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CP3 Medicine > Cardiology p2 > Flashcards

Cardiology p2 Flashcards

1
Q

What is congestive cardiac failure?

A

Structural/functional disorder affecting ability to function as a pump

Either caused by impaired left ventricular contraction (“systolic heart failure”) or left ventricular relaxation (“diastolic heart failure”). This impaired left ventricular function results in a chronic back-pressure of blood trying to flow into and through the left side of the heart

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2
Q

What is cardiac output made up of?

A

pre-load
afterload
myocardial contractility

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3
Q

What adaptations occur to the heart in CCF?

A

Decreased CO: activation of SNS and RAAS

RAAS leads to vasoconstriction and increased water and sodium retention. increases BP and cardiac work

SNS leads to myocyte apoptosis and necrosis

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4
Q

What are the causes of CCF commonly?

A

Ischaemic Heart Disease
Valvular Heart Disease (commonly aortic stenosis)
Hypertension
Arrhythmias (commonly atrial fibrillation)

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5
Q

What are the more rare causes of CCF?

A 
congenital heart disease
Cor pulmonale
Alcohol/drugs
AF
Heart block
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6
Q

What is the most common cause of RHF?

A

LHF

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7
Q

What is the presentation of LHF?

A

fatigue
exertional dyspnoea
paroxysmal nocturnal dyspnoea
orthopnoea

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8
Q

What are the examination findings of LHF?

A

Cardiomegaly + displaced apex beat

3rd heart sound, gallop rhythm
bi-basal coarse crackles

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9
Q

What is the presentation of RHF?

A

breathless
fatigue
anorexia
swollen ankles

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10
Q

What are the signs of RHF?

A 
Increased JVP
Splenomegaly
Pitting oedema 
Pleural effusion
Cardiomegaly/gallop rhythm
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11
Q

What investigations would you do for CCF?

A

Bloods - FBC, U+E, LFT, TFT, cardiac enzymes

BNP: normal excludes heart failure

CXR: cardiomegaly and pulmonary oedema

ECG: ischaemia, HTN or arrhythmia

Ejection fraction <45% is diagnostic

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12
Q

What further investigations can be done for CCF?

A

Cardiac MRI, cardiac catheter (measure pressure) or functional testing

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13
Q

What is the NYHA classification?

A

I - disease present, no undue dyspnoea from normal activity

II - dyspnoea present, on ordinary activities

III - less than ordinary activity causes dyspnoea which is limiting

IV - dyspnoea at rest, any activity causes discomfort

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14
Q

What is the management of LV failure?

A

Lifestyle:
vaccines
stop smoking
exercise as tolerated

Medical:
ABAL:
A:ACE inhibitor: Ramipril (titrated to 10mg o.d)
B: Beta blocker: bisoprolol titrated to 10mg o.d.)
A: Aldosterone receptor antagonist
L: Loop diuretic (furosemide 40mg) for symptoms

Third line: digoxin

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15
Q

What are the lifestyle measures for CCF?

A

Obesity control and diet (decrease salt and fluid intake)
stop smoking
physical activity
vaccination (pneumococcal vaccine)
Sex - don’t take viagra (causes hypotension)

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16
Q

What ACEis should be given for CCF?

A

ramipril, lisinopril
low dose and titrate up to 10mg once a day
don’t use with NSAIDs (renal damage)

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17
Q

What are the Side effects of ACEi?

A

Dry cough (give candesartan 32mg if this is the case)

Renal side effects so monitor U+Es

First dose hypotension - give at night

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18
Q

Which diuretics are used in CCF?

A

thiazides - bendroflumethiazide

Loop - furosemide

both can cause hypokalaemia

Spironolactone (potassium sparing)

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19
Q

What is digoxin?

A

+ve inotrope and -ve chronotrope SO increases force and decreases heart rate

Inhibits Na/K pump and leads to Na+ accumulation
contra-indicated in heart block and bradycardia

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20
Q

What are the causes of valvular heart disease?

A

Degenerative
Rheumatic fever
Congenital
Ischaemic

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21
Q

Describe how infection causes valvular heart disease?

A 
Immune mediated (rheum)
or direct: bacterial/functional endocarditis

result is:
collagen exposure and thrombus development
post-inflammatory scarring - functional impairment

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22
Q

Which side of the heart is more commonly affected in endocarditis?

A

LH - emboli can affect systemic organs

Mitral valve most commonly affected

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23
Q

What is the most common cause of chronic valve scarring?

A

Rheumatic fever

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24
Q

What is rheumatic fever caused by?

A

Group A B haemolytic streptococci

Antibody production to GAS cross reacts with cardiac antigens causing a self-limiting myocarditis

damage to valves - fibrosis so you get shrunken, fibrotic valves

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25
Q

What congenital causes of valvular disease are there?

A

Congenital bi-cuspid aortic valve - calcification –> aortic stenosis

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26
Q

How does ischaemic cause valvular heart disease?

A

Infarction –> papillary muscle dysfunction leads to mitral regurgitation

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27
Q

What are the causes of aortic stenosis?

A

Calcification of congenital bicuspid valve

rheumatic fever

Senile calcific degeneration

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28
Q

Describe the pathology of aortic stenosis

A

Progressive outflow obstruction leads to LV hypertrophy and angina

risk of sudden cardiac death due to arrhythmias

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29
Q

What are the symptoms of aortic stenosis?

A

syncope, angina and dyspnoea on exercise

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30
Q

What are the signs of aortic stenosis?

A

EJECTION systolic high pitched murmur (aortic region to carotid)

Pulse: small volume, slow rising

BP: narrow pulse pressure

crescendo-decrescendo murmur

31
Q

What are the treatments for aortic stenosis?

A

Valve replacement

percutaneous valvuloplasty

32
Q

What are the causes of mitral regurgitation?

A

idiopathic weakening of the valve with age
Ischaemic heart disease
Infective Endocarditis
Rheumatic Heart Disease
Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome

33
Q

What are the symptoms of mitral regurg?

A

Incompetent mitral valve allows blood to leak back through during systolic contraction of the left ventricle

AF - palpitation
pulmonary HTN - SOB/orthopnoea
Fatigue

34
Q

What are the signs of mitral regurg?

A

pan-systolic, high pitched “whistling” murmur due to high velocity blood flow through the leaky valve. The murmur radiates to left axilla. You may hear a third heart sound

laterally displaced apex beat + systolic thrill

LHF/RHF

35
Q

What is the mx of mitral regurg?

A

treat heart failure
echo
surgery if deteriorate

36
Q

What are the causes of aortic regurg?

A

post inflammatory scarring
infective endocarditis
age-related calcification
dilation of aortic root due to inflammatory disease

Connective tissue disorders such as Ehlers Danlos syndrome or Marfan syndrome

37
Q

What are the symptoms of aortic regurg?

A

asymptomatic until acute left ventricular failure

angina pectoris and dyspnoea

38
Q

What are the signs of aortic regurg?

A

early diastolic, soft murmur. It is also associated with a Corrigan’s pulse (bounding/collapsing pulse)
wide pulse pressure
signs of LVF

39
Q

What are the signs of severe aortic regurg?

A

Quinke’s - pulsation in nail bed
DeMusset - nodding
Durozies - femoral murmur
pistol shot femoral (bang if auscultated)

40
Q

What is the management of aortic regurg?

A

replace valve before significant LV dysfunction

41
Q

What is the cause of mitral stenosis?

A

Rheumatic fever - post inflammatory scarring

Infective endocarditis

42
Q

Describe the pathophysiology of mitral stenosis

A

LA can’t empty
pulmonary HTN
LA dilates and hypertrophies –> AF

Pulmonary HTN: RHF

43
Q

What are the symptoms of MS?

A

pulmonary HTN: SOB and haemoptysis
RHF: fatigue, weakness, limb oedema

AF - palpitation

44
Q

What are the signs of MS?

A 
rumbling MID DIASTOLIC murmur 
Malar flush 
small volume pulse
jugular vein distortion 
left parasternal heave

AF

45
Q

What is the management of MS?

A

Treat AF
Diuretics
Surgery - balloon valvuloplasty + valvotomy

46
Q

What is the cause of pulmonary / tricuspid disease?

A

due to post-inflammatory scarring
rheumatic heart disease
IVDU endocarditis
carcinoid syndrome

47
Q

What are the symptoms of tricuspid disease?

A

symptoms of right heart failure

48
Q

When is tricuspid stenosis heard?

A

MID DIASTOLIC murmur

49
Q

When is tricuspid regurg heard?

A

Pan-systolic

50
Q

When is pulmonary stenosis heard?

A

Ejection systolic

N.B in MCQ if you get a pan systolic murmur LOUDEST on inspiration - pulmonary stenosis

51
Q

When is pulmonary regurg heard?

A

Diastolic murmur

52
Q

How is the right heart catheterised?

A

Peripheral vein: FEMORAL

53
Q

How is the left heart catheterised?

A

Peripheral ARTERY: femoral

54
Q

What is the cause of eisenmenger’s syndrome?

A

Large L-R shunt causes an increase in pulmonary artery pressure

Increased pressure in RHS

RHS>LHS therefore blood flows L-R

55
Q

What are the features of eisenmenger’s syndrome?

A 
Cyanosis 
SOB
Fatigue
Chest pain 
Haemoptysis
56
Q

What are the examination findings of Eisenmenger’s syndrome?

A

RV heave
Clubbing
Cyanosis

57
Q

What re the cause of eisenmenger’s syndrome?

A

VSD

PDA

58
Q

What is the management of Eisenmenger’s syndrome?

A

Heart lung transplant

59
Q

What is infective endocarditis?

A

Infection of the endocardium of the heart

By staph aureus most commonly

60
Q

Who is at risk of infective endocarditis?

A

Patients with a structural abnormality in their heart e..g value disease, replacements of congenital defects

Patients with normal hearts

61
Q

How does Inf Endo occur in structural abnormality?

A

Normal GI/Skin commensal that enter blood trivially

Become enmeshed in platelet aggregates and lead to abnormal proliferation

62
Q

How does inf endo occur in patients with structurally normal hearts?

A

acue
pathogenic organisms that directly invade valve:

IVDU after heart surgery or sepsis

63
Q

What are the RF for infective endocarditis?

A

Previous IE, Rheumatic fever, prosthetic valves, congenital heart defect, IVDU and piercings

64
Q

What is the presentation of infective endocarditis?

A 
FEVER + NEW MURMUR 
micro-haematuria 
splenomegaly 
osler node
splinter haemorrhage 
clubbing
Roth spot - pale areas + haemorrhage on retina 
Janeway lesions
65
Q

What Ix do you do for infective endocarditis?

A

Bloods - FBC, U+E, LFT, CRP, ESR

Blood cultures (3 sets)

Urinalysis ++ protein, microscopic haematuria
ECG
CXR
Transthoracic echo

66
Q

What are the Major criteria on Dukes?

A

+ve blood culture

endocardial involvement on echo

67
Q

What are the minor criteria on Dukes?

A

Predisposition
Fever >38
Vascular/Immunological phenomenon
Culture/echo not enough for major

68
Q

what are the criteria for diagnosis of infective endocarditis?

A

2 x major

1 x major and 3 minor

69
Q

What organisms cause infective endocarditis?

A

staph aureus
strep viridian’s (20%)
strep epidermis (most common post-surgery)

70
Q

Describe the pathology of acute IE?

A

Bacterial proliferation in valve
necrosis of valve tissue
perforation of valve
acute cardiac failure

71
Q

Describe the pathology of subacute IE?

A

infective organisms have decreased virulence

Gradual onset destruction of valves

Stimulation of thrombus formation - systemic embolizaion

72
Q

What are the complication of IE?

A 
systemic emboli
pulmonary abscesses 
valvular incompetence 
CCF
Glomerulonephritis
73
Q

What is the management of IE?

A

Empirial - ben-pen, gentamicin and fluclux

IV for 4 weeks

CP3 Medicine (19 decks)

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