scan
CTPA is contraindicated as contrast-induced renal damage will be a problem.
Features of cardiac signs in mitral stenosis
- Increased risk of AF
- Loud first heart sound (S1)
- P2 increased in intensity and widely transmitted as pulmonary HTN develops
- Murmur: low-pitched diastolic rumble (heard at apex, using bell of stethoscope, laying patient at left side)
- Mild MS: murmur in late diastole, just before S1, called presystolic accentuation.
NO THIRD HEART SOUND
Post-viral congestive cardiac failure features
Likely viral myocarditis
Give one dose of frusemide, then
Send to hospital as URGENT TTE is required to rule out cardiomyopathy and heart failure
Most appropriate first line investigation for suspected acute PE?
Management:
ABG or VBG
- to assess severity and need for supported ventilation
Followed by ECG, cardiac troponin, serum BNP level, CXR, FBC, RP, LFT
Morphine
O2
Nitrates
Diuretics
What is heard on lung auscultation for APO?
Pulmonary rales, ronchi; expiratory wheezing
Rheumatic Fever is a sequela of group A streptococcus infectious of the throat or skin (during scabies). Which criteria do we use to diagnose rheumatic fever?
Jones Criteria
Reactive Arthritis
Cannot pee, cannot see, cannot walk.
All inflamed!
Has history of GI or genitourinary infection
Gonococcal Arthritis
Single joint
History of unsafe sex and urethral discharge
Juvenile idiopathic arthritis
Common chronic disease of childhood
At least 6 weeks history of arthritis prior (often with morning stiffness and spiking fevers)
Best prevention for peri operative cardiac event is in those with at least one cardiac risk factor?
Beta Blockers!
Not recommend in those with baseline HR 60 or SBP < 90mmHg or when time is not sufficient for titration
Cardiomyopathy (AKA impaired myocardial function) is the most common cause of heart failure.
What are the most common causes?
Most Common:
Coronary heart disease
Smoking
HTN
Obesity
DM
Valvular heart disease
Routine initial investigations for newly diagnosed heart failure?
Lab tests:
ECG, CBC, urinalysis, serum creatinine, potassium and albumin, and TFT.
ECHO! To identify structural abnormalities and measure EF
Harsh or rumbling murmur
Think of?
AS or MS
Blowing or musical murmur
Think of?
AR or MR
Physical examination features seen in Aortic Stenosis (AS)?
- Ejection clicking in S1 + Harsh, rasping cresendo-decrescendo systolic murmur
- Heard best at second intercostal space at right upper sternal border (radiates to carotid)
- Carotid pulse: small and rises slowly (pulsus parvus et tardus)
- In elderly, commonly heard in the apex, resembling MR
- Paradoxical splitting S2
- Use diaphragm of stethoscope
Acute dyspnea from acute decompensated heart failure (ADHF).
Initial measures?
- Airway and oxygenation assessment and management (SPO2, O2, ventilatory support, vital sings, IV access, seated posture…)
- Initiate tx: prompt diuretic therapy
- Then early vasodilator therapy (for severe HTN, acute MR, or acute AR); later vasodilator use
Nitroprusside lowers arterial tone
Nitroglycerin lowers venous tone - Urine output monitoring
- VTE prophylaxis
- Sodium restriction
- Generally avoid opioid therapy in ADHF patients
Page 130 MPlusX PDF
1st Degree AV Block - delay in conduction through AV node
ECG?
Causes?
Significance?
ECG: PR Interval > 200ms
Causes:
Increased vagal tone (younger patients / athletes)
Fibrosis (elderly patients)
Drugs (AV node blocking agents: BB, CCB, Digoxin)
Normal Variant
Coronary Artery Disease
Mitral Valve Surgery
Electrolyte Imbalance (hypokalaemia, hypomagnesaemia)
Significance:
Usually asymptomatic
Occasional progresses
3x risk of developing AF
If symptomatic, with PR interval > 300ms, pacemakers can be considered
2nd Degree AV Block has two types.
What are they called?
Mobitz 1 = Wenkebach Block
Mobitz 2 = Hay Block
2nd Degree Heart Block
Mobitz 1 (Wenkebach)
ECG?
Causes?
Significance?
ECG:
- Progressively longer PR interval, followed by non-conducted beat
(Due to progressively fatigue of AV cells)
- Cyclical, e.g. 4:3 (P:QRS)
Causes:
Increased vagal tone
Normal variant
Myocardial Infarction (Inferior)
Drugs
Mitral Valve Surgery
Hyperkalaemia
Significance:
Does not usually require treatment
May cause bradycardia and hypotension
- atropine, reduce AV blockers, pacing
2nd Degree Heart Block
Mobitz 2 (Hay)
ECG?
Causes?
Significance?
ECG:
- PR interval constant with intermittent dropped beat
- May have fixed ration P:QRS e.g. 2:1, 3:1
Causes:
Usually structural heart disease (myocardial ischaemia / fibrosis)
** Below Bundle of His in 75% - wide QRS
** Within Bundle of His in 25% - narrow QRS
Significance:
Often symptomatic (syncope, fatigue, chest pain, death)
High risk progression
35% per year risk of asystole
Requires temporary pacing —> pacemaker
Atropine can precipitate Complete Heart Block
3rd Degree AV Block (Complete Heart Block)
No association between atria and ventricle contractions
Junctional/ventricular escape rhythm
ECG?
Causes?
Significance?
ECG: No correlation of P waves and QRS complexes
Number of P waves > QRS complexes
Causes:
Inferior Myocaridal Infarction
AV blocking agents (digoxin/metoprolol)
Degeneration of conduction system
Significance:
Often symptomatic (syncope, fatigue, chest pain, SOB, death)
Atropine (initial treatment), however rarely effective - Dopamine / Adrenaline are other medical options
Transcutaneous/transvenous pacing (treatment of choice) —> pacemaker
Malignant Hypertension
What is it?
Treatment?
- High blood pressure with end organ damage (retinopathy!)
- BP rises rapidly + diastolic BP > 120mmHg
- Histologic changes: fibrinoid necrosis of vessel wall; if not treated, may lead to death from progressive renal failure, heart failure, aortic dissection or stroke
Treatment:
IV sodium nitroprusside
Or infusion of labetalol
Nicardipine
Hydralazine (pregnant women)
Can give frusemide or losartan once diastolic BP is ~ 100mmHg
Long Term Complication of Mitral Stenosis?
Pulmonary Hypertension
Mitral valve stenosis → increase in left atrial pressure → backup of blood into lungs → increased pulmonary capillary pressure → cardiogenic pulmonary edema → pulmonary hypertension → backward heart failure and right ventricular hypertrophy
Heart Failure
Mitral valve stenosis → obstruction of blood flow into the left ventricle (LV) → limited diastolic filling of the LV (↓ end-diastolic LV volume) → decreased stroke volume → decreased cardiac output (forward heart failure)
Best treatment for supraventricular tachycardia (SVT)
Vagal manoeuvres + IV adenosine 6mg
Pulmonary Embolism
What is commonly seen in ECG?
What scoring system do we use to assist us in management?
- Sinus tachycardia
- RBBB
- T-wave inversions
- S1Q3T3 commonly seen in PE
Well’s Score
Which criterion is used for diagnosis of IE?
Modified Duke’s Criteria
Definitive Diagnosis:
2 major criteria
or 1 major and 2 minor criteria
or 5 minor criteria
Possible Diagnosis:
1 major and 1 minor criteria
or 3 minor criteria
Management for haemodynamically stable AF
Rate-control:
- BB
- Diltiazem/verapamil
- Digoxin (if needed to add a second drug)
Usually BB +/- Digoxin is preferred.
Long term management will require anticoagulation as well if CHA2DS2-VASc score is 2 or above to prevent thromboembolism or for planned pericardioversion procedure.
ECG Features of Hypertrophic Cardiomyopathy (HCM)
- LA enlargement (“P mitrale”)
- LVH a/w ST segment / T-wave abnormalities
- Deep, narrow (“dagger-like”) Q waves in the lateral > inferior leads
- Giant precordial T-wave inversions in apical HCM
- Signs of WPW (short PR, delta waves)
- Dysrhythmias: AF, SVT, PACs, PVCs, VT
Summary of management based on CVD risk
Most common type of primary cardiac tumour
Myxomas
- typically pedunculated, does not involve ventricular myocardium
Causes of Long QT Syndrome
- Hypothyroidism
- Hypothermia
- Hypocalcaemia, hypokalaemia, hypomagnesaemia…
- Sotalol
- Methadone
- Antipsychotics: olanzapine, haloperidol, quetiapine, haloperidol and chlorpromazine
- Antidepressants: TCA, SSRI
Symptomatic Bradycardia
IV Atropine 0.5mg every 3-5 minutes, max dose of 3mg in total
Dopamine and epinephrine may be beneficial
Not improving? Temporary cardiac pacing
Initial choice of investigation for those suspected to have PE
Chest X-Ray
- first exclude pathologies that mimic PE
- usually normal in PE
- May present with:
Focal oligemia (Westermark’s sign)
Peripheral wedged-shaped density above the diaphragm (Hamptom’s Hump)
Enlarged right descending pulmonary artery (Palla’s Sign)
[CTA - investigation of choice for diagnosis; V/Q scan - second line]
Atherosclerosis stenosis of the superficial femoral artery will likely reuslt in reduce in pulse in…?
Popliteal artery, pedal pulses….
According to anatomy
Erythema Marginatum
of Acute Rheumatic Fever
‘E’ of the
JONES CAFE PAL criteria for ARF
Initial test when suspecting ARF
Confirm by taking throat swab to show preceding GAS infection first and foremost.
(Blood Culture is only for cases where one is unsure or unaware of GAS infection)
Ventricular Septal Defect (VSD)
- holosystolic murmur at left sternal border
- left-to-right shunt
After Birth:
PVR declines —> RV contracting against pulmonary vascular resistance (PVR) + LV contracting against systemic vascular resistance (SVR) —> pressure difference causes left-to-right shunting.
Small VSDs: usually insignificant
Larger VSDs:
- volume overload and dilation of RV —> excess volume pumped through the lungs and delivered to LA
- Increased left atrial preload —> LA and LV also enlarges
THEREFORE, see enlarged left heart contour and and RV
Pericardial Effusion
- Often secondary to viral pericarditis (+/- pleural effusions)
- ECG: ‘’electrical alternans” (QRS complexes whose amplitudes vary from beat to beat = heart swinging back and forth within an increased quantity of pericardial fluid)
+ Jugular vein distension, muffled heart sounds, borderline low BP developing cardiac tamponade - CXR: Enlargement of cardiac silhouette often seen
- ECHO is confirmatory
Wolff-Parkinson-White Syndrome
- a type of heart arrhythmia caused by an accessory pathway, or an extra electrical conduction pathway, called the Bundle of Kent. It connects the atria and ventricles, or the upper and lower chambers of the heart.
- In WPW, the ventricles start to contract a little bit early, which is called pre-excitation. If the Bundle is on the left side of the heart, it’s called “type A pre-excitation.” If it’s on the right side, it’s called “type B pre-excitation.” Type A is a lot more common.
ECG:
- short PR interval with a delta wave (upsloping just before QRS complex), as well as QRS prolongation.
- This makes sense because the signal is taking the shortcut and contracting the ventricles early.
- Also, the ST segment and T wave (representing repolarization), will often be directly opposite the QRS complex.
Chronic Lymphadema
