Cardiology mushkies Flashcards
1
Q
Midline sternotomy + metallic click
A
Mechanical valve
2
Q
Midline sternotomy + murmur?
A
Tissue Valve or Valvotomy
3
Q
Midline sternotomy + vein harvest on legs?
A
CABG
4
Q
Midline sternotomy + old scar + young pt?
A
Repair of congenital defect
5
Q
Midline sternotomy + immunosuppression?
A
Heart transplant
6
Q
Midline sternotomy + nothing?
A
- Trauma = tamponade, aortic
- IMA CABG
- Tissue valve
7
Q
If you see a midline sternotomy what other things should you be looking for?
A
- Metallic click
- Murmur
- Vein harvest on legs
8
Q
What are the cardiac causes of clubbing?
A
- Infective endocarditis
- Congenital cyanotic heart disease
- Atrial myxoma
9
Q
What are 2 examples of congenital cyanotic heart disease?
A
- Tetralogy of Fallot
2. Transposition of the Great Arteries
10
Q
What is the tetralogy of Fallot?
A
- VSD
- Pulmonary stenosis
- RVH
- Overriding aorta
11
Q
What complex are atrial myxomas associated with?
A
Carney Complex = LAMES Lentigines Atrial Myxomas Endocrine tumours Schwannomas
12
Q
What are the causes of a collapsing pulse?
A
A collapsing pulse is caused by hyperdynamic circulation
- Aortic Regurgitation
- Thyrotoxicosis
- Pregnancy
- Anaemia
13
Q
What are the causes of an impalpable apex beat?
A
COPD
- COPD
- Obesity
- Pericardial effusion
- Dextrocardia
14
Q
What are 5 features of pulmonary HTN (and thus also RHF)?
A
- Raised JVP
- Left parasternal heave
- Loud P2 + PSM of TR
- Pulsatile hepatomegaly
- Ascites and peripheral oedema
15
Q
What is S1?
A
Mitral valve closure
16
Q
What is S2?
A
Aortic valve closure
17
Q
What is S3?
A
Rapid ventricular filling of dilated left ventricle
18
Q
What is S4?
A
Atrial contraction against stiff ventricle
19
Q
What must you do upon completion of a cardio exam?
A
- Observation chart
- Drug chart
- 12-lead ECG
20
Q
What is S4?
A
Atrial contraction against stiff ventricle
21
Q
What must you do upon completion of a cardio exam?
A
- Observation chart
- Drug chart
- 12-lead ECG
22
Q
What are the general principles of cardio management?
A
- General = MDT, Optimise CV risk (statins, anti-HTN, DM, anti-platelets), Monitor (regular f/u and echo)
- Specific
- Surgical
23
Q
Who is part of the cardio MDT?
A
GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses
24
Q
What are the 2 pulse characteristics in aortic stenosis?
A
- Slow rising (anacrotic)
2. Narrow pulse pressure (<30mmHg)
25
What murmur do you hear in aortic stenosis?
An ejection systolic murmur in the right 2nd ICS that radiates to the carotids and is accentuated when sitting forward in end-expiration
26
What are the 3 common causes of aortic stenosis?
1. Age related calcification
2. Bicuspid aortic valve
3. Rheumatic heart disease
27
What are the precordial findings in aortic stenosis?
1. Apex = forceful, non-displaced (pressure overload)
2. Heart sounds = quiet A2
3. Murmur = An ejection systolic murmur in the right 2nd ICS that radiates to the carotids and is accentuated when sitting forward in end-expiration
28
What are the echo features of severe aortic stenosis?
1. Valve area <1cm²
2. Pressure gradient >40mmHg
3. Jet velocity >4m/s
29
What is the management for Aortic stenosis?
1. General = MDT, optimise CV risk, monitor
2. Specific = TAVI, balloon valvuloplasty
3. Surgical = Valve replacement +/- CABG
30
What are the indications for surgical management of aortic stenosis?
1. Symptomatic AS
2. Severe asymptomatic AS with reduced EF (<50%)
3. Severe AS undergoing CABG or other valve op
31
How can you classify the causes of a raised troponin?
ACS related and Non-ACS related
32
What are the ACS-related causes of a raised troponin?
1. Acute MI
2. Post-PCI
3. Open heart surgery
33
What are the non-ACS causes of a raised troponin?
Playboy CARRTIIS
Strenuous exercise/endurance athletes
Cardiovascular = Pericarditis/Myocarditis, Aortic Dissection, Acute HF/Chronic HF
Respiratory = PE
Renal = ESRF
Trauma = Blunt chest wall trauma
Iatrogenic = Cardiotoxic chemotherapy, Cardioversion
Inflammatory = Cardiac infiltrative disorders (amyloidosis)
Systemic = sepsis, rhadbomyolysis
34
How can you classify the causes of a raised D-dimer?
Pathological and Non-Pathological
35
What are the non-ACS causes of a raised troponin?
Playboy CaRRTIIS
Strenuous exercise/endurance athletes
Cardiovascular = Pericarditis/Myocarditis, Aortic Dissection, Acute HF/Chronic HF
Respiratory = PE
Renal = ESRF
Trauma = Blunt chest wall trauma
Iatrogenic = Cardiotoxic chemotherapy, Cardioversion
Inflammatory = Cardiac infiltrative disorders (amyloidosis)
Systemic = sepsis, rhadbomyolysis
36
What are the non-pathological causes of a raised D-dimer?
1. Age > 70y/o
2. Cigarette smoking
3. Functional impairment
4. Postoperative
5. Pregnancy
6. Race (black people)
37
What are the pathological causes of a raised D-dimer?
```
Cardiac = ACS, AF, CCF, intracardiac thrombus
Vascular = Acute limb ischaemia, ATE/VTE
Respiratory = PE
Renal = AKI, CKD, nephrotic syndrome
Iatrogenic = anticoagulants, thrombolytics
Systemic = DIC, SIRS, surgery, trauma
Pregnancy = eclampsia/pre-eclampsia
Infection
Malignancy
Hepatic
Haem = sickle cell anaemia
Neuro = stroke
GI = upper GI bleed
```
38
What are the precordial findings for mitral regurgitation?
1. Apex = displaced
2. HS = Soft S1, S2 not heard separately from murmur +/- loud P2
3. Murmur = blowing pan systolic murmur loudest at the apex in the left lateral position in end expiration, radiates to the axilla
39
What are the causes of mitral regurgitation?
1. Functional = LV dilatation 2° to HTN/IHD
2. Primary = Infective endocarditis, rheumatic valve disease, degenerative valve disease (Barlow's disease and FED)
3. Congenital causes and cardiomyopathies
40
What are the investigations for the cardio exam?
```
Bedside = ECG
Bloods = FBC, U&E, NT-proBNP, lipids, glucose
Imaging = CXR, Echo + Doppler, Cardiac Catheterisation
```
41
What is the management for mitral regurgitation?
```
General = MDT, optimise CV risk, monitor
Specific = AF (rate control and anticoagulate), emboli (anticoagulate), reduce afterload (ACEi/BB and Diuretics)
Surgical = valve replacement or repair
```
42
What is the prognosis of mitral regurgitation?
1. Often asymptomatic for >10 yrs
| 2. Symptomatic = 25% mortality at 5 years
43
What are the 7 eponymous signs associated with Aortic regurgitation?
1. Quincke's = capillary pulsation in nail beds
2. Corrigan's = visible rigorous carotid pulsation
3. De Musset's = head nodding
4. Traube's = pistol-shot sound over femorals
5. Duroziez's = systolic murmur over the femoral artery with proximal compression and diastolic murmur with distal compression
6. Mueller's = systolic pulsations of the uvula
7. Rosenbach's = systolic pulsations of the liver
44
What are the pulse characteristics of aortic regurgitation?
1. Collapsing pulse
| 2. Wide pulse pressure e.g. 180/45
45
What are the precordial findings of aortic regurgitation?
1. Aortic thrill
2. Apex = displaced (volume overload)
3. Heart sounds = soft S2 +/- S3
4. Murmur = high pitched end diastolic murmur loudest at LLSE when sitting forward in end expiration
46
What are the additional murmurs that may be heard in aortic regurgitation?
1. Ejection systolic flow murmur
2. Austin-Flint murmur = rumbling mid diastolic murmur at apex secondary to a regurgitant jet fluttering the anterior mitral valve
47
How can you classify the causes of aortic regurgitation?
Acute vs. Chronic
48
What are the acute causes of aortic regurgitation?
1. Infective endocarditis
| 2. Type A Aortic Dissection
49
What are the chronic causes of aortic regurgitation?
1. Bicuspid aortic valve
2. Rheumatic heart disease
3. Autoimmune = ankylosing spondylitis, RA
4. Connective tissue = Marfan's, Ehler's Danlos
50
What is the management of aortic regurgitation?
1. General = MDT, optimise CV risk, monitor
2. Specific = reduce afterload (ACEi/BB and Diuretics)
3. Surgical = aim to replace the valve before significant LV dilation and dysfunction
51
Which valvular diseases may result in AF on pulse examination?
Mitral regurgitation and Mitral stenosis
52
What are the precordial findings of mitral stenosis?
1. Left parasternal heave
2. Apex = tapping (palpable S1), non-displaced
3. HS = loud S1, early diastolic opening snap
4. Murmur = rumbling mid-diastolic murmur at apex LLP in end expiration with the bell, radiates to the axilla, pre-systolic accentuation if pt in sinus rhythm
53
What additional murmur may be heard in mitral stenosis?
1. Graham Steele murmur = end-diastolic murmur due to pulmonary regurgitation
54
What are the causes of mitral stenosis?
1. Rheumatic heart disease
| 2. Other causes are rare = prosthetic valve, congenital
55
What is the management of mitral stenosis?
1. General = MDT, optimise CV risk risk, monitor
2. Specific = Rheumatic fever prophylaxis (e.g. Pen V), AF (rate control and anticoagulate), diuretics provide symptom relief
3. Surgical = indicated in moderate-severe MS, percutaneous balloon valvuloplasty is treatment of choice, otherwise surgical valvotomy/commissurotomy or valve replacement
56
What is rheumatic fever?
An antibody-mediated type II hypersensitivity reaction due to cross-reaction following an S.pyogenes infection, with antibodies cross-reacting with myosin, muscle glycogen and smooth muscle cells
57
How is rheumatic fever diagnosed?
Revised Jones criteria
1. Evidence of GAS infection +
a. 2 major criteria or
b. major and 2 minor criteria
58
What are the major criteria for rheumatic fever?
```
CASES
Pancarditis
Arthritis
Sydenham's Chorea
Erythema Marginatum
Subcutaneous Nodules
```
59
What are the minor criteria for rheumatic fever?
FEAPP
Fever
ESR or CRP raised
Arthralgia (not if arthritis is a major)
Prolonged PR interval (not if carditis is a major)
Previous rheumatic fever
60
What are the investigations for rheumatic fever?
ECG
Bloods = FBC, ESR, ASOT
Echo
61
What is the management of rheumatic fever?
1. Bed rest until CRP normal for 2 weeks
2. Analgesia for carditis/arthritis = aspirin/NSAIDS
3. Benpen 0.6-1.2mg IM for 10 days
4. Add oral prednisolone if CCF/cardiomegaly/3rd degree heart block
5. Chorea = Haloperidol or diazepam
62
What is the prognosis of rheumatic fever?
1. Attacks last around 3m
2. 60% carditis develop chronic rheumatic heart disease
3. Recurrence ppt by further strep infection/pregnancy/OCP
4. Valve disease = regurgitation --> stenosis
63
Which valves are affected by rheumatic fever?
1. Mitral = 70%
2. Aortic = 40%
3. Tricuspid = 10%
4. Pulmonary = 2%
64
What is secondary prophylaxis for rheumatic fever?
Pen V 250mg/12h PO for 5-10yrs
65
What are risk factors for acute endocarditis?
1. IVDU
2. Skin wounds
3. Immunosuppression
66
What organisms cause acute endocarditis?
S. aureus and S. epidermidis
67
What are risk factors for subacute endocarditis?
1. Prosthetic valves
| 2. Valve disease
68
What organisms cause subacute endocarditis?
S. viridans and S. bovis
| HACEK --> culture negative IE
69
What are the HACEK organisms?
The HACEK organisms are a group of fastidious gram-negative bacteria that are an unusual cause of infective endocarditis
Haemophilus e.g. influenzae/para/haemolyticus/para
Aggregatibacter e.g. aphrophilus
Cardiobacterium e.g. hominis
Eikenella e.g. corrodens
Kingella e.g. kingae
70
What are the clinical features of infective endocarditis?
1. Hands x4 = clubbing, splinters, Janeway lesions, Oslers nodes
2. Other x5 = fever, Roth spots, splenomegaly, haematuria, anaemia
3. Cardiac = new/changing murmur, MR (85%), AR (55%)
71
How do you diagnosis infective endocarditis?
Duke Criteria = 2 major OR 1 major + 3 minor OR 5 minor
72
What are the major Duke Criteria?
1. +ive blood culture = typical organism in 2 separate cultures OR persistent positive blood cultures taken >12h apart OR 3 or more positive cultures taken over 12hr
2. Endocardial involvement = positive echo findings of of vegetations OR new valvular regurgitation
73
What are the minor Duke Criteria x5?
1. Predisposition = heart condition/IVDU
2. Fever = >38C
3. Vascular phenomena e.g. splinters/Janeway
4. Immunologic phenomena e.g. GN/Oslers
5. Blood culture growing organism but doesnt fulfil major criteria
74
What do you see on histology of rheumatic fever?
Aschoff bodies and Anitschkow myocytes
75
Is Abx prophylaxis to solely prevent IE recommended?
No
76
What is the empiric management of infective endocarditis?
1. Acute severe = fluclox/vanc + gent IV
| 2. Subacute = benpen + gent IV
77
What are the 2 main questions to task when examining a pt with a valve replacement?
1. When and where is the closing prosthetic sound?
| 2. Are there any murmurs?
78
How many artificial sounds are there with a Starr-Edwards aortic valve?
3 artificial sounds
79
How many artificial sounds are there with a tilting disc/bileaflet valve?
1 artificial sound
80
What are the sounds like with a biological valve?
Often normal heart sounds
81
What does an artificial aortic valve sound like?
Lub-click
82
What does an artificial mitral valve sound like?
Click-dub
83
What are the types of mechanical heart valves?
1. Ball and cage = Starr-Edwards
2. Tilting disc = Bjork-Shiley
3. Bileaflet = St. Jude (most common)
84
What is the lifespan of a mechanical valve, and what INR are you aiming for?
Approx 20 yrs, INR 3-4
85
What are the types of biological valves?
1. Porcine valve = Carpentier Edwards
| 2. Bovine pericardium sewn into a metal frame = discontinued
86
What are the 4 most common causes of AF?
1. IHD
2. RHD
3. Thyrotoxicosis
4. HTN
87
What are the 'other' causes of AF
1. Pneumonia
2. PE
3. Post-op
4. Hypokalaemia
5. Alcohol
6. RA
88
What is a pulse deficit and what is it a sign of?
A difference in HR between the wrist and apex, found in AF
89
What is the management of acute AF (<48hrs)?
1. Haemodynamically unstable = cardioversion
2. Haemodynamically stable = rate control (diltiazem or metoprolol), start LMWH, cardiovert (DC or medical (flecainide or amiodarone))
90
What is the management of paroxysmal AF (recurrent episodes lasting <7d)?
1. Pill in pocket = flecainide/amiodarone
| 2. Prevention = BB/Sotalol
91
What is persistent AF? How do you manage it?
Lasting >7d
| Rate control or rhythm control
92
What is rate control?
1st line = BB or rate-limiting CCB
| 2nd line = Add digoxin (not monotherapy)
93
What is permanent AF and how do you manage it?
Failed cardioversion/unlikely to succeed --> rate control
94
What are non-medical ways of managing AF?
1. RFA of AVN
2. Maze procedure
3. Pacing
95
What is the CHA2DS2VASc score?
Determines necessity of anticoagulation in AF
96
What are the components of the CHA2DS2VASc score?
1. CCF
2. HTN
3. Age ≥ 75 (2pts)
4. DM
5. Stroke/TIA (2pts)
6. Vascular disease
7. Age 65-74
8. Sex category: female
97
How does one use the CHA2DS2VASc score?
A score ≥ 2 --> anticoagulation with warfarin or NOAC
98
What are the complications of warfarin?
1. Bleeding
| 2. Osteoporosis
99
What are the 6 contraindications of warfarin?
BCR PPP
1. Bleeding diatheses
2. Compliance issues e.g. dosing, monitoring
3. Risk of falls
4. Peptic ulcer disease
5. Pregnancy
6. Pt choice
100
What fruit must one avoid whilst on warfarin?
Grapefruits
101
What must one wear when on warfarin?
A medic alert bracelet
102
What do the letters mean when classifying pacemakers?
1. Pacing = O/A/V/D
2. Sensing = O/A/V/D
3. Action = O/Inhibited/Triggered/Dual
4. Programmability = O/Programmable/Multiprogrammable/Communicating/Rate modulation
5. Anti-tachycardia functions = O/Pacing/Shock/Dual
103
What 3 things should you ask for after examining a pacemaker and why?
1. ECG (look for pacing spikes, evidence of ischaemia)
2. CXR (no. leads, ICD wire (thick lead))
3. Echo (valvular pathology, LV function, structural abnormalities)
104
What are the indications for permanent pacing?
1. Nodal disease = symptomatic bradycardia (SSS), drug-resistant tachyarrhythmia
2. Conduction problems = complete AV block, Mobitz II, symptomatic Mobitz I
3. Assistance = BVP in chronic HF
105
How can you classify the complications of pacemakers?
Insertion and post-insertion
106
What are the complications of inserting pacemakers?
Bleeding and arrhythmias
107
What are the complications post-insertion of pacemakers?
PLEM
1. Erosion
2. Lead malfunction
3. Pocket infection
4. Malfunction
108
What is the definition of HF?
HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.§
109
What are the causes of left sided HF?
1. IHD
2. HTN
3. Mitral/aortic valve disease
4. Idiopathic DCM
110
What are the symptoms of left sided HF?
```
FEPONW
Fatigue
Exertional dyspnoea
PND
Orthopnoea
Nocturnal cough (+/- pink, frothy sputum)
Weight loss and muscle wasting
```
111
What do you call the wheeze you sometimes get with chronic HF?
Cardiac asthma
112
What are the causes of right sided HF?
1. LVF
2. Cor pulmonale
3. Tricuspid/pulmonary valve disease
113
What are the symptoms of RHF?
Anorexia and Nausea
114
What are the signs of RHF?
1. Raised JVP
2. Left parasternal heave
3. Loud P2 + PSM of TR
4. Pulsatile hepatomegaly
5. Ascites and peripheral oedema
115
What are the NYHA classes of HF?
1. No SOB
2. SOB with moderate exertion
3. SOB with mild exertion
4. SOB at rest
116
What are 3 POI about NT-proBNP
1. It is secreted from the ventricles in response to increased stretch and HR
2. Raised levels are the most diagnostic indicator of HF
3. NICE recommends that HF is not dx w/o raised NT-proBNP
117
What is the A-F of chronic HF on CXR?
1. Alveolar shadowing
2. Kerley B lines
3. Cardiomegaly
4. Diversion of upper lobe
5. Effusions
6. Fluid in fissures
118
What may ECG show on HF?
1. Ischaemia
2. Hypertrophy
3. AF/other arrhythmia
119
What is the specific management of chronic HF?
1. Triple therapy with ACEi + BB + Spironolactone
2. Consider digoxin
3. Consider CRt
120
What is the surgical management for chronic HF?
1. LVAD
| 2. Heart transplant
121
Causes of absent radial pulse?
1. Dead
2. Trauma
3. Thrombosis/embolism
4. Coarctation of the aorta
5. Takayasu's arteritis
122
AS Ix?
1. Bedside = ECG (LVH, arrhythmias)
2. Bloods = FBC, U&E, NT-proBNP, lipids, glucose
3. CXR = calcified AV, LVH, pulmonary oedema
4. Echo + doppler = valve area, cause, LV function, other valve function
5. Cardiac catheterisation = valve gradient and assess coronaries
123
5 bloods that you could do for any cardio condition?
1. FBC
2. U&E
3. NT-proBNP
4. Lipids
5. Glucose
124
MR Ix?
1. Bedside = ECG (LVH, arrhythmias, p-mitrale)
2. Bloods = FBC, U&E, NT-proBNP, glucose, lipids
3. CXR = LA and LVH, mitral valve calcification, pulmonary oedema
4. Echo + doppler = severity, LV function, other valve function
5. Cardiac catherisation
125
Prognosis of aortic stenosis?
1. Angina = 50% dead in 5 years
2. Syncope = 50% dead in 3 years
3. Dyspnoea = 50% dead in 2 years
126
AR Ix?
1. ECG = LVH, LV strain, arrhythmias
2. Bloods = FBC, U&E, Nt-proBNP, glucose, lipids
3. CXR = cardiomegaly, pulmonary oedema
4. Echo + doppler = cause, severity, LV function, other valve function
5. Cardiac catherisation = assess coronaries
127
4 reasons to do echo an any cardio valve problem pt?
1. Cause
2. Severity
3. LV function
4. Other valve function
128
Mitral stenosis Ix?
1. ECG = AF, p mitrale
2. Bloods = FBC, U&E, NT-proBNP, glucose, lipids
3. CXR = LA hypertrophy --> splaying of carina, calcified mitral valve, pulmonary oedema
4. Echo + doppler = cause, severity, LV function, other valve function
5. TOE = LA thrombus if intervention is planned
129
Histology of myocardium in rheumatic fever?
Aschoff bodies and Anitschkow mycocytes
130
What kind of murmur will a well seated valve replacement produce?
A soft flow murmur
131
What kind of murmur will a poorly seated valve replacement produce?
Regurgitant murmurs (aortic = diastolic murmur, mitral = systolic murmur)
132
Lifespan of a biological valve?
<10 years, less durable than mechanical
133
Pt groups that would receive a biological valve?
1. Pregnant
2. Old
3. Bleeding risk e.g. peptic ulcer, frequent falls
134
Complications of valve surgery?
1. Complications of surgery = 5% mortality
| 2. Complications of valve
135
Complications of valve after surgery?
FABIT
1. Failure = acute (dehiscence, breakage, thrombus) or chronic (stenosis or incompetence)
2. Anaemia = warfarin and haemolysis
3. Bleeding
4. IE
5. Throboembolism = 1-2% per annum despite warfarin
136
AF Ix?
1. ECG = irregularly irregular, p waves, cause (ischaemia, p mitrale)
2. Bloods = FBC, U&E, TFTs, Troponin, D dimer
3. CXR = Pulmonary oedema, calcified mitral valve, pneumonia
4. Echo = valve pathology, LV function
5. TOE = LA thrombus
6. Cardiac catheterisation
137
2 causes of an irregularly irregular pulse?
1. AF
| 2. Multiple ventricular ectopics
138
How to differentiate b/w AF and MVE as a cause of an irregularly irregular pulse?
Exercise the pt
1. AF = stays irregularly irregular
2. MVE = regular pulse (reduced diastole time closes window for ectopics)
139
Causes of tricuspid regurgitation?
1. Congenital = Ebstein's anomaly
| 2. Acquired = Acute (Infective Endocarditis), Chronic (functional, rheumatic, carcinoid syndrome)
140
What could cause a double right heart border on CXR?
Enlarged RA
141
Mx of Tricuspid regurgitation?
1. Medical = triple therapy and support stocking for oedema
| 2. Surgical = valve repair/annuloplasty if medical tx fails
142
Causes of pulmonary stenosis?
1. Tetralogy of Fallot
2. Noonan's syndrome
3. Functional
4. Carcinoid syndrome
143
Pulmonary stenosis on CXR?
Oligaemic lung fields
144
Mx of pulmonary stenosis?
1. Pulmonary valvotomy
2. Percutaneous pulmonary valve implantation
3. Surgical repair/replacement
145
How does carcinoid syndrome cause pulmonary stenosis?
Secreted mediators cause right sided heart valve fibrosis resulting in stenosis/regurgitation
146
Mx of carcinoid tumour?
1. Medical = octreotide
| 2. Surgical = resection
