Cardiology IV Flashcards
At which stage of pregnancy does peri-partum cardiomyopathy usually occur [1] and go on till? [1]
Which subpopulations of pregnant women usually suffer from peripartum cardiomyopathy? [2]
peri-partum cardiomyopathy:
- last month of pregnancy and 5 months post-partum
- usually older; greater parity and multiple gestations
Name two infective organisms that can cause cardiomyopathy [2]
Coxsackie B virus
Chagas diesease
State an autoimmune disorders that dispose patients to cardiomyopathy [1]
SLE
Explain the clinical consequences of HOCM [5]
Myocardial hypertrophy:
- predominantly in the interventricular septum
- asymmetric septal hypertrophy narrows the left ventricular outflow tract (LVOT).
Diastolic dysfunction:
- Reduced compliance and elevated filling pressures ddue to hypertrophy
LVOT obstruction:
- The interventricular septal hypertrophy, combined with systolic anterior motion (SAM) of the mitral valve, causes dynamic obstruction of the LVOT during systole.
- This increases the pressure gradient across the LVOT, reducing cardiac output and provoking symptoms.
Mitral regurgitation:
- The SAM of the mitral valve contributes to mitral regurgitation by displacing the valve leaflets, exacerbating the hemodynamic abnormalities and worsening heart failure symptoms
Arrhythmogenesis:
- Myocardial disarray, fibrosis, and ischemia increase the risk of ventricular and atrial arrhythmias
- can lead to sudden cardiac death.
Describe the typical signs seen in HOCM patient [7]
Ejection systolic murmur (left ventricular outflow obstruction):
- harsh crescendo-decrescendo shortly after S1 and loudest at the apex and lower left sternal edge
Mid-late systolic murmur (mitral regurgitation):
- occurs at the apex. Depending on the extent of mitral regurgitation and the direction of the jet regurgitating through the mitral valve it may be pansystolic
S4 gallop:
- This can be heard in patients with impaired diastolic function, reflecting atrial contraction against a noncompliant left ventricle.
Heave (visible or palpation pulsation)
Thrill (palpable murmur)
Features of heart failure:
- raised JVP, crackles on lung auscultation, peripheral oedema
Bifid carotid pulse:
- A rapid upstroke followed by a mid-systolic dip may be observed, known as the ‘spike and dome’ pulse.
Increased left ventricular wall thickness ≥[] mm in the absence of any other identifiable cause is consistent with HCM
Increased left ventricular wall thickness ≥15 mm in the absence of any other identifiable cause is consistent with HCM
Describe the medical managment plan for a patient with HOCM used to reduce symptoms and LVOT obstruction [5]
A. Beta blockers
- 1st line: atenolol or propranolol
B. CCBs:
- Verapamil
C. antiarrhythmic agents:
- Disopyramide
D. Diuretics:
- furosemide
- Caution is warranted due to the potential for hypovolemia and exacerbation of LVOT obstruction.
E. Anticoagulation:
- Indicated in patients with atrial fibrillation or a history of thromboembolic events.
Which drug classes should be avoided in HOCM patients? [3]
nitrates
ACE-inhibitors
inotropes
How do you manage arrhythmogenic right ventricular cardiomyopathy? [3]
Management
* drugs: sotalol is the most widely used antiarrhythmic
* catheter ablation to prevent ventricular tachycardia
* implantable cardioverter-defibrillator
Describe the different classifications of Necrotising soft tissue infections (NSTIs) with regards to their infective organisms
Type I:
- polymicrobial: typically mixed anaerobes & aerobes, on average four or more organisms
Type II:
- group A streptococcus (Strep. pyogenes +/- Staph. aureus)
Type III:
- Gram-negative monomicrobial infection.
- Typically associated with Vibrio species infection
Type IV:
- Fungal infection (typically Candida species, zygomycetes).
NSTI:Type 2 is caused by []
PassMed
type 2 is caused by Streptococcus pyogenes
Treatment of gangrene varies depending on location and cause but is centred around radical surgical debridement +/- amputation. Surgical procedures may also include what? [4]
- Removal of embolus or thrombus
- Balloon catheterisation or stent
- Arterial or venous bypass surgery
- Hyperbaric oxygen treatment.
Which of the following is usually caused by trauma, such as a bite?
Type 1
Type 2
Type 3
Type 4
Which of the following is usually caused by trauma, such as a bite?
Type 1
Type 2
Type 3
Type 4
You investigate a patient who is demonstrating signs of CLI.
How do you determine from the vessel affected if this patient needs open surgery or endovascular revascularization? [2]
Open surgery: lesions of common femoral artery and infrapopliteal disease
Endovascular: short segments: aortic iliac disease
What ECG changes would indicate myocarditis [3]
- tachycardia
- Prolonged QRS
- QT prolongation
- Diffuse T wave inversion
Can trigger arrhythmias
What are the potential complications of myocarditis? [2]
Complications
* heart failure
* arrhythmia; frequent premature ventricular complexes, irregular and polymorphic VT, or ventricular fibrillation possibly leading to sudden death
* dilated cardiomyopathy: usually a late complication
What treatment is given to patients with suspected giant cell myocarditis? [1]
In patients with suspected giant cell myocarditis, steroids are recommended and have been shown to improve survival
E.g. methylprednisolone
What are key differences between constrictive pericarditis and cardiac tamponade with regards to: [4]
- JVP
- Pulsus paradoxus
- Kussmauls sign
- Features on CXR
What sign is thought to be is considered to be specific for pericarditis? [1]
- Pain that has radiation to the trapezius ridge
What is Kussmaul’s sign? [1]
Increased jugular venous pressure with inspiration
State the different risk stratifications based of GRACE scores [5]
How do you determine if an NSTEMI patient needs coronary angiography (with follow-on PCI if necessary):
Immediately [1]
Within 72 hours [1]
immediate:
- patient who are clinically unstable (e.g. hypotensive)
within 72 hours:
- patients with a GRACE score > 3% i.e. those at immediate, high or highest risk
coronary angiography should also be considered for patients is ischaemia is subsequently experienced after admission
What drug therapy should be given to patients with NSTEMI undergoing PCI? [2]
unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI:
If the patient is not taking an oral anticoagulant:
- prasugrel or ticagrelor
if taking an oral anticoagulant:
- clopidogrel
Describe the 4 types of MI [4]
Type 1: Traditional MI due to an acute coronary event
Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)
Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
Type 4: MI associated with procedures such as PCI, coronary stenting and CABG
NB: Type 1 MI have better prognosis than Type 2 MIs
Describe what causes T ype 2 MI [1]
Give two examples of Type 2 MI [2]
Troponin leak due to ischaemia due to oxygen supply and demand imbalance.
E.g. Severe HTN & sustained tachy arythmias
MI complications:
What would cause persistent ST elevation without chest pain? [1]
Ventricular aneurysm
Left ventricular free wall rupture
This is seen in around 3% of MIs and occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds). Urgent pericardiocentesis and thoracotomy are required.
How do you differentiate between a posterior and anterior MI on an ECG?
Anterior MI
- ST-segment elevation in the precordial leads V1-V4
Posterior MI
- tall R waves V1-3 PosteRioR contains 2 tall Rs
- Horizontal ST depression in V1-3
How do you confirm a posterior MI? [1]
Posterior infarction is confirmed by ST elevation and Q waves in posterior leads (V7-9)
