Cardiology COPY Flashcards
Types of MI
Type 1 - plaque rupture with intraluminal thrombus
Type 2 - demand ischaemia
Type 3 - MI resulting in death without biomarkers
Type 4 - PCI related
4a related to PCI
4b related to in-stent thrombosis
Type 5 - CABG related
Cannon “a wave”
Simultaneous contraction of atria and ventricle against a closed tricuspid valves
Seen in;
- complete heart block
- ventricular tachycardia
- Ventricular ectopics
- single chamber ventricular pacing
C wave
Closure of tricuspid valve
Normal A wave
Contraction of atria
Absent in AF
V wave
Passive filling of atria against a closed tricuspid valve
Large V waves in tricuspid regurgitation
X descent
fall in atrial pressure during ventricular systole
Y descent
opening of tricuspid valve
Findings of Mitral Stenosis
Often caused by RHD
Early diastolic murmur loudest expiration
Reduced pulse volume
Prominent A and V waves due to subsequent R) heart failure
Mitral facies
Loud P2
Indications mitral valve repair in MS
MCV < 1.5cm
No thrombus
No calcifications
If symptomatic - NYHF 4
If asymptomatic - Pulm arterial pressure > 50mmHg or new AF
Contraindications to mitral valvuloplasty in MS
Valve > 1.5cm
Thrombus or calcification
NYHF < 3 without AF or pulmonary pressures > 50
Mod - Severe MR
Absence of commissural fusion
Other severe valve pathology
Coronary artery disease requiring CABG (Opt for repair instead)
Indications for MV repair
MCV < 1.5cm and symptomatic - NYHF 4 with contraindications for balloon valvuloplasty;
- Clot, calcification
- Mod/severe MR
- CABG or other vascular disease requiring surgery
CHADSVASC
CCF
HTN
AGE > 75 (2), Age > 65 (1)
Diabetes
Stroke or TIA in past (2)
Vascular disease
Sex category Female
Age > 75 is biggest risk factor
0 < 2% risk
1 < 3%
2 < 4%
3 < 6%
4 < 9%
5 < 13%
6 < 19%
Bernoulli equation
Used to estimate pulmonary artery pressure by measuring the velocity of the TR jet
p = 4V^2
Indications HCM interventions
Rx if syncope, NYHF symptoms 3-4 or LVOT gradient > 50mmHg
ICD indications
- FHx SCD
- LV or septal thickness > 30mm
- Cardiac arrest or VT
- NSVT > 3 beats
- Unexplained syncope, not post-exercise
Severe Mitral Stenosis
MVA < 1.5cm2
PAP > 50mmHg
Gradient > 10mmHg across valve
Mitral Stenosis balloon Valvuloplasty indications
Indicated for;
- Severe MS < 1.5cm
- Symptomatic NYHF 3-4
- Pliable valve, no clot, minimal MR
- consider if asymptomatic but RVSP > 50 or new AF (class 2 indications)
Balloon Valvuloplasty contraindicated if;
- Non-pliable valve
- moderate MR
- Clot
- Combined aortic or tricuspid disease
- Requiring Bypass surgery
Indications MV surgery in MS
- MV < 1.5cm
- Symptomatic NYHF 3-4
- Non-pliable valve, clot or MR which contraindicates balloon valvuloplasty
Austin Flint murmur
Low pitched mid to late diastolic rumble AR jet impinges on the Anterior Mitral Valve leaflet
Severe AR
Valve > 0.6cm
Holodiastolic murmur indicative of flow reversal
Regurgitation volume > 60ml
Regurgitation fraction > 50%
Requires valve replacement If above, with symptoms, LVEF < 55% or indication for other valvular surgery
Features of Complete Heart Block
Cannon A waves
HR 30 - 50bpm
Syncope
Variable intensity of S1
Murmurs
Systolic
- Aortic stenosis - ejection - mid systolic
- Mitral regurgitation, tricuspid - pansystolic
- Mitral prolapse - late systolic
Diastolic
Aortic regurgitation - early diastolic + Austin flint murmur
Pulmonary regurgitation - early diastolic
Mitral stenosis, tricuspid stenosis- holodiastolic
Murmurs
Aortic stenosis - mid ejection systolic crescendo, decrescendo
Mitral regurgitation - early or pansystolic
Tricuspid regurgitation -early or pansystolic
VSD - Pansystolic
Mitral valve prolapse - late systolic
Tricuspid valve prolapse - late systolic
Aortic regurgitation - Early diastolic
Pulmonary regurgitation - Early diastolic
Mitral stenosis - Holodiastolic
Tricuspid stenosis - Holodiastolic
Atrial Myxoma - Late diastolic
NYHA classification
Class 1; no limitation of physical activity
Class 2; Slight limitation of physical activity
Class 3 - Marked limitation of physical activity
Class 4 - Unable to carry out any physical activity, breathlessness at rest
Graham Steell Murmur
- Murmur of pulmonary regurgitation
- Early diastolic murmur
- due to a high velocity flow back across the pulmonary valve a consequence of pulmonary hypertension secondary to mitral valve stenosis.
Management HCM
- Beta blockade
- Non-dihydropuridine CCB
- Avoid Nitrates and EtOH
- Septal reduction therapy
- Disopyramide - Na channel blocker (Class 1a)
- Septal ablation
- Myectomy
Kussmaul’s sign VS. Pulsus paradoxus
Kussmauls - Elevation of JVP on inspiration due to poor RV filling.
eg. constrictive pericarditis, cardiac tamponade
Pulsus paradoxes; BP decreases > 10mmHg with inspiration eg. Cardiac tamponade, constrictive pericarditis, severe COPD, asthma, tension PTX, PE, large bilateral pleural effusions
Brugada criteria for VT
- Concordance in precordial leads
- Absence of RS complex in all precordial leads
- R to S interval > 100s in any precordial lead
- AV disassociation
- Morphology of VT
Most common acquired valve disease?
Aortic stenosis
Long QT Syndrome
Sex - Exercise - Type 1 - increased amplitude (KCNQ1); Beta blockers most protective
Orgasm - Excitement, alarmed - Type 2 - low amplitude (KCNQ2/HERG)
Sleep - Resting, shortens with exercise - Type 3 - normal T wave but long isoelectric ST segment (gain of function SCN5a (Brugada is loss of function))
SCN5A
Gain of function gene in Type 3 Long QT syndrome
Loss of function gene in Brugada
Diagnosis HCM
- LV > 15mm
- Septum 1.3 x thickness posterior free wall
Origin of arrhythmias
Atrial Flutter - Tricuspid annulus
Idiopathic VT - RVOT
Atrial fibrillation - Pulmonary veins
AVNRT - Kochs triangle
WPW - Bundle of Kent
Indications for MV repair in MR
PRIMARY
MV > 0.7
Symptomatic
LVEF < 60%
SECONDARY
Severe symptoms despite GDMT
Severity AS
Severe
< 1cm (< 0.6cm if corrected fro BSA)
Mean gradient > 40
Aortic Velocity > 4
If symptomatic and severe - for AVR/TAVI
Mod
1.0 - 1.5cm
Mean gradient 20 - 40
Velocity 3-4
Mild
> 1.5
Mean gradient < 20
Velocity 2.6 - 2.9
Aortic sclerosis - velocity < 2.5
Pseudo severe AS
Low-flow low gradient (AS severity is overestimated due to incomplete opening of the valve secondary to loss of LV systolic function)
Valve < 1.0 cm
Gradient < 40
LVEF < 40
Paradoxical low flow low gradient
Valve < 1.0
Gradient < 40
LVEF > 50 but with reduced stroke volume < 35ml/min
Pseudo severe AS
Valve >1.0
Gradient < 40
Can be tested with Dobutamine Stress Test which will increase valve opening
Indications for AVR in AR
Severe AR with valve > 0.6cm and holodiastolic flow reversal > 60ml
Surgery if;
If symptomatic
If asymptomatic - LVEF < 55%
PCSK9 inhibitors
PCSK9 is a protein that targets LDL receptors for degradation and its inhibition thereby means there are more LDL receptors on the livers surface to bind LDL and remove it from our system. liver’s ability to remove LDL-C
Evolocumab
Alirocumab
- Reduces LDL by 50-60% even if already on statin therapy
- Reduce reoccurrence of MI
Ezetimibe
Inhibits cholesterol absorption from gut by blocking via NPC1L1
Inclisiran
Inhibits hepatic synthesis of PCSK9 to reduce cholesterol (rather than blocking action in PCSK9 inhibitors)
FFR
FFR < 0.8 indicates haemodynamic significant obstruction
TIMI flow grade
0 - no perfusion
1 - penetration without perfusion
2 - partial reperfusion
3 - normal flow
Ticagrelor side-effects
B’s!
Breathlessness
Bleeding
Block (can precipitate ventricular pauses so do not use in first or second degree heart block)
Bradycardia
BD dosing
Indications ICD or CRT-D
ICD
- Sustained VT with or without arrest
- EF < 35% on GDMT
- Must be > 40 days after MI
CRT-D
- NYHF III
- EF < 35% on GDMT
- LBBB
- QRS > 100
- Must be in sinus rhythm
Beta blockers in stable angina
Decreased myocardial demand (rather than increased coronary flow)
Beta Blockers
Beta 1 selective - Metoprolol, Atenolol, Nebivolol (has nitric oxide vasodilatory effects)
Beta 1 + Alpha 1- Carvedilol (evidence of improvement in HF)
Non-selective - Propanolol, Sotalol
Treatment RHD
Treatment must be started within 9 days of strep throat
Stat IM benpen
Oral BD dosing Penicillin V for strep pharyngitis
Treatment should be started within 9 days of symptom onset for patients with Strep pharyngitis to avoid rheumatic heart disease
Aspirin for arthritis
Jones criteria
Major
Polymigratory arthritis
Carditis
Nodules (subcutaneous)
Erythema marginatum
Syndenham criteria
Minor
- Arthralgia
- prolonged PR interval
- Fever
- Elevated CRP/ESR
RHD investigations
Anti-streptolysin antibody (sensitivity improved when combined with Anti-DNAse B)
Anti-DNAse - B
Poor diagnostic yield from throat swabs
NO screening for asymptomatic family members
Chorea is self limiting
Indications for CABG
LM disease
3-vessel disease
2-vessel disease with LAD involvement or LVEF < 50%
Indications for PCI in stable angina
- Proximal LAD/LM disease
- FFR < 80
- Stenosis > 90%
- EF < 35% secondary to IHD
- > 10% ischaemia LV
Biomarkers Timeline
Sgarbossa Criteria
- ST elevation 1mm in 2 x concordant leads with positive QRS
- ST depression 1mm in leads V1-3
- ST elevation > 25% S wave in leads with negative QRS complex
Contraindications to Thrombolysis
- BP > 180/100
- Anticoagulation use
- GI/GU bleeding in 4 weeks
- Stroke or TIA within 12 months
- AV malformation
- Recent surgery
- Bleeding diathesis
- Head trauma in 3 months
High Lateral STEMI
Occlusion first diagonal branch LAD
South African Flag sign;
- STE I, AvF, V2
- STD III
Relies on preload and require fluid resuscitation and avoidance of nitrates!
TIMI score - risk stratification NSTEMI
PCI within 24hrs if high risk
PCI within 72 hrs if medium risk
AMERICA
Age > 65
Markers elevated
ECG changes
Risk factors (HTN, FHx, High cholesterol, DM, Smoking)
Ischaemia (2 or more episodes of angina in 24hrs)
CAD with known lesions > 50%
Aspirin within 7 days
Disease association with SCAD
Fibromuscular dysplasia
Becks Triad
Cardiac Tamponade
- Distended Neck Veins
- Muffled Heart Sounds
- Hypotension
Electrical Alternans; 2: 1 ratio of alternating QRS
Pulses Paradoxus; drop in BP > 10mmHg with inspiration
S4
Atrial Gallop caused by left atria contracting against a stiff LV which forces blood through the mitral valve - S4 is produced by the blood striking the non-compliant left ventricle.
Indications MVR in MR
For primary MR
Valve > 0.7cm
Symptomatic
LVEF < 60%
For secondary MR (i.e. RHD)
Must try GDMT -> then can consider MVR
Sokolow Criteria
For LVH
S wave in V1 or V2 > 35mm PLUS R wave in V5 or 6 > 35mm (7 large boxes)
Types of cardiac amyloidosis
Acquired monoclonal immunoglobulin light chain - AL - associated with MM and peri orbital purpura. Rapidly progressive.
Heriditary Transthyretin-related form, mutant type - ATTRm - mutation of transthyretin protein synthesised in liver. Rx Liver transplant. Common in African americas
Non-mutant, wild-type transthyretin-related (senile amyloid)- ATTRwt - wild-type mutation in elderly males with cardiac deposition. Associated with carpal tunnel syndrome.
Types of AF
Paroxysmal AF - 48 hours to 7 days
Persistent - > 7 days, or requires cardio version to terminate
Permanent - when no further attempts made to achieve sinus rhythm
Dabigatran (Pradaxa)
- Absorbed as a pro-drug
- Direct Thrombin inhibitor
- Reversed by Idarucizumab (Praxbind)
- Absorbed and re-absorbed in gut by p-glycoprotein -> drugs that inhibit P-glycoprotein will increase plasma concentrations
- 85% renally excreted (contraindicated in renal impairment)
- High rate dyspepsia
Inhibitors of the P-glycoprotein transporter can increase plasma concentrations
“Azoles”
Protease inhibitors
Macrolides
Calcineurin inhibitiors
Amiodarone
Verapamil
Potentiators of P-glycoprotein will decrease plasma concentrations
Rifampicin
Carbemazepine
Phenytoin
Class 1 indication PPM
- Type 3 AV Block
- Mobitz 1 or 2 with symptoms
- Mobitz type 2 with wide QRS
- Exercise induced second or third degree AV block
Arythmogenic RV dysplasia
Two Major or One Major and two minor
Major criteria
- RV dysfunction
- Fibrofatty infiltrate of tissue
- Epsilon waves
Minor criteria
- Mild RV dysfunction
- TWI V2-3 without RBBB
- Frequent PVCs
- VT with LBBB
Anti-arrythmics
Class 1, work at phase 0
1a - Na+ and K+ channel inhibitors - prolongs action potential and refractory periodn- Moderate Na blocker
1b - Inactive Na+ channel inhibitors - shortens action potential and refractory period - weak Na blocker (lidocaine for VT)
1c - Active Na+ channel inhibitors - No effect on length of action potential - strong Na blocker
Class 2
Beta blockers - work at phase 4 action potential
Class 3
K+ blockers - prolong action potential and refractory period, work at phase 3
Class 4
Non-dihydropyridine - Verapamil and Diltizem, negative inotropic effect, work at stage 2
Treatment of high cholesterol
Statins - inhibit HMG-CoA to reducer endogenous production of cholesterol
Ezetimibe - inhibit NPC1L1 to decrease intestinal reabsorption of cholesterol
Fenofibrates - Activates PPAR-alpha - to increase synthesis of HDL and induce lipolysis of TAGS
Evolocumab/Alirocumab - PCSK9 inhibitors - inhibit resorption of LDL receptor on liver surface to increase LDL uptake
Non-cyanotic Congenital heart disease
- ASD with epsteins anomaly - large RA with displaced tricuspid valve and small RV leading to arrhythmias and commonly WPW. Most common ASD is Secondum - can be treated percutaneous. Others require surgery (Ovale, Venosus, Coronary sinus)
- VSD
- Patent Ductus arteriosus - leads to LVH and infantile heart failure
- Pulmonary stenosis - Williams syndrome - growth retardation, star pattern in eyes, widely spaced teeth.
Noonans syndrome - short stature, distinctive facial features, postpartum oedematous limbs, Rash, developmemental delay - Aortic stenosis/coarctation aorta - requires Ross procedure
Cyanotic Heart disease
- Tetrology of Fallot; RV hypertrophy, VSD, Overarching Aorta, Pulmonary stenosis
- Translocation of Great Arteries; TGA-D, Aorta from RV - not compatible with life unless coexisting PDA or PFO, TGA-L - complete translocation of ventricles with VSD - requires Fontan procedure - bypass right side of heart and SVC drains into pulmonary artery
