Cardiology Medicine incorrects Flashcards
in people with heart valves, what prophylactic antibiotics are administered before procedures?
oral amoxicillin - before dental or resp procedures
iv vancomycin - if skin and soft tissue infections
patient with new onset AF. transthoracic echo has been done to rule out valvular dysfunction or LV failure as the cause. what is the next best investigation?
serum TSH levels!!!
hyperthyroidism is a trigger!
describe the mechanism of nitrates as anti anginal drugs
systemic vasodilation!!! (not coronary) -> lowers preload and LV end diastolic volume!!!
what is the management of ventricular tachycardia??
- in a pulseless patient?
- pulse but hemodynamically unstable (angina, hypotension, confusion)??
- pulse and stable??
- defibrillation
- dc cardioversion
- amiodarone!!!!. use drugs if stable
AAAAmiodarone is used to treat
Ventricular AAArythmiass
(also used for rhythm control in patients with a fibrillation or left ventricular systolic disfunction)
contrast to stable NARROW complex tachycardias eg AVNRT (a type of SVT) which is treated with adenosine
patients with severe mitral regurgitation (holosystolic murmur at the apex) develop LV overload and dilation with an audible S3 gallop
dypnea on exertion due to reduced cardiac output. may progress to heart failure.
A 32!! year old woman comes in with
shortness of breath, orthopnea, bilateral ankle oedema. S3 on cardiac exam. CXR reveals enlarged cardiac silhoutte and small bilateral effusions. ECG shows non specific st segment changes
what is the diagnosis and what is the most likely cause?
decompensated heart failure and dilated cardiomyopathy ->
Viral myocarditis!!!. most likely cause of HF in young patient.
21 year old. syncope repeatedly
prodrome of warmth!!! lightheadedness, diaphoresis111 nausea.
first episode when blood drawn. others standing in a crowded church
most likely diagnosis?
what would be seen in ecg immediately before the syncopal episode?
if ECG is normal and physical examination is normal, next step in management?
-:> vasovagal syncope -> triggers are pain, anxiety, emotional stress, heat, prolonged standing!!
-> sinus bradycardia and asystole due to sinus arrest
typical prodrome of warmth etc
no further testing needed!!! no eeg needed if no classic seizure symptoms
recurrent episodes -> counsel avoid trigegrs and counter techniques
there is also something caled situational syncope-> cough, micturition, defecating, eating, hair-combing
man with palpitations. high amplitude jugular venous pulsations seen intermittently. ECG revelas regular wide complex tachycardia.
history of MI
what best explains physical findings?
atrioventricular dissociation!!
jugular venous pulsation waveform represents right atrial dynamics. cannon a waves are waves caused by surge in jugular venous pressure occuring due to right atrium contracting against a closed tricuspid valve (atrium and ventricle contracting same time).
waves indicate arythmia involving arioventricular dissociation!! -> eg ventricular tachycardia, complete atrioventricular block
not history of MI is risk factor for VT
young patient with palpitations, dsypnea, 3/6 holoSYSTOLIC murmur that decreases in intensity with squatting and increases with standing and vasalva.
no peripheral edema or jugular venous distention. most likely diagnosis?
where is murmur heard?
why does it increase with standing?
Hypertrophic cardiomyopathy
- Note that HCM is a SYSTOLIC murmur heard at the LEFT STERNAL border
standing -> decreases venous return to heart as blood pools in legs. LV collapses in as volume decreases -> worsening of LV outflow obstruction
describe the steps in peripheral artery disease management
step 1 - stop smoking, aspirin and statin!!! -> important to reduce cardiovascular risk
diabetes/htn control
step 1b - supervised exercise programme
step 2 - cilostazol (preffered to pentoxyfyline)
step 3 - angioplasty with stent
management of acute coronary syndrome (unstable angina, nstemi, stemi)
nitrates -> to reduce ischemia!! (only used if chest pain is actively present)
beta blocker!! -> to reduce myocardial oxygen demand
antiplatelet agents and anticoagulation -> aspirin!!, (P2y12 inhibitors later) heparin!!! to reduce thrombus
NOTE - DOACS eg apixaban not used in ACS
statin -> to stabilze the plaque
NSTEMI or stable angina = coronary angiography!!!
STEMI - PCI, or fibrinolytics if PCI unavailable !!!
37 year old woman with left sided weakness/hemiparises. over 6 months, exertional dyspnea, nocturnal cough and occasional hemoptysis. frequent episodes of palpitations and irregular heartbeat. emigrated from cambodia 2 years ago.
most likely diagnosis?
mitral stenosis!!
stroke from afib in setting of mitral stenosis
patient from a developing country with progressive dsypnea, nocturnal cough and orthopnea, hemoptysis, PND -> suggestive of mitral stenosis due to rhuematic heart disease
MS causes increase in atrial pressure -> increase in pulmonary pressure -> dyspnea symptoms
MS causes left atrial enlargement -> afib
ruling out other things:
pulmonary arterial hypertension does not affect the atrium so afib is not expected
(also note mitral stenosis can be radiation induces in history of lymphoma)
what is the management of uremic pericarditis? (occurs in setting of acute or chronic kidney failure.
rule out cardiac tamponade as 50% of cases accompanied by pericardial effusion. -> then dialysis!!!
patient comes in with popliteal aneurysm. what else do you need to screen/ further management?
ultrasound other leg in popliteal region
AND
abdominal ultraosund to rule out abdominal aorta anuerysm!!!
shortness of breath and dry cough. feeling weak over last coup le days with dyspnea on exertion. elevated bNP. TEMP 37.1
what other signs will most likely be found
S3!
congestive heart failure -> fatigue, dypsnea, elevated BNP
normal body temp ends at 37.2!!
you need to be able to identify paroxysmal sypraventricular tachycardia (SVT) on an ecg
what are the ecg findings?
what is the most common type of PSVT affecting young patients below 40? and what is the mechansim of action of this condition?
NARROW QRS complex tachycardia
-> regular rate helps rule out AFib
AVNRT affects young people -> 2 distinct conduction pathways in the AV node!!!!
chest pain brought on by walking that subsides. htn and hyperlipidemia.
echo shows left atrial dilation and mild concentric left ventricular hypertrophy.
aortic valve is calcified with restricted opening. aortic valve area = 1.6cm
most likely condition?
coronary artery disease!!! = unstable angina
aortic stenosis does not cause symptoms unless valve area is <1 cm so not responsible for chest pain or left ventricular hypertrophy here
LVH most likely due to HTN
what does the S4 sound sound like? it can be heard over the cardiac apex
name a cause of this
name symptoms that can develop?
TEN-nes-see . du du, du du, du du, du-du du
normal finding in elderly patients over 70.
in younger, indicated ventricular wall stiffening such as in LVH which occurs with chronic hypertension!!!!
symptoms
- dyspnea!!! LVH progression -> heart failure with preserved ejection fraction
s4 causes vs s3 heart sound causes
s3 = HF with REDUCED ejection fraction, mitral or aortic regurg, high output states eg thyrotoxicosis
s4 = concenctric LV hypertrophy and HF with preserved ejection fraction!, restrictive cardiomyopathy, acute MI (due to left ventricular stiffening and impaired relaxation due to ischemia)!!
how to distinguish athletes heart from Hypertrophic cardiomopathy?
both cause LVH
unlike HCM, athletes heart does not cause impaired diastolic filling, atrial enlargement or ecg changes
how does sinus sick syndrome present?
bradycardia leading to fatigue dyspnea, syncope
in elderly patients
ecg shows bradycardia with delayed or dropped p waves. but patients may experience a bradycardia-tachycardia syndrome with palpitations/atrial fibrillation
caused by degeneration of sinoatrial node
treat with pacemaker
sharp intense chest pain radiating t neck and scapula. diaphoretic and uncomfortable
early decrescendo diastolic murmur in the upper sternal area
patient is hypotensive
most likely diagnosis?
management after resus?
aortic dissection
transesophageal echo as patient is hypotensive!!!!
if not -> CT angiography of chest!!!
first line management for cocaine induced chest pain?
IV benzodiazepine
what is part of the dual antiplatelet
therapy post MI eg STEMI or NSTEMI?
PY12 inhibitor eg clopidogrel (for 12 months) and aspirin long term!!
post MI, patients also given statin, beta blocker, ace inhibitor or arb to inhibit cardiac remodelling and spirinolactone if evidence of reduced LVEF
different from UK strokeeee management guidlines where aspirin is given for 2 weeks and then clopidogrel long term
patient with exertional shortness of breath, exertional chest pain, and exertional lightheadedness
ecg shows sinus rhythm with LVH
most important next step in diagnosis?
TRANSTHORACIC ECHO!!!
Patient most likely has aortic stenosis
remember SAD - syncope/pressyncope (lightheadedness), angina, dyspnea for aortic stenosis
exercise stress test is used for stable angina butttt if you suspect aortic stenosis, transthoracic echo first!!! as exercise is a contraindication
when would you give a statin in addition to lifestyle modifications for primary prevention of cardiovascular risk?
age >/= 40 with diabetes mellitus
OR
LDL > = 190
or
estimated 10 year CV risk >7.5%
patient on digoxin
now started on amiodarone as well after hospital admision
profound anorexia, nausea, vomiting, weakness
most likely cause?
drug interaction!!
amiodarone can increase serum levels of digoxin and cause digoxin toxicity
digoxin toxcity acute = profound anorexia, nausea and vomiting, abdominal pain, weakness, confusion
chronic toxicity - same neuro findings and visual changes
patient suicide attempt
presents with profound bradycardia, atrioventricular block, hypotension, diffuse wheezing
atropine has not helped
what is the diagnosis?
next step in management
beta blocker toxicity
glucagon counteracts toxicity!!!
decompensated heart failure is a common cause of secondary mitral regurgitation (holosystolic murmur best heard at heart apex)
describe the mechanism behind the mitral regurgitation
left ventricular papillary muscle displacement
increased LVEDV causes impaired valve closure. this resolves/murmur resolves with reduction of LVEDV
*contrast to primary mitral regurg caused by problems with valve
contrast to dynamic left ventricular outflow obstruction which occurs in HOCM which causes crescendo-decrescendo murmur which intensifies/decreases with certain maneuvres
what are the things you check for cardiovascular risk before non cardiac surgery (RCRI points)
- high risk sugery - vascular or intrathoracic
- IHD
- History of congestive HF
- history of stroke or TIA
- Diabetes mellitus treated with INSULIN
- preoperative creatinine > 2
> /= 2 is higher risk so you check functional capacity and if less than 4 METS -> You do a pharmacological!! stress test!!!
premature atrial complexes captured on a patients routine ecg
no symptoms.
next step in management?
advice to limit tobacco and alcohol use!!!!
if symptomatic -> beta blocker therapy
24 hour holter monitor is used to capture intermittent arrhythmias in patients with symptoms eg syncope palpitations -> does not require this as patient is asymptomatic and arrhythmia has already been captured on standard ecg!
ventricular arythmias (premature ventricular contractions, VT and VF) occur frequently with MIs. VF is the most common cause of sudden cardiac death with acute MIs
32 YO man, has palpitations. family history of heart problems.
decrescendo early DIASTOLIC mumur at the LEFT sternal border which increases with leaning forward and holding breath in full expiration
most likely diagnosis?
what are the symptoms of this condition?
BICUSPID AORTIC VALVE!! -> CAUSING (valvular) AORTIC REGURITATION!
valvular aortic regurgitation heard at left sternal border. contrast to aortic regurgitation due to root dilation (seen in marfans, syphliis) which is heard in the classic aortic area!!
note that despite location, aortic regurg is always a decrescendo diastolic murmur.
diastolic murmur in LSB therefore aortic regurgitaiton. constrast SYSTOLIC murmur of HCM in LSB
AR may be asymptomatic or cause palpitations, chest pain, dyspnea
*bicuspid aortic valve can cause valvular AR more commonly or AR due to aortic root dilation
76 year old woman, cancer and has been unable to eat or drink for past few days. blood pressure 80/30. mucous membranes dry. pulse 60 (just normal)
ecg shows no p waves!!! and a sine wave pattern
next step in management?
administer calcium gluconate!!! and insulin
ecg indicates hyperkalemic emergency. progressive changes tall t waves -> loss of p waves -> widened qrs -> sine wave pattern -> asystole
diminished food and water intake _> hypovolemic shock -> severe electrolyte abnormalities so hypernatremia/hypo, hyperkalemia, metabolic acidosis
management of symptomatic HCM?
beta blocker! eg metoprolol!!!
in addition to IV furosemide for acute heart failure, what should be used if uncontrolled HTN is present?
nitroprusside, a vasodilator
what causes poor renal function/cardiorenal syndrome in acute heart failure?
how does iV furosemide help?
back pressure from failing heart. increased central venous and renal venous pressure so theres no gradient and eggr decreases
furosemide decreases renal venous pressure
PCI involves cardiac catheterization!!
what anatomic site does atrial fibrillation origiinate?
pulmonary veins
after adminstration of a statin which is first line for hypertryglyceride. next step in managament?
limit alcohol intake!!!!!
omega fatty acids also help
54 YO man, shortness of breath and abdominal distention. treated for hodgkins lymphoma with radiation and chemo 18 years ago. JCP 9 cm above sternal angle, abdomen distended iwth fluid wave, liver 5 cm below costal margin. bilateral pitting edema
most likley cause of patients condition?
inelastic pericardium -> constrictive pericarditis!!!
patient presents with right heart failure signs, most likely due to constrictive pericarditis
mediastinal radiation = risk factor for constrictive pericarditis!!!
others include:
tuberculosis!!!
viral pericarditis
cardiac surgery
management of first degree AV block?
benign finding -> observation only
which class of antihypertensives is associated with weight gain and impaired glucose control?
beta blockers - conventional ones eg metoprolol, atenolol, propanolol
increased risk of T2DM
atrial fibrillation with a high pulse rate>100 can cause tachycardia induced cardiomyopathy, this is reversible with rate and rhythm control
which extra heart sound can be heard in an MI and why?
S4 - left ventricular stiffening and impaired relaxation due to ischemia
diastolic and continuous murmurs require workup with echo. mid systolic murmur in a young asymptomatic adult is typically benign and does not require further workup
statins are used in patients with established ASCVD as is aspirin.
However, aspirin is not used in patients with a high ASCD risk eg 10.5% without evidence of ASCD. only statins are used here. unless patients are over 50 where aspirins may be used too
learn st segment elevations and what the occluded artery will be
patient with acute heart failure. resp rate is 30/min (tachypnea as more than 20 breaths per minute) and there is accessory muscle use. next step in management?
non invasive positive pressure ventilation!!! = BIPAP
patient is experiencing respiratory failure due to HF
patient with a fibrillation. becomes unresponsive. no pulses. cardiac monitor still shows a fib at same rate. next step in management?
chest compressions!!
patient has pulseless electrical activity/PEA. ie no pulse but organized cardiac activity (bradycardia, afib).
managed by chest compressions + identification and treatment of cause. can progress to asystole which is treated the same
CONTRAST to patients with
Pulselessness VT OR VF which are treated with defibrillation.
