Cardiology (Quesmed) Flashcards
1
Q
What are the main causes of Acute Bradycardia?
A
Sinus/ AV Nodal Disease
Drug Induced (Beta Blockers, Calcium Channel Blockers)
Electrolyte Abnormalities- hyperkalaemia and hyponatremia
Hypothyroidism
2
Q
What is the 4 step management of Acute Bradycardia?
What is given if beta blockers are the cause?
A
Assess via DRABCDE
You do NOT need to treat unless symptomatic
Then ECG Monitoring and identify any reversible causes
If any Adverse Features (Heart Failure, Myocardial Ischaemia, Shock, Syncope),
1) Give 500mcg IV Atropine
If these don’t work,
2) Repeat Atropine up to 3mg
3) Transcutaneous Pacemaker can be given while waiting for Transvenous/ Permanent Pacemaker
4) Give Isoprenaline and Adrenaline
Give GLUCAGON if Beta blockers cause the Bradycardia
3
Q
What JVP Waveform is seen in Complete Heart Block?
A
Cannon A waves
4
Q
What is Acute Myocarditis? What are the signs of Acute Myocarditis?
What kinds of heart sounds (S sounds) may be heard?
A
It is an inflammatory disease of the Myocardium
Signs
- FEVER
- Cardiac-type Chest Pain
- Fatigue
- Palpitations
- Symptoms of Heart Failure
- PULMONARY OEDEMA
Suspect in young people with a new onset flu-like illness and chest pain with pulmonary edema
Signs of heart failure may be evident along with S3 and S4 gallops. If Pericarditis is associated, Auscultation can reveal a Pericardial Friction Rub
5
Q
What 5 investigations should be ordered in Acute Myocarditis?
What does the ECHO show in Myocarditis?
What is the gold standard?
A
1) ECG shows ST Elevation and T wave Changes
Ectopic Beats and Arrhythmias may be present
2) Troponin may be elevated
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3) Echocardiogram reveals Ventricular Dysfunction in the form of Diastolic Dysfunction or Regional Wall Motion Abnormalities
4) Cardiac MRI Findings can help confirm the diagnosis of Myocarditis by showing the presence and extent of the Inflammation
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5) Endomyocardial Biopsy via Cardiac Catheterisation is the GOLD STANDARD diagnostic tool. BUT it is INVASIVE so has its own risks
6
Q
What is the management of Myocarditis?
*What should be given for viral myocarditis?
A
Address the Underlying cause- ANTIBIOTICS if bacterial
ITU support may be required as the patients may need VASOPRESSORS
Corticosteroids are sometimes needed if they have Viral Myocarditis
After Recovery- they should limit activity for a few months
7
Q
What is the management of Narrow Complex Tachycardia?
What is done if there are HISS features?
And if there are no HISS features, what is given if it is regular?
If it is irregular, what is given if there was AF in the last 2 days?
And if AF was >2 days ago?
A
1) ABCDE
2) If HISS Features- Synchronised DC Cardioversion is needed- UP TO 3
3) If Haemodynamically Stable
- Regular= Carotid Sinus Massage/ Vagal Manouevre, if it fails then 6mg IV Adenosine, then 12mg, then 18mg
- Irregular=
a) AF within last 2 days- Rhythm Control= LMWH and Flecainide if there is no Structural Heart Disease or Amiodarone if there is Structural Heart Disease
b) > 2 days ago Rate Control= BETA BLOCKERS/ Verapamil, or Digoxin (if Heart Failure) AND Anticoagulation
8
Q
What is Aortic Dissection and what are the 4 risk factors for it?
A
A tear in the Tunica Intima causes blood to flow between the Inner and Outer Walls of the Aorta
Risk Factors-
- Hypertension
- Connective Tissue Disorder (Marfan’s- Tall with Pectus Excavatum)
- Valvular Heart Disease
- Cocaine/ Amphetamine Use
9
Q
What are the 2 types of Aortic Dissection?
A
Type A- Ascending Aorta
Type B- Descending Aorta
10
Q
What are the signs of Aortic Dissection?
A
Usually Men over 50 years old
Sudden, Tearing Interscapular Pain Radiating to the back- in the CHEST or UPPER BACK
WEAK or ABSENT PULSE
Can also present with (depending on how far the Dissection Extends):
- Limb/ Bowel Ischaemia
- Renal Failure
- Syncope
1) Radio-radial Delay (Ascending)
2) Radio-Femoral Delay (Descending)
3) Blood Pressure Differences between Arms
11
Q
What investigations should be ordered in Aortic Dissection?
What is seen on CT?
What is seen in Echocardiography?
What is seen on Chest Xray and ECG?
What is diagnostic?
A
The following sings MAY or MAY NOT be there:
1) Diagnostic- CT, if not Trans-Oesophageal Echocardiography (TOE)- FALSE LUMEN IS SEEN
2) ECG- Ischaemia in Specific Territories if Dissection extends into the Coronary Arteries- mainly INFERIOR RCA
3) Echocardiography- Pericardial Effusion and Aortic Valve Involvement
4) Chest Xray- Widened Mediastinum
5) Bloods-
- Troponin may be raised
- D-Dimer may be positive
12
Q
What is the Initial and Definitive Management of an Aortic Dissection?
A
1) Resuscitation
2) Cardiac Monitoring
3) Strict Blood Pressure Control (IV Metoprolol/ Labetalol) and Opioid Analgesia
Definitive
- Type A- Surgical Management= Aortic Graft
- Type B- Conservatively with Blood Pressure Control UNLESS there is End-Organ Damage, then Surgery may be performed
13
Q
What are the Complications of Aortic Dissection?
A
- Death due to Internal Haemorrhage
- Rupture
- End-Organ Damage (Renal or Cardiac Failure)
- Cardiac Tamponade
- Stroke
- Limb Ischaemia
- Mesenteric Ischaemia
14
Q
What are the 4 AcuteCauses of Aortic Regurgitation?
Which 2 should you remember?
A
1) Infective Endocarditis (destroys and perforates the valve)
2) Aortic Dissection (impedes valve closure)
3) Traumatic Rupture of Valve Leaflets (blunt chest trauma or deceleration injury)
4) Iatrogenic Causes- Balloon Valvotomy or TAVI
Most Common Causes- Infective Endocarditis and Aortic Dissection
Valve Replacements can be complicated by Aortic Regurgitation- leading to the degeneration of a tissue valve or thrombosis of a mechanical one
15
Q
What are the Chronic Causes of Aortic Regurgitation?
What are the 2 main causes and the different causes of these causes?
What is the most common cause in the developing and developed world of Aortic Regurgitation?
A
Valve Disease or Aortic Root Dilatation
Valve Disease
1) Calcific Aortic Valve Disease (Age Related)
2) Myxomatous Degeneration
3) Congenital Disease (Bicuspid Aortic Vale)
4) Rheumatic Heart Disease (Most Common in the Developing World)
5) Infective Endocarditis
6) Rheumatic Causes (Rheumatoid Arthritis, Antiphospholipid Syndrome)
Aortic Root Dilatation
1) Congenital Bicuspid Aortic Valve
2) Genetic Cause- Marfan’s, Ehler’s Danlos
3) Systemic Vasculitides- Giant Cell Arteritis
16
Q
What are the signs of Acute Aortic Regurgitation?
A
Sudden Cardiovascular Collapse
Pulmonary Oedema
Pallor
Sweating
Peripheral Vasoconstriction
17
Q
What are the signs of Chronic Aortic Regurgitation?
If it is severe enough, what can it lead to?
A
(Usually Asymptomatic for years and then Insidious Presentation)
The Pulmonary Heart Failure Signs
Exertional Dyspnoea
Orthopnoea
Paroxysmal Nocturnal Dyspnoea
If Severe Enough, can lead to Stable Angina even if there are no Coronary Artery Diseases present. This is due to a reduction in diastolic Coronary Perfusion
18
Q
What are the Examination Findings of Aortic Regurgitation?
What are De Musset’s and Quinke’s signs?
What kind of heart sounds are heard- S sounds?
What is the pulse pressure like?
What investigations should be ordered? What is definitive?
A
Waterhammer Pulse
De Musset’s Sign- bobbing of Head
Quincke’s Sign- Pulsation of Nail Beds
Traube’s Sign- Pistol Shots heard in Femoral Pulse
Muller’s Sign- bobbing of Uvula
Widened Pulse Pressure due to LOW DIASTOLIC PRESSURE
Early Diastolic Murmur- Heard best when patient is leaning forward and exhaling
Soft S1 and occasionally an Ejection Flow Murmur
Imaging-
- DEFINITIVE Echocardiogram
- Cardiac MRI if Echo isn’t enough
- Invasive Cardiac Catheterisation and Angiography once Non-Invasive tests are inconclusive
19
Q
~~~~
What is the management of Aortic Regurgitation?
What 5 things indicate a TAVI/ surgery?
A
Medical-
- Beta Blockers AND/OR Losartan- to slow Aortic Dilatation
- If Severe and Asymptomatic, monitor them yearly
Surgical (Surgical Replacement) TAVI unless they are too weak to tolerate the Surgery)
- Indicated if:
1) Significant Enlargement of Ascending Aorta
2) Symptomatic Aortic Regurgitation
3) Asymptomatic Aortic Regurgitation WITH:
- Poor LVEF (<50%)
- Left Ventricular End Diastolic Diameter>70 or Left Ventricular End Systolic Diameter> 50 (S50, D70)
- Infective Endocarditis doesn’t get helped by Medical Therapy
20
Q
What are the signs of Aortic Stenosis?
What is the pulse pressure?
What is the carotid pulse like?
What is the apex beat like?
What are the Heart Sounds (S sounds) like in Aortic Stenosis?
A
(End Stage)
1) Heart Failure
2) Angina
3) Syncope
4) Exertional Dyspnoea and Reduced Exercise Tolerance
5) SLOW RISING Carotid Pulse
6) Narrow Pulse Pressure
7) Heaving, Non-displaced Apex Beat
- ABSENT S2
- S4 if SEVERE
EVEN NUMBER HEART SOUNDS affected in Aortic Stenosis
8) Ejection Systolic Murmur (heard best at second intercostal space at the right)- Harsh sound transmitted to the Carotids
9) Ejection Click may be heard
21
Q
~~~~~~~
What are the Investigation Findings for Aortic Stenosis?
These MAY be seen or may not be seen so don’t worry too much
What is a sign of severity that warrants surgery?
A
1) ECG- Left Ventricular Hypertrophy MAY be seen
- Sokolov-Lyon- S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
- Left Axis Deviation
- Poor R Wave Progression
2) CXR
- Cardiomegaly or Calcified Aortic Valve MAY be there
3) Echocardiogram
- MAIN TEST for DIAGNOSIS
- Severe if:
- Peak Gradient> 40- SURGERY IF THIS IS THE CASE
- Valve Area<1
- Aortic Jet Velocity>4
Exercise Testing to assess Severity
Cardiac MRI to assess Severity
22
Q
What are the 5 indications for Intervention in Aortic Stenosis?
2 are also indications for Aortic Regurgitation Surgery
What about the BNP?
Also something about the BLOOD PRESSURE in Aortic Stenosis??
A
1) Symptomatic
2) Asymptomatic with LVEF<50%
3) Asymptomatic with LVEF>50% but BP falls during exercise (EXERCISE TOLERANCE)
4) High BNP/ Severe Calcification
5) Peak gradient >40
23
Q
What is the management of Aortic Stenosis?
A
TAVI or Surgical Aortic Valve Replacement
1) Surgery is preferred if Low Risk and <75 years old
2) TAVI is preferred if High Risk (previous heart surgery, frail, restricted mobility) or >75 years old
24
Q
How is Aortic Stenosis treated if they can not have the TAVI or Surgical Replacement?
YOU ONLY NEED TO MANAGE IF THEY ARE SYMPTOMATIC or GRADIENT>40- otherwise just observe them for Aortic Stenosis
A
Heart Failure Treatment- ACE Inhibitors, Beta Blockers, Diuretics
They should be checked on every 6 months
25
What is Aortic Sclerosis?
An Asymptomatic Condition caused by Senile Degeneration of the Valve causing IRREGULAR VALVE THICKENING and FOCAL INCREASED ECHOGENICITY
_ONLY EJECTION SYSTOLIC MURMUR- nothing else is there_
- Ejection Systolic Murmur that _does NOT radiate to the valves_
- Normal S2- (Absent in Aortic Stenosis)
- Normal Pulse Character- is NOT Slow Rising and does NOT have Narrow Pulse Pressure
- Peak DOPPLER VELOCITIES are normal (raised in Aortic Stenosis)
26
What is Atrial Flutter?
It is when the MacroCircuit within the _Right Atrium_ becomes Aberrant (deviates from the norm)
This activates the AV Node but because this node has a long refractory period it is not able to conduct the impulses down the His-Purkinje System at such a fast rate
Instead there is a degree of block meaning that only 2:1 (2 p waves per 1 QRS complex), 3:1, 4:1 or rarely 5:1 AV Blocks are conducted to the ventricle
27
What are the causes of Atrial Flutter?
*COPP ATICS
Pulmonary Disease
1) COPD
2) Obstructive Sleep Apnoea
3) _Pulmonary Emboli_
4) Pulmonary Hypertension
Other causes
1) Alcohol
2) Thyrotoxicosis
3) Ischaemic Heart Disease
4) _Cardiomyopathy_
5) Sepsis
28
What are the symptoms of Atrial Flutter?
Asymptomatic
Palpitations
Dizziness
_Chest Pain_
29
What are the ECG signs of Atrial Flutter?
What is the HR of a 2:1 Atrial Flutter?
What is the rhythm (regular/ irregular)? What are the QRS complexes like in Atrial Flutter?
_Regular Rhythm_
Sawtooth Baseline with Repetition at 300bpm (these are atrial flutter waves)
_NARROW QRS Complexes_
Ventricular Rates which depends on the level of AV Block
- _150bpm if 2:1_
- 100bpm if 3:1
- 75bpm if 4:1
- 60bpm if 5:1
Sometimes they may have variable block which makes the rhythm irregular and can make it look like AF
30
What is the management of Atrial Flutter?
What should be done in septic or dehydrated Atrial Flutter patients which will also fix the Atrial Flutter?
What is the first line? What should be done if this fails? (remember it is similar to Atrial Fibrillation)
_What is usually curative_?
Similar to AF- so doesn't really matter if you successfully differentiate them
Haemodynamic Stable-
- *Fluid Resuscitation* in Septic or Dehydrated Patients can reverse Atrial Flutter into Sinus Rhythm
1) RATE CONTROL- _Beta Blocker or Calcium Channel Blocker_ should be attempted First Line
- If it Fails to Respond then Cardioversion
ELECTRICAL CARDIOVERSION is better
But if contraindicated- PHARMACOLOGICAL CARDIOVERSION
1) Amiodarone
2) Sotalol
3) Verapamil
4) Digoxin
FURTHER MANAGEMENT-
- _CURATIVE= Catheter Ablation of the Cavotricuspid Isthmus_
- If Symptomatic Despite Rate Control
31
What are the causes of Atrial Fibrillation? What is the most common cause in the UK? And the most common cause in the developing world?
(Similar to Atrial Flutter)
Cardiac Causes
- _Ischaemic Heart Disease_ (Most common cause in UK)
- Rheumatic Heart Disease (usually of Mitral Valve)- (most common in Less Developed Countries)
- _Hypertension_
- _Peri-Myocarditis_
Non-Cardiac Causes (EE PIED)
- *Environmental Toxins* (Alcohol Abuse)
- Electrolyte Disturbances (_Hypokalaemia, Hypomagnesaemia_)
- _Pulmonary_ Causes (Pneumonia or Pulmonary Embolism)
- *Infective* Causes (Sepsis)
- Endocrine Causes (like Hyperthyroidism)
- Dehydration
32
What are the signs of Atrial Fibrillation?
What is the JVP like
(similar symptoms to Atrial Flutter)
What is the Pulse like?
Palpitations
Chest Pain
Shortness of Breath
Dizziness
_Single Waveform on JVP_ (there is the loss of the A wave which usually represents atrial contraction)
Irregularly Irregular Pulse
_APICAL to RADIAL PULSE DEFICIT_
33
What is the Chronic management of Atrial Fibrillation? _(no need if CHADSVAS= 0 and no symptoms)_
What should be done if there are HISS features?
What should be done in terms of pharmacological management (if <2 days / >2 days)?
What should be done if Electric Cardioversion Rhythm Control is needed (<2 days/ >2 days since onset)?
What are the options for Rate control and Rhythm control?
What is CURATIVE
*4 steps
RATE OR RHYTHM if Onset< 48 hours, otherwise RATE
ABCDE Approach
Assess for HISS Features and DC Cardiovert if present
_Consider Reversible Causes_-
- Infection- Antibiotics and Fluids
- Dehydration- Fluids
- Replace Abnormal Electrolytes
If there are no reversible causes or if AF persists- _Rate Control FIRST_/ Rhythm Control/ Cardioversion
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1) Rate Control (_MONOTHERAPY remember)_ -
- Either _Beta-blocker (Bisprolol) or Calcium-channel blocker (Dilitiazem or Verapamil)_ (_monotherapy_)
- If >7 days and they are sedentary- then _Digoxin can be added_
2) Rhythm Control-
- *Electrical Cardioversion* or Pharmacological (_Beta blockers_, Dronederone, AMIODARONE (if Heart Failure)) Cardioversion
- (if <48 hours- cardiovert asap, if >48 hours- ANTICOAGULATION for 3 weeks then cardiovert
3) Based on CHADVASC- Anticoagulation for 2 months if 0, or for life if >1 *(if =1, anticoagulate for males only)*
- Anticoagulation for 4 weeks prior to _catheter ablation_
4) Catheter Ablation is CURATIVE
34
????????- Ignore this one
What is the Acute management of New-Onset Atrial Fibrillation?
If <48 hours ago- DC cardioversion with sedation
If > 48 hours ago or onset is uncertain- Anticoagulate for 3 weeks then DC Cardioversion (Check ORBIT score to ensure they can have anticoagulation)
- No NEED for management if ASYMPTOMATIC with CHADVAS=0
or They can have a Transoesophageal ECHO to rule out Thrombus in the Left Atrial Appendage before Cardioversion takes place
35
What are the 3 Specific Drugs given for Atrial Fibrillation?
Give info on Flecainide, Amiodarone and Sotalol
Flecainide
- Can be either given regularly or as a "pill in the pocket" when symptoms come on.
- Is preferred in *young patients who have structurally normal hearts* because it can induce fatal arrhythmias in structurally abnormal hearts.
- it is the _CHOICE for PAROXYSMAL AF_
Amiodarone
- Extremely effective drug in controlling both rate and rhythm.
- However it comes with a massive list of significant side-effects so should normally only be given to *older, sedentary patients*.
Sotalol
- This is a beta blocker with additional K channel blocker action
- Used for those that don't meet the demographics for either flecainide or amiodarone.
36
What are the Anticoagulation options in Atrial Fibrillation?
Just remember DOACS are the preferred option
For what specific type of Atrial Fibrillation is Warfarin given for? What must you remember about LMWHs?
1) DOACS are generally preferred
- Do not require monitoring and less bleeding risks than Warfarin
2) Warfarin
- Requires cover with LMWH for 5 days when initiating treatment as _Warfarin is initially Prothrombotic_
- INR can be affected by a whole host of drugs and foods
- It is the only Oral Anticoagulant licensed for _Valvular Atrial Fibrillation_ (USUALLY MITRAL STENOSIS)
3) LMWH (like Enoxaparin)
- Only _if they can't tolerate Oral_
- It needs Daily Treatment Dose Injections
37
What are the complications of Atrial Fibrillation?
There are technically just 3
*_Heart Failure_*
Systemic Emboli- Ischaemic Stroke, Mesenteric Ischaemia, Acute Limb Ischaemia
_Bleeding_- GI/ Intracranial
38
What are the contradictions for Warfarin?
Bleeding Disorders
_Severe Hypertension_
Pregnancy
_Peptic Ulcer Disease_
39
What is the CHA2DS2VAS Score?
1- _Congestive Heart Failure_
1- Hypertension
2- (Age) 75 years old or older
1- Diabetes Mellitus
2- (Stroke) Previous Stroke or TIA
1- Vascular Disease
1- (Age) 65-74 years old
1- (Sex) Female
(Anticoagulation if Males score 1 or more and Females score 2 or more)
40
What are the ECG features of Ventricular Fibrillation?
Polymorphic Irregular Bord Complex Tachycardias
This is usually Pulseless as well
41
What is the management of Ventricular Fibrillation?
- Basic Life Support - ABCDE and CPR
- _VF is Shockable_- so Administer Defibrillation (Unsynchronised Cardioversion using a 200J Biphasic Shock)
- Resume Chest Compressions
- _1mg Adrenaline_ (10ml 1:10,000) plus _300mg Amiodarone_ after the 3rd Shock. Then give Adrenaline after every other shock
42
What are the ECG Features of Ventricular Tachycardia?
Tachycardia (>100bpm)
_Absent P Waves_ (as beats originate in the Ventricles)
Monomorphic Broad QRS Complexes (which means longer ventricular depolarisation)
43
What is the management of Pulseless Ventricular Tachycardia?
Same as Ventricular Fibrillation lol
- Basic Life Support - ABCDE and CPR
- It is a Shockable Rhythm so a 200J Biphasic Unsynchronised shock should be administered
- CPR should be resumed for 2 minutes before rechecking the Rhythm
- _Intravenous_ Adrenaline (1mg of 10ml 1:10,000 solution) and Amiodarone (300mg) should be administered after the 3rd Shock. Then give Adrenaline every other shock
44
What is the management of Ventricular Tachycardia with a Pulse with Adverse Features?
(HISS FEATURES)
- DC Shock- *How many times?* (3 attempts)
- Then Expert Help and then _300mg IV Amiodarone over 20 minutes_, followed by _900mg over 24 hours_
45
What is the management of Ventricular Tachycardia with a Pulse and No Adverse Features?
300mg IV Amiodarone _over 20 minutes_ (same as what you give after shocking if pulseless), followed by 900mg over 24 hours
46
What is Torsades de Pointes?
What type of arrhythmia is it exactly?
What causes it?
QRS Complexes Twisting around the Isoelectric Line
It is a _Polymorphic_ _Ventricular Tachycardia_ caused by QT Prolongation
47
What are the causes of Torsades de Pointes?
What is the main cause?
What are the 4 drugs causes of Torsades de Pointes? (_AA_/AA/K)
Which HYPOTHs (2) lead to Torsades de Pointes?
Congenital Long QT Syndrome (Romano Ward Syndrome and Jervell and Lange-Nielsen Syndrome)
Medications *(4 As and Ketoconazole)*(Antiarrhythmics, Antibiotics (like Erythromycin), _Tricyclics_, Antipsychotics, _Ketoconazole_)
_Myocardial Infarction_
Renal/ Liver Failure
_Hypothyroidism/ Hypothermia_
AV Block
Toxins
48
What is the management of Torsades de Pointes in Haemodynamically Unstable Patients?
HISS FEATURES
- Direct Current Shock and _IV Amiodarone_ (so similar to a Pulseless Ventricular Tachycardia)
MINUS the Adrenaline
49
What is the management of Torsades de Pointes in Haemodynamically Stable Patients?
(Remember the FIRST LINE)
_IV Magnesium Sulphate (2g over 10 minutes)_
Stop Drugs that Prolong QT and Correct Electrolyte Abnormalities
_Isoprenaline Infusion and Pacing may be considered_. These may be used in patients with recurrent Torsades de Pointes despite Initial Therapy with Magnesium Sulphate
50
Which Broad Complex Tachycardia is often seen Post-MI?
So if they say there is a broad complex tachycardia after the patient has had an MI it is most likely....
_Ventricular Tachycardia_
51
What is Brugada Syndrome?
Which channel is affected and what is the inheritance of this condition?
How may patients present/ what does it increase the risk of patients getting?
What is it worsened by?
It is a genetic condition caused by _Sodium Channelopathies_
It is autosomal DOMINANT
Patients may be Asymptomatic or present with Palpitations and Syncope due to Arrhythmias such as AV Nodal Re-entrant Tachycardias (AVNRTs), VT or VF
This is worsened by _FEVERS_
52
How is Brugada Syndrome diagnosed?
What is given to make the diagnosis easier?
ECG changes and a clinical sign (Palpitations and Syncope that gets worse AFTER Fever)
- Brugada Sign- _ST Elevation (>2mm) in V1-2_ and _Negative T Waves_
Flecainide and Ajmaline can help make the diagnosis easier
53
What investigations should be ordered for Brugada?
Genetic Testing (as it is genetic- AUTOSOMAL DOMINANT), Family History and Special Provocation Tests (like Ajmaline/ ECG)- also used for diagnosis
Also remember ECG
54
What can precipitate symptoms in Brugada Syndrome?
What electrolyte abnormalities can cause the symptoms?
1) *_Fever_*
2) Excess Alcohol
3) Dehydration
4) Medication-
- Antidysrhythmics like Flecainide
- Verapamil
- Antidepressants like _Amitriptyline_
5) Electrolyte Abnormalities _(HYPOKALAMEIA and HYPOMAGNESAEMIA)_
55
What is the management of Brugada Syndrome?
How can we stop it turning into VF/VT
ICD Defibrillation to reduce the risk of sudden cardiac death due to VT/VF
56
What is the management of Brugada Syndrome?
How can we stop it turning into VF/VT
Implantable Cardiac Defibrillator (ICD) to reduce risk of death from VF and VT
57
What are the Indications for Cardiac Catheterisation?
1) Imaging- (_Contrast Dye_ into Coronary Vessels to image anatomy and blood supply)
2) _Angioplasty_- Ball Dilatation and Stenting (PCI)
3) Valvuloplasty- Transcatheter Aortic Valve Implantation (_TAVI_)
4) Repair- Transcatheter Repair of Septal Defects
5) Electrophysiology- Studies and _catheter ablation_ (for AF, Atrial Flutter, Wolff-Parkinson-White)
6) Measurement- Pressures within Heart and Great Vessels
7) Biopsy- _Endomyocardial Biopsies for Inflammatory or Infiltrative Disorder Diagnosis_
58
What is the role of Cardiac Catheterisation in Coronary Artery Disease and Post-MI?
Cardiac Catheterisation is regularly conducted if Post MI or with Coronary Artery Disease for Diagnostic Purposes and if necessary- _PCI and Angioplasty_
59
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What are the complications of Cardiac Catheterisation?
What is the most common complication?
_Bleeding is the most common Complication_, which occurs due to Arterial Puncture
Arterial Thrombosis causing Occlusion of the Radial or Femoral Artery can cause _Ischaemia of the Distal Limb_. Loss of Distal Pulse can be caused by Arterial Vasospasm
Arrhythmias can also occur but are _Transient_ and include Ventricular Tachycardia and Ventricular Fibrillation. Bradycardia can also occur
Allergic Reaction to Iodine Contrast or Local Anaesthetic
Perforation of the Great Vessels which leads to _Tamponade_
60
What is Cardiac Myxoma?
Myxomas are benign and composed of unspecialised _Mesenchymal cells_ with a Mucopolysaccharide Stroma (which gives it a smooth Gelatinous Appearance)
61
What are the signs of Cardiac Myxoma?
May be systemic and include _FEVER and WEIGHT LOSS_
Other signs include-
- Audible Tumour Plop
- Nail _Clubbing_ due to Embolisation
- Symptoms of _Mitral Obstruction and Stenosis_ (like Atrial Fibrillation)
62
What Investigations should be ordered in Cardiac Myxoma?
Raised ESR and CRP
63
What is Carney Complex?
What can it cause? (remember the 2 main things it can cause)
Myxomas can occur secondary to Carney Complexes which is an Inherited _AUTOSOMAL DOMINANT DISORDER_ characterised by _Myxomas_, Schwannomas, Endocrine Tumours (Pituitary, Adrenal, Testicular) and Abnormal Skin Pigmentation
Therefore it can cause _Cushing's Syndrome_
64
What are the 4 types of Cardiomyopathies?
Which is the most common?
Dilated (most common)
Hypertrophic (most common cause of death out of all of these)
Restrictive
_Arrhythmogenic Right Ventricular Cardiomyopathy_
65
What are the causes of Dilated Cardiomyopathy?
_Ischaemic Changes_ can over time manifest with Dilated Cardiomyopathy- specifically Post-MI (think of it like heart muscle is losing energy so gets weak and thin)
Hypertension
Genetic
Toxin-related- Alcohol, Cocaine (DCM and Ischaemia)
Infiltrative (-Osis diseases)- Sarcoidosis or Haemochromatosis
Infections- _Myocarditis_
66
What are the signs of Dilated Cardiomyopathy?
What type of valve disease is usually seen?
What are the heart sounds (S sounds like)?
_Heart Failure symptoms_ (LEFT SIDED- like Shortness of Breath and Fatigue)
So what you see is the HEART FAILURE that arises basically
Other symptoms due to the consequence of Cardiomyopathy- Arrhythmia, Conduction Disturbances, Sudden Cardiac Death
_Displaced Apex Beat_
S3 gallop rhythm (rapid ventricular filling)
Mitral Regurgitation (due to Displacement of the Valve Leaflets)
67
What are the ECG findings of Dilated Cardiomyopathy?
Poor R Wave Progression (From V1 to V6)
Echocardiography is diagnostic
68
What is Hypertrophic Cardiomyopathy?
What is the inheritance?
Genetic Condition characterised by LVH of varying degree (Autosomal Dominant)
It causes DIASTOLIC DYSFUNCTION (Dilated is systolic)
69
What are the symptoms of Hypertrophic Cardiomyopathy?
What type of murmur is usually heard?
Double Beef Jerky HOCM
Little to no Symptoms
_EXERTIONAL DYSPNOEA_
Initial presentation= Syncope, Presyncope or _Sudden Death in Young People_
Jerky Pulse and Double Apex Beat *(DOUBLE BEEF JERKY)*
Harsh Ejection Systolic Murmur- _LOUDER with VALSALVA and QUIETER with SQUATTING_. May also be a PANSYSTOLIC MURMUR
Apical Thrill
70
What are the 4 ECG Findings of Hypertrophic Cardiomyopathy?
DEEP Q Waves
Deeply Inverted T waves
ST changes (usually depression)
LVH
71
What is Restrictive Cardiomyopathy?
Non-Dilated Non Hypertrophied Ventricles with _Impaired Filling_
72
What are the signs of Restrictive Cardiomyopathy?
What does the ECHO show? What should be suspected if the ECHO appears SPARKLY??
What is used to differentiate between restrictive cardiomyopathy and constrictive pericarditis?
1) Heart Failure- _RIGHT SIDED Heart Failure Symptoms_- Hepatomegaly and Oedema (Left Sided with Dilated)
2) Symptoms like _Constrictive Pericarditis_
75% will have Atrial Fibrillation
Diagnosis= Echo shows _Thickened Ventricular Walls_ and Valves. _If Sparkly= Amyloidosis_ (Oedema also seen due to Nephrotic Syndrome and Proteinuria)
Cardiac MRI= Differentiates between Restrictive Cardiomyopathy and Constrictive Pericarditis
73
Which Heart Sounds are audible in which Cardiomyopathies?
S3= In DCM
S4= In HOCM
74
Which Cardiomyopathy is the most common cause of Sudden Cardiac Death in Young People?
Hypertrophic Cardiomyopathy
75
When is CABG preferred over PCI?
there are 4 reasons why you would do CABG over a PCI?
It has a mortality advantage if:
- Over 65 years old
- Diabetes
- 3 Vessel Disease
- _Significant LEFT MAIN STEM Stenosis_
76
What scars are seen in CABG?
Mid-line Sternotomy Scar
_Longitudinal Graft Scar_
77
What are the 5 causes of Ejection Systolic Murmur?
Aortic Stenosis
Aortic Sclerosis
_Flow Murmur_ (Anaemia, Pregnancy, Thyrotoxicosis)
Hypertrophic Obstructive Cardiomyopathy
_Pulmonary Stenosis_
78
What are the 3 causes of Pan Systolic Murmur?
When and where is TR loud?
Mitral Regurgitation- Loudest at the Apex- Radiating to the Axilla- _Loudest in Expiration_
Tricuspid Regurgitation- Loudest at _Left Sternal Edge- Loudest in Inspiration_
_Ventricular Septal Defect_
79
How does Digoxin work?
What kind of tropicness does it show?
It _Inhibits_ the _Sodium/Potassium Pump in the Myocardium_ and also has Parasympathetic Effects on the AV Node
It is _Negatively Chronotropic_ and _Positively Ionotropic_- Slows the Heart Rate and Increases Contractility
80
What are the 4 ECG signs of Digoxin (NOT TOXICITY- just Digoxin)?
Long, Short, T, Tick
_Slight PR Prolongation_
_Shortened QT Interval_
_T Wave Inversion_
Downsloping ST Depression- Reverse Tick
81
Where do the ECG Leads go?
V1- 4th Intercostal Space- Right Sternal Margin
V2- 4th Intercostal Space- Left Sternal Margin
V3- Halfway between V2 and V4
V4- 5th Intercostal Space Mid Clavicular Line
V5- 5th Intercostal Space Anterior Axillary Line
V6- 5th Intercostal Space Mid Axillary Line
82
What are the signs of First Degree Heart Block? What are the 4 causes of First Degree Heart block?
What drugs can cause it?
_PR>200_
1) High Vagal Tone (Athletes)
2) Acute _Inferior MI_
3) Electrolyte Abnormalities (_Hyperkalaemia_)
4) Drugs (NHP-CCBs, Beta Blockers, Digoxin, Cholinesterase Inhibitors (dementia medications))
- acute Heart medications aside from ACE inhibitors
83
What is the management of First Degree Heart Block?
It is benign and does not need to be treated
But treat the cause
84
What are the signs of Mobitz I (Wenkebach)?
What are the 5 causes of Mobitz I?
PR gets longer and longer until P wave no longer has QRS Complex
1) High Vagal Tone (Athletes)
2) MI (Mainly Inferior)
3) Cardiac Surgery
4) Myocarditis
5) Drugs (NHP-CCBs, Beta Blockers, Digoxin, Cholinesterase Inhibitors)
(SAME as First Degree Heart Block)- but also _Cardiac Surgery and Myocarditis_ can cause it
85
What is the management of Mobitz I?
Generally Asymptomatic and does not require specific management. So treat the cause
If symptoms do arise
1) ECG monitoring may be needed
2) Removing Precipitating Drugs
3) _Atropine if Bradycardic_
- Basically similar-ish to First Degree but you give Atropine if there are symptoms
86
What are the signs of Mobitz II?
What are the 6 causes of Mobitz II?
Constant but Long PR Interval With the occasional solo P Wave (usually regularly)
-- *Remember the 2 I's that you keep forgetting- Inflammatory/ Autoimmune and Infiltrations*
1) Infarction- _Anterior MI_ which damages the Bundle Branches
2) Surgery- Mitral Valve Repair or Septal Ablation
3) _Inflammatory/ Autoimmune_- Rheumatic Heart Disease, SLE, Systemic Sclerosis, Myocarditis
4) Fibrosis (Lenegre's Disease)
5) _Infiltrations_ (Sarcoidosis, Haemochromatosis, Amyloidosis)
6) Drugs (NHP-CCBs, Beta Blockers, Digoxin, Cholinesterase Inhibitors, Amiodarone)
87
What is the management of Mobitz II?
Permanent Pacemaker as patients are at risk of Complete Heart Block
88
What are the signs of Complete Heart Block and the 3 causes?
Severe Bradycardia and complete dissociation between P waves and QRS complexes
1) Myocardial Infarctions (usually Inferior)
2) Drugs (Beta Blockers and Calcium Channel Blockers)- so this time it is mainly just TWO DRUGS that can cause it
3) _Idiopathic Fibrosis_
89
What is the management of Complete Heart Block?
Permanent Pacemaker
90
What are the investigations of Hypertension?
Patients with _2 measured BP readings> 140/90_ should be offered either _Ambulatory BP Monitoring_ or Home Blood Pressure Monitoring
Assess for _End Organ Damage_-
- Urine Dip and Albumin: Creatinine Ratio
- Blood Glucose, Lipids and Renal Function
- Fundoscopy for evidence of Hypertensive Retinopathy
- ECG- look for LVH
91
What is the management of Hypertension?
When should management be offered based on the Hypertension stage?
What is the 4 step pharmacological management?
What is an example of an Alpha Blocker?
Control Risk Factors-
- Weight Loss
- Healthy Diet (_less salt and saturated facts_)
- Reduce Alcohol and Caffeine
- Reduce Stress
- Stop Smoking
Start Pharmacological management if:
- Stage 1 if<80 years old with _End Organ Damage_ (_HEART KIDNEYS DIABETES_), CVS Disease, Renal Disease, Diabetes or 10-year CVS risk>10%
- Stage 2 or 3
*Pharmacological Management-*
1) ACE (Ramipril) if <55 years old or Diabetic OR DHP-CCB (Nefedipine) if >55 years old or Afro-Caribbean
2) Combine ACE and DHP-CCB or Add a Diuretic (A+C/ A+D and C+A/C+D)
3) Then A + C + D
4) *Potassium*< 4.5= Spironolactone, Potassium>4.5=
- _Alpha Blocker (*Doxacosin*), Beta Blocker (Atenolol)_, Referral
92
~~~~
What are the stages of Hypertension?
Stage 1- 1 reading> 140/90 and Average Ambulatory Readings> 135/85
Stage 2- 1 reading> 160/100 and Average Ambulatory Readings> 150/95
Stage 3- 1 reading where Systolic > 180 or Diastolic> 120
93
What is Malignant Hypertension?
What are the signs?
BP> 180/120
Evidence-
- _Papilloedema and/or Retinal Haemorrhages_
- New Onset Confusion (*Encephalopathy*)
- Seizure
- Chest Pain
- Heart Failure
- AKI
94
What is the management of Malignant Hypertension?
What should you have in mind when managing Malignant Hypertension?
What are the 3 indications for IV management?
CONTROLLED drop in Blood Pressure (to avoid Ischaemic Stroke if Uncontrolled)
1) ORAL _Amlodipine or Nifedipine_ is used first line
- IV only if (_Aortic Dissection, Heart Failure, Encephalopathy_)
95
What are the 5 Specific Situations in Hypertension Control?
What do you avoid in Pulmonary Oedema Hypertension?
1) Hypertensive Encephalopathy- _IV Labetalol or IV Sodium Nitroprusside_
2) Aortic Dissection- IV Labetalol or IV Sodium Nitroprusside (target 100-120 Systolic)
--
3) Pulmonary Oedema- _IV Infusion GTN_ or Sodium Nitroprusside (AVOID BETA BLOCKERS)
--
4) Pregnancy Induced- IV Magnesium Sulphate with IV Labetalol/ Hydralazine/ Methyldopa
--
5) _Phaeochromocytoma_- IV Phentolamine/ Phenoxybenzamine (Alpha Blockers) before Beta Blockers- PHENS first
96
What are the causes of Secondary Hypertension?
What is the most common cause?
Kidney Diseases (Most Common)
Cushing's
Conn's
Phaeochromocytoma
Hyperthyroidism
_Coarctation of aorta_
97
What are the side effects of Calcium Channel blockers?
Ankle Swelling
Gum Hypertrophy
Dizziness
98
What are the side effects of Statins?
Muscle Aches and Abdominal Discomfort
99
When are Thiazide Diuretics Contraindicated?
In Severe Renal Failure
- so bear this in mind for blood pressure management!
100
What is Hypertrophic Cardiomyopathy?
It is the most common Genetic Heart Condition that often causes sudden cardiac death (unexplained syncope is a risk factor) in young people
Autosomal Dominant
101
What investigations should be ordered in Hypertrophic Cardiomyopathy?
ECG- LVH, Left Axis Deviation, Conduction Abnormalities and Ectopic Activity
_Echocardiogram- Septal Hypertrophy_
Cardiac MRI- To measure the extent of LVH
Genetic Testing
102
What is the management of Hypertrophic Cardiomyopathy?
remember ABC and what to avoid
_Amiodarone_
_Beta-blockers or verapamil_ for symptoms
_Cardioverter defibrillator_
Dual chamber pacemaker
Endocarditis prophylaxis
AVOID- ACE inhibitors, Nitrates, Digoxin
Risk stratification and presence of symptoms (OCD for sudden cardiac death patients, exercise restriction, reduction of outflow obstruction (beta blockers, verapamil)
103
What kind of Murmur is heard in Hypertrophic Cardiomyopathy?
Ejection Systolic Murmur that is Louder with Exercise/ Standing/ Valsalva and Quieter when Supine/ Squatting- due to Left Ventricular Outflow Obstruction
Pansystolic Murmur Loudest at Apex and radiating to Axilla (Mitral Regurgitation)- due to Systolic Anterior Motion
Pulse will be Jerky and Apex Beat will be Displaced, Apical Thrill
104
What ECG Changes are seen in Hypokalaemia?
1) Long QT
2) Prolonged PR Interval
3) ST Depression
4) T Wave Inversion
5) U Waves
LONG PR and LONG QT
U are DEPRESSed cos there is no T
105
What are the risk factors for Infective Endocarditis?
Remember the MITRAL VALVE is usually affected, unless IV DRUG use
_IV Drug Use_ (predisposition for Staph Aureus and Right-sided Valve Disease (_Tricuspid Endocarditis_))
_Poor Dentition and Dental Infections_
Comorbid Conditions-
- Valvular Disease (Rheumatid Heart Disease, Mitral Valve Prolapse, Aortic Valve Disease)
- _Congenital Heart Disease_ (Bicuspid Aortic Valve, Pulmonary Stenosis, Ventricular Septal Defect)
- Prosthetic Valves
- Previous Endocarditis
- Intravascular Devices (Central Catheters, Shunts)
- *Haemodialysis*
- *HIV Infection*
106
What are the most common Infective Organisms involved in Infective Endocarditis? (4)
1) Staph. Aureus
2) Strep Viridans
3) Strep Bovis- seen in _Colorectal Cancer_
4) Staph EPIDERMIS if _<2 months after valve surgery_
107
What are the signs of Infective Endocarditis?
Fever and Mitral Regurgitation (Fever and Murmur is Infective Endocarditis unless proven otherwise)
What is (may be) seen on ECG and what does it indicate?
What causes the Abdominal Pain?
Abdominal pain due to MESENTETRIC ISCHAEMIA (do CT Angiography)
F - Fever
R - Roth's spots
O - Osler's nodes
M - Murmurs (_Mitral Regurgitation_)
J - Janeway lesions
A - Anemia (Normocytic, Normochromic)
N - Nail bed hemorrhages (Splinter)
E - Emboli (Septic Emboli)
- Anorexia and Weight Loss
- Headache
- Myalgia and Arthralgia
- Night Sweats
- Cough
- Abdominal Pain and Pleuritic Pain
- _Microscopic Haematuria and Glomerulonephritis_
- _PR Prolongation (this is a sign of AORTIC ROOT ABSCESS) or Complete AV Block_
On Examination-
- Janeway Lesions (nontender macules on palms and soles)
- Osler Nodes- Tender Nodules on fingerpads and toes
- Roth Spots- Exudative Haemorrhagic Retinal Lesions with pale centres
- Splinter Haemorrhages
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What investigations should be ordered in Infective Endocarditis?
What is first line? What is most sensitive?
What bloods should be taken and how many of them?
1) Transthoracic Echocardiogram is First Line
2) Transoesophageal Echocardiogram is most sensitive
/////
_At least 3 sets of bloods should be taken at different times_ from various sites
Blood tests- FBC, U&Es, LFT, CRP
109
What is the Dukes' Criteria for diagnosing Endocarditis?
There are 2 MAJOR and 5 MINOR
Infective Endocarditis if 2 Major Criteria OR *1 Major and 3 Minor* OR all 5 Minor Criteria
Major Criteria-
1) Blood Cultures= S. Viridans, S. Bovis, S, Aureus- from _2 separate cultures_. Single positive culture for *Bart, Cox or Chlamydia*
2) Imaging= _Echo positive_ for IE- vegetation, abscess, partial dehiscence of prosthetic valve, _new valvular regurgitation_. Abnormal activity around site of Prosthetic Valve Implantation on PET-CT. Perivalvular Lesions on Cardiac CT- *Any imaging that shows that the valves are not normal*
Minor Criteria-
1) _Fever > 38.0°C_
2) Predisposition e.g. predisposing heart condition or intravenous drug use
3) _Vascular_ phenomena e.g. arterial emboli, infarcts, mycotic aneurysms, intracranial or conjunctival haemorrhages, Janeway lesions
4) Immunological phenomena e.g. _glomerulonephritis, Osler's nodes, Roth's spots, rheumatoid factor_
5) Microbiological evidence e.g. blood culture not meeting major criteria, or serological evidence of active infection with organism consistent with IE
110
What does PR Prolongation in Infective Endocarditis indicate?
Surgery should be done
as this can be due to Aortic Root Abscess
111
What is the management of Infective Endocarditis?
What are the indications for surgery?
Long Term IV Antibiotics (minimum 6 weeks)
Initially Broad Spectrum but can be changed to more specific ones if the organism is known
_Amoxicillin first, then 1) Flucox if Staph and 2) Benzylpenicillin if Strep_
Surgery if:
- _Haemodynamically unstable_
- Severe Sepsis despite antibiotics
- _Severe Heart Failure_
- Repeated Emboli
- _Aortic root abscess (Prolonged PR)_
- _Persistent Bactraemia_
- Infected Prosthetic Valve
- Valvular Obstruction
112
What is the management of Pulseless Electrical Activity and Asystole?
These are non-shockable
- CPR
- 1mg IV Adrenaline
- 1mg Adrenaline every 3-5 minutes
113
What are the 4 causes of Mitral Valve Prolapse?
Marfan's
Ehler's Danlos
_Turner Syndrome_
Fragile X
114
What are the signs of Mitral Valve Prolapse?
*Pan systolic murmur and Mid systolic Click*
- A non-ejection click (not an early systolic ejection click) which is variable in timing (due to snapping of the mitral chordae during systole when the valve bows into the atrium) (MID SYSTOLIC CLICK)
-A mitral regurgitation (pansystolic) murmur
- Features of a secondary cause may also be noted on examination.
- Symptoms are inconsistent but can include- Chest Pain, Palpitations, Dyspnoea, Exercise Intolerance, Dizziness, maybe even Asymptomatic)
115
What are the ECG signs of Mitral Regurgitation?
What is the MAIN ECG sign?
_P Mitrale (broad notched P wave due to Atrial Enlargement)_
Right Ventricular Hypertrophy
Right Axis Deviation
116
What is Acute Mitral Regurgitation? What may it indicate and how urgent is it?
A Cardiac Emergency (may have sudden onset Pulmonary Oedema, Hypotension and _Cardiogenic Shock_)
117
What is seen on the Chest Xray of Mitral Regurgitation?
Pulmonary Oedema (hence why Acute MR is an emergency) and Left Atrial Enlargement (hence the p mitrale)
118
What is the management of Mitral Regurgitation?
Treat the complications
- Atrial Fibrillation (common cause of MR)
- Thromboembolism
- Heart Failure _(caused by MR)_
Definitive management for MR- Surgery
- Mitral Valve Repair (Valvuloplasty) is preferred
- Otherwise Mitral Valve Replacement
119
What are the signs of Mitral Regurgitation?
Pansystolic Murmur
- Loudest at Apex
- Radiates to Axilla
- Louder on Expiration
- Louder on rolling to left
120
What is Mitral Stenosis and what are its causes?
When do you suspect MS?
It is the impaired opening of the mitral valve which affects blood flow from the left atrium to the ventricle
Suspect if _Atrial Fibrillation+ Mid-late diastolic murmur_
Caused by:
1) _Rheumatic Fever_ (most common cause)- streptococcal antigens cause the damage
2) Mitral Annual Calcification (Age related)
3) Mucopolysaccharidosis- Metabolic Disorder which affects Connective Tissues
4) Carcinoid Syndrome
5) Systemic Diseases- _SLE and Rheumatoid Arthritis_
121
What is the presentation of Mitral Stenosis?
What is the JVP like?
What is the Apex Beat like?
What 2 lung-related signs are seen?
What is seen in the face?
Atrial outflow obstruction like Atrial Myxoma may produced similar Symptoms
- Gradual _Exertional Dyspnoea and reduced Exercise Tolerance_ (seen in 70% of patients)
- _Haemoptysis_
- Palpitations (_Atrial Fibrillation_)
- Chest Pain
- Thromboembolism (Cerebral or Systemic)- due to the Atrial Fibrillation
- Hoarseness- the enlarged Left Atrium presses on the Laryngeal Nerve
- Peripheral Oedema/ Hepatomegaly due to Right Heart Failure
- Mitral Face (_Malar Flush_)
- _Elevated JVP_ (A wave due to high Atrial Pressure)
- _Tapping_, Non-displaced Apex Beat
- Right Ventricular Heave (due to Pulmonary Hypertension)
- _Inspiratory Crepitations_ (Pulmonary Oedema and other signs of Heart Failure)
122
What are the Cardiac Auscultation Findings of Mitral Stenosis?
_Loud S1_- becomes softer with increased calcification
Loud P2 due to Pulmonary Hypertension
_*Opening Snap* Heard at Apex_
Mid- Diastolic Murmur-
- Low Pitched _Rumble_ prominent at APEX
- Heard best when lying at Left Side
- Loudest in Expiration
Graham-Steell Murmur- Early Diastolic Murmur- Only if Pulmonary Regurgitation is present- due to Pulmonary Hypetension
123
What are the ECG, X ray, Echo and MRI signs of Mitral stenosis?
same as MR
ECG-
- P Mitrale (broad notched P Wave due to Left Atrial Enlargement)
- Right Ventricular Hypertrophy
- Right Axis Deviation
- Atrial Fibrillation (due to Left Atrial Enlargement)
CXR- signs of Pulmonary Oedema and Left Atrial Enlargement
Echocardiogram
Cardia MRI- Valvular Vegetations may be present if infective cause (Rheumatic Heart Disease)
124
What is the management of Mitral Stenosis?
If left Untreated- High Left Atrial Pressures and High Pressures in Pulmonary Vasculature and Right Heart
- If Asymptomatic, Regular Follow Up Echocardiography to assess progression as it can progress to Pulmonary Hypertension and Right Heart Failure
- If Atrial Fibrillation- Anticoagulation and Rate-Controlled
- DIURETICS and BETA BLOCKERS can provide Symptomatic Relief in decompensated states due to illness or for stabilisation prior to surgery
////////
- If Symptomatic (Heart Failure signs), (unless valve area is >1.5 cm)
1) Balloon Valvuloplasty (only appropriate if Valve is pliable and non-calcified)
2) Percutaneous _Mitral Valvotomy_- if moderate disease
3) Open _Valve Repair/ Replacement_- severe disease
125
What are the complications of Mitral Stenosis?
_Atrial Fibrillation_ and Thromboembolism
Pulmonary Hypertension (Dyspnoea and Haemoptysis)
_Dilated Left Atrium_- affects local structures leading to _Hoarseness, Dysphagia and Bronchial Obstruction_
*Left Atrium dilates and presses on the local structures*
126
What are the 4 causes of NSTEMIs where the patient may not need or benefit from Conventional Treatment?
_Severe Sepsis_
Hypotension
Hypovolaemia
_Coronary Artery Spasm_
127
What is the most important investigation that should be ordered if MI is suspected?
ECG (before Bloods)
128
What type of MI presents with ST depression in V1-3?
Posterolateral MI (ST elevation in V7-9)
129
When should Troponin be measured in an MI patient and what would the results indicate?
_3 hours after MI_
3 groups of Troponin Levels
1) Low- definitely no myocardial death. Patient is not having an MI but may be Unstable Angina
2) Mildly Raised- may be due to other Non-MI Factors. _Do another test in 6-12 hours_. If raised- then MI, if not raised- then unlikely to be MI
3) Definitely raised- MI confirmed
130
What are the causes of Raised Troponin?
(Anything that affects the heart p much)
What are the 3 non-cardiac causes?
DPS
Myocardial Infarction
Pericarditis
Myocarditis
Arrhythmias
_Defibrillation_
Acute Heart Failure
_Pulmonary Embolism_
Type A Aortic Dissection
Prolonged Strenuous Exercise
_Sepsis_
131
What is the Post-MI management of patients? (5)
ALL patients post-MI patients should be started on the following 5 drugs:
1) _Aspirin 75mg_ OM + _second anti-platelet_ (clopidogrel 75mg OD or ticagrelor 90mg OD)
2) Beta blocker (normally bisoprolol)
3) ACE-inhibitor (normally ramipril)
4) High dose _statin_ (e.g. Atorvastatin 80mg ON)
All patients should have an _ECHO performed to assess systolic function_ and any evidence of heart failure should be treated.
All patients should be referred to cardiac rehabilitation.
Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia.
132
What are the 9 complications of MI?
Which murmur and septal defect are seen?
What 2 things are seen regarding the Left Ventricle?
What 2 Heart ______'s?
What 3 other complications are there? (V.I.D.)
What kind of MI's lead to Heart Block and Left Ventricular Thrombus/ Aneurysm?
What is the management of Dressler's and Left/Right Ventricular Rupture?
1) _Ventricular_ Arrhythmias- during cardiac catheterisation or after reperfusion. Most should self-resolve but if VT/VF treat as per guidelines
2) Recurrent Ischaemia, Infarction, Angina. Inserted stents can thrombose which requires Reintervention. This is more common with Unstable Angina
3) Congestive _Heart Failure_- due to heart muscle ischaemia
4) Heart Block- particularly after _Inferior Infarcts_. Treat with simple observation, Transcutaneous/ Venous _Pacing if Symptomatic_ or Permanent Pacing if this fails to resolve
5) Left Ventricular Thrombus/ Aneurysm- Aneurysm can occur following _Anterior MI_ where the myocardium can be susceptible to Wall Stress which leads to an Aneurysm. It is definitively diagnosed via ECHO but ECG may show persistent ST Elevation. The Thrombi can embolise which causes Stroke, Limb Ischaemia and Mesenteric Ischaemia
6) Left/ Right Ventricular Free _Wall Rupture_- Necrosis of the free walls of either ventricle can lead to rupture, causing blood to enter the Pericardial Space. Treatment= _Pericardiocentesis and Surgery_ but prognosis is poor
7) Acute _Mitral Regurgitation_
8) Ventricular Septal Defect- Shortness of Breath, Chest Pain, Heart Failure, Hypotension, Harsh Pansystolic Murmur at the Left Sternal Border, Palpable Parasternal Heave. Diagnosis via ECHO. Manage with _Emergency Cardiac Surgery_
9) Dressler's Syndrome- _Pericarditis_, presents with pleuritic chest pain and _FEVER_ that happens a few weeks after MI. Symptoms usually resolve after a few days. _Treat with NSAIDs_
133
What are the drug causes of Pericarditis?
*MA HIPP*
- Methyldopa
- Anthracycline Chemotherapy
///
- Hydralazine
- Isoniazid
- _Phenytoin_
- Penicillin (Hypersensitivity)
134
What are the ECG changes in Pericarditis?
Remember the 2 main signs
1) _Saddle-shaped ST Elevation_ (Widespread)
2) _PR Depression_
1-3 weeks= Normalisation of ST changes, T wave flattening
3-8 weeks= flattened T waves become inverted
8+ weeks= ECG returns to normal
135
What is the management of Pericarditis?
For Viral/Idiopathic and Bacterial?
- Viral and Idiopathic-
1) Exercise Restriction and _NSAIDs_
1a) Add _Colchicine_ but use with caution if Renal/Hepatic Impairment
2) _Corticosteroids if NSAIDs don't work_, or if Non-viral Pericarditis and once infection has been ruled out
//////
- Bacterial-
1) _IV Antibiotics and Pericardiocentesis_ if Purulent Exudate
136
What are the causes of Pulmonary Stenosis?
Which 3 Congenital conditions and which Congenital infection?
Which of these is the most common cause of Pulmonary Stenosis?
Usually Congenital
1) Noonan Syndrome (Valvular) (most common)
2) Williams Syndrome (Supravalvular)
3) _Tetralogy of Fallot_ (Valvular)
It may also be associated with _Congenital Rubella_ Infection (Valvular)
Can also be due to Carcinoid Syndrome
137
What is the management of Pulmonary Stenosis?
Valvotomy (if Valvular) or Balloon Angioplasty (if Supravalvular), treatment is considered if Transvalvular Pressure Gradients>50mmHg
138
What kind of Murmur does Pulmonary Stenosis cause?
Ejection Systolic Murmur, loudest at Pulmonary Area and radiates to Shoulders (not Carotids like AS)
139
What is Rheumatic Fever?
What pathogen causes it? What kind of infection usually occurs before the fever?
It is a systemic complication of Lancefield group A Beta-haemolytic Streptococcal Infection (typically _Pharyngitis_) that occurs 2-4 weeks after the infection
_Streptococcus Pyogenes_
140
What is needed to diagnose Rheumatic Fever?
- _Recent Streptococcal Infection_ (history of _Scarlet Fever_, Positive Throat Swabs or High Antistreptolysin O Titre >200U/ml or DNase B Titre)
- Either 2 Major Jones Criteria or _1 Major and 2 Minor Criteria_
141
What are the 5 Major Jones Criteria for Rheumatic Fever?
What is Sydenham's Chorea like?
What shape does Erythema Marginatum look like in Rheumatic Fever?
*APSEN*- Remember _PANCARDITIS_
Arthritis
- Usually the earliest manifestation- typically FLITTING or Migratory _Polyarthritis_. Commonly affects the _knees, ankles, elbows and wrists_- so *similar in arms and legs*
Pancarditis
- Affects all layers of the myocardium, however Endocardial Infection usually dominates- presenting as Valvulitis. It manifests as Tachycardia, a _New Murmur_ or Conduction Defect
Sydenham's Chorea
- Involuntary Movements with Muscular Weakness and _Emotional Disturbance_. They usually happen on just _one side_ and stop during sleep
Erythema Marginatum
- Pink/ Red, _Non Pruritic_ Rash involving the _trunk, thighs and arms- *so within the area where the arthritis starts*_. The rash usually has sharp, raised outer edges with diffuse clear centre, making a _ring_
Subcutaneous Nodules
- Firm, mobile painless lesions
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What are the 4 Minor Jones Criteria for Rheumatic Fever?
_FARP_- A/P only if APSEN criteria does not cover it
1) Fever
2) Arthralgia (unless Arthritis meets major Criteria)
3) _Raised ESR/ CRP_
4) Prolonged _PR intervals_ (Unless a carditis is the major Criteria)
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What is the 5 step management of Rheumatic Fever?
What are the 2 first line treatments?
What is given for the Sydenham's Chorea, Carditis (if Heart Failure)and the Erythema Marginatum?
What must be stopped if Heart Failure occurs?
_Remember the First 2 AT Least_
1) _IV Benzylpenicillin STAT and 10 day course of Phenoxymethylpenicillin_
2) Analgesia for Arthritic Symptoms (Aspirin or _NSAIDs_)- use aspirin with caution in young children due to risk of Reye's Syndrome
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3) If Carditis is complicated by Heart Failure- _Glucocorticoids (Prednisolone)- and stop NSAIDs_. Diuretic Treatment can also help
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4) Sydenham's Chorea is self-resolving, however _Haloperidol or Diazepam_ can help with distressing symptoms or risk of harm
5) Erythema Marginatum- _Antihistamines_ can help with pruritus, but otherwise no need to treat
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Which valves are commonly affected in Rheumatic Heart Disease?
What is the most common?
_Mitral Stenosis (most common)_
Mitral Regurgitation
Aortic Regurgitation
Aortic Stenosis
Tricuspid Regurgitation or Stenosis
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What are the 5 causes of LBBB and 5 causes of RBBB?
I-MADH
AVEN-I
LBBB (it is NEVER normal- always pathological)
1) Ischaemic Heart Disease
2) Myocardial Infarction
3) *_Aortic Stenosis_*
4) Digoxin Toxicity
5) _Hyperkalaemia_
RBBB
1) (Atrial Septal Defect) Congenital Heart Disease
2) (Ventricular) Right *Ventricular* Hypertrophy
3) (Embolism) _Pulmonary Embolism_
4) Normal Variant
5) Ischaemic Heart Disease
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What does RBBB look like on an ECG?
Bunny ears on V1 (RSR)- R for Rabbit
Slurred S Waves on V6 (QRS is normal though)- Sloping DOOOOOWN S waves
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What are the causes of Right Heart Strain?
Pathologies that affect the _Pulmonary Vasculature_
1) Pulmonary Emboli
2) Pulmonary Hypertension
3) Chronic Lung Disease
4) _Pulmonary Stenosis_
5) Pneumothorax
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What are the ECG Features of Right Heart Strain?
What is the most common feature?
What shows Right Ventricular Strain?
What type of P wave is typically seen and what does it show?
1) _Sinus Tachycardia_ (most common)
2) Right Ventricular Strain (_ST Depression and T Wave Inversion_ in _Inferior Leads_)
3) RBBB
4) Right Axis Deviation
5) P Pulmonale- _shows Right Atrial Enlargement_
6) S1 Q3 T3
7) Atrial Arrhythmias
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What are the target INRs for different diseases?
- Atrial Fibrillation- 2-3
- Metallic Valve Replacement- 2-3 (if Aortic Valve), 2.5-3.5 (if Mitral Valve)
- VTE (2-3), if _recurrent VTE (3-4)_
*GENERALLY it is 2-3, but if Recurrent VTE then 3-4*
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What are the signs of Tricuspid Regurgitation? (even though it is usually asymptomatic even if severe)
What kind of JVP waves are seen?
What is the actual murmur like?
Signs of _Right Sided Heart Failure_ (remember Tricuspid is in the Right Heart)- Ascites, Peripheral Oedema, Pulsatile Hepatomegaly
Heart Sounds- _Pansystolic Murmur_ loudest in Left Parasternal Region, Louder on Inspiration
JVP- _Prominent V waves_
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What investigations should be ordered in Tricuspid Regurgitation?
What are the P waves like in Tricuspid Regurgitation?
ECG- may show _Peaked P Waves_ or incomplete Right Bundle Branch Block
Echocardiography- Used to detect and Quantify the Regurgitation and Heart Function
Cardiac MRI- to evaluate the Right Ventricular Size and Function
Cardiac Catheterisation- to be used BEFORE SURGERY to assess for Coronary Artery Disease
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What is the presentation of Ventricular Septal Defects?
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*Just remember they show exertional dyspnoea and maybe heart failure signs if it progresses*
May be Asymptomatic if they are small
May be incidentally found on examination due to their _Pan-Systolic Murmur_
Signs-
- Shortness of breath on exertion (like Breastfeeding)
- As the work of breathing is less effective there may be Poor Weight Gain leading to Faltering Growth
- Undetected cases may lead to _Heart Failure_
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How are VSDs diagnosed?
What might the CXR/ ECGs show?
They are definitively diagnosed through an Echocardiogram, where their severity is also graded
Chest X Rays and ECGs may show _Enlarged Left Ventricle_
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What is the management of Ventricular Septal Defects?
How are they surgically managed?
Majority of them will _Self-resolve_ so manage the infant conservatively with increased Calorie Intake and Observation with Follow Up
Large Defects need Closure- _Catheter Intervention_ usually
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When should Congenital Valve Diseases be suspected in patients if a murmur is heard?
What is the most common and second most common?
If there is NO MEDICAL history and the murmur is found incidentally
The most common defect is Bicuspid Aortic Valve. The second most common defect are Ventricle Septal Defects
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What investigation is typically done if a patient is haemodynamically unstable for Aortic Dissection?
Echocardiogram (TOE) as this can be done bedside- OVER a CT
157
What are the contraindications for Carotid Sinus Massage?
Cerebrovascular Disease
158
What should be done in Atrial Fibrillation if a CHA2DS2VAS score suggests that there is no need for anticoagulation?
Do a TRANSTHORACIC ECHO to exclude _VALVULAR DISEASE_!!!!!
cos even if the CHA2DS2VAS is 0, you NEED anticoagulation if there is valvular disease!
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Is Age or Risk of Falls enough to conclude that a patient should not have ANTICOAGULATION???
Nope (do ORBIT score if AF)
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Which 2 components of the ORBIT Scoring System for AF risk of bleeding with anticoagulation should you remember?
Anaemia and Renal Impairment (Anemia= 2, Renal Impairment= 1)
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What is the first line investigation to be ordered if Pericarditis is suspected?
Transthoracic Echocardiography
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What are the 3 signs of Pericarditis?
Pleuritic chest pain relieved by Sitting Forward
NON-productive cough, Dyspnoea, FLU-like symptoms- may also be FEVER
PERICARDIAL RUB
