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Internal Medicine > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

What does JVP measure

A

Pressure in right atrium (indirectly)

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2
Q

4 causes of raised JVP

A

Pqrst

  • pericardial effusion/ tamponade ( cause Kussmaul’s sign- paradoxical increase JVP during inspiration); constrictive pericarditis
  • quantity: Fluid overload
  • right Heart failure
  • superior vena cava obstruction
  • tricuspid regurg (V waves), tricuspid stenosis;
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3
Q

Path of constrictive pericarditis

A

Pericardium thickens and scars leading to decreased elasticity

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4
Q

Def of cardiac tamponade

A

Accumulation of pericardial fluid under pressure in pericardial sac, leading to compression of heart

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5
Q

How to tell difference between JVP and carotid pulse

A

JVP has 2 pulses, carotid 1

JVP pulse not palpable, carotid is.

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6
Q

Normal JVP?

A

3Cm

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7
Q

Draw JVP waveform

A

See picture 1 internal medicine folder

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8
Q

What does A wave on JVP waveform represent

A

A for Atrial contraction

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9
Q

What does X descent on JVP waveform represent

A

First part after A wave: relaXation of atria

C = tricuspid closure

Second part after C wave: end of RV contraction. Creates space in pericardium so atria can expand. Thus passive atrial filling

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10
Q

What does C wave on JVP waveform represent

A

Start of systolic Contraction
C for Closure of tricuspid

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11
Q

What does V wave in JVP waveform represent?

A

Atrial relaxation, tricuspid still closed. Maximal atrial filling

V for villing (filling)

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12
Q

What does y descent in JVP waveform represent?

A

Tricuspid opening and emptYing of atrium

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13
Q

What can cause an absent A wave in the JVP waveform?

A

Atrial fibrillation

Bc a wave = atrial contraction. Not contracting properly.

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14
Q

Which 2 diseases can cause large A waves in JVP waveform?

A 
RV hypentrophy (pulmonary ht/pulmonary stenosis)
Tricuspid stenosis

Bc causes huge atrial contraction to overcome force

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15
Q

What can cause large V waves in JVP waveform?

A

Tricuspid regurgitation.

Bc makes atria super full

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16
Q

5 symptoms of LHF

A 
Exertion dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Cough W/ white frothy or pink sputum
Fatigue
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17
Q

3 vital signs of LHF

A

Tachypnea
Hypotension
Tachycardia

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18
Q

Breathing pattern of LHF

A

Cheyne-stokes breathing
(Deep breathing then apnea)

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19
Q

JACCOLD signs of LHF

A

Peripheral and central cyanosis

Periph oedema due to associated RHF

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20
Q

Pulse of LHF

A

Tachycardia
Low pulse pressure
Pulsus alterans - rare

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21
Q

Apex beat of LHF (2)

A

Displaced
Gallop rhythm = extra heart sounds + tachycardia due to overload
( dyskinetic if had ant MI or has dilated cardiomyopathy)

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22
Q

Auscultate LHF ( 2)

A

Left ventricular s3 best heard at apex.

Functional mitral regurg secondary to valve ring dilatation

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23
Q

Lung findings LHF

A

Basal inspiratory crackles due to pulmonary congestion

Crackles and wheezes throughout due to pulmonary oedema

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24
Q

JVP signs LHF

A

Increased

Positive abdominojugular reflux test

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25
Q

4 broad causes of LHF and examples

A
  1. Cardiomyopathy: hereditary (dilated/hypertrophic) or acquired (secondary to thyrotoxicosis, viral disease, drugs etc)
  2. Ischaemic heart disease / coronary heart disease eg atherosclerosis
  3. Valve disease: aortic regurg or stenosis, mitral regurg,(PDA)
  4. Hypertensive heart disease
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26
Q

Symptoms of RHF (4)

A

Ankle/sacral/abdominal swelling
Anorexia
Lethargy
Dyspnea (poor pulmonary perfusion)

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27
Q

JACCOLD of RHF

A

Peripheral cyanosis

Pitting ankle and sacral oedema

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28
Q

Pulse in RHF

A

Low volume

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29
Q

JVP in RHF (3)

A

Raised
Kussmaul’s sign (increase on inspiration)
Large v waves (functional tricuspid regurg)

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30
Q

Chest palpation RHF

A

Right ventricular heave = RV hypertrophy = LLSB heave
If severe, epigastric heave

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31
Q

Auscultate RHF heart ( 2)

A

Right ventricular s3 best heard at lower left sternal edge but soft.
Pansystolic murmur of functional tricuspid regurg

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32
Q

Abdomen signs RHF (3)

A

Tender hepatomegaly - raised venous hepatic pressure
Pulsatile liver if tricuspid regurg
Ascites

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33
Q

5 broad causes and examples of RHF

A
  1. Chronic obstructive pulmonary disease (most common cause cor pulmonale)
  2. LHF
  3. Volume overload - ASD, primary tricuspid regurg
  4. Other causes pressure overload- pulmonary stenosis, idiopathic pulmonary HT
  5. Myocardial disease: R ventricular MI, cardiomyopathy
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34
Q

3 broad complications of mitral stenosis and examples of symptoms

A

Increased LA pressure (paroxysmal nocturnal dyspnoea )
Ruptured bronchial Veins (haemoptysis )
Pulmonary HT (oedema, fatigue)
Atrial fibrillation → thrombus

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35
Q

Face and neck signs of mitral stenosis (3)

A

Mitral faces

Normal JVP but prominent a wave if pulmonary HT, loss a wave if Afib

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36
Q

Vitals of mitral stenosis (4)

A

Tachypnea
HR+ BP may be normal or reduced volume
May be a-fib present due to LA enlarge

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37
Q

Chest palpation findings on mitral stenosis (3)

A

Apex beat tapping (short duration)
Palpable P2 if pulmonary HT
R ventricular heave

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38
Q

Findings on auscultation of mitral stenosis (5)

A

Diastolic murmur mid→late - low pitched and rumbling (use bell)
Loud s1
Opening snap before murmur “the OS is MS”
Louder on expiration (means murmur is on left), left lateral position, exercise
Late diastolic accentuation of murmur If sinus rhythm

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39
Q

2 causes of mitral stenosis

A
  • Rheumatic fever!
  • connective tissue disease: SLE, RA
  • Congenital parachute valve (all chordae insert into one papillary muscle)
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40
Q

Chest palpation of mitral regurg findings (5)

A

Apex displaced, diffuse, hyperdynamic (forceful but ill sustained) - due to ventricular dilatation due to volume overload
Pansystolic thrill at apex
Parasternal impulse

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41
Q

How will anatomy of heart change in mitral stenosis and how will this complicate (5)

A

Left atrial dilatation

  • leads to Afib → thrombus, embolism
  • back flow to lungs → pulmonary congestion + oedema
  • PHT
  • RHF
  • dysphagia: oesophagus compressed by dilated atrium
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42
Q

How will anatomy of the heart change in mitral regurg and how will this complicate

A

Left atrial (and ventricular) dilatation → cardiomegaly

Complications same as stenosis: lung and R heart pathology

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43
Q

Findings in auscultation of mitral regurg (7)

A
  • pansystolic murmur
  • Maximal at apex on inspiration, squat/leg raise, hand grip
  • softer on valsalva
  • Higher pitched and blowing character - use diaphragm
  • Radiate to axilla!
  • Soft/absent s1
  • Left ventricular s3 due to rapid ventricular filling in early diastole.
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44
Q

7 causes of mitral regurg

A

Acute

→ organic (primary)

  • Papillary muscle dysfunction or rupture (due to lhf or ischaemia)!
  • Infective endocarditis

Chronic

→ organic (primary)

  • Mitral valve prolapse!
  • Degenerative myxomatous - ageing
  • Connective tissue diseases- marfan’s, rheumatoid arthritis, ankylosing spondylitis
  • Rheumatic fever!

→ functional (secondary)

  • Cardiomyopathy (hypertrophic/dilated/restrictive) →> stretch valve
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45
Q

Symptoms of aortic stenosis (3)

A

SAD
Exertion all chest pain (angina) , dyspnoea and syncope.

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46
Q

Pulse in aortic stenosis

A 
Slow rising ("anacrotic/late peaking” ) = pulsus parvus et tardus 
Small volume
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47
Q

Chest palpation aortic stenosis

A

Systolic thrill at heart base (2nd-3rd intercostal space)

Apex beat bounding

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48
Q

Auscultation aortic stenosis findings (6)

A
  • S2 paradoxical split: Reversed = split during expiration (or narrowly split) s2 (due to delayed Lv ejection)
  • Harsh midsystolic ejection murmur crescendo decrescendo
  • Max over aortic area RUSB
  • Radiate to carotid arteries!
  • Loudest on expiration and sitting up, squat/leg raise; softer on valsalva
  • Ejection click preceding murmur in congenital stenosis (absent if calcified value or if stenosis not at valve level)

(Associated aortic regurg Common)

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49
Q

6 causes of aortic stenosis

A
  1. Degenerative calcific aortic stenosis (elderly, common)!
  2. Congenital bicuspid valve (younger calcific, common)
  3. Rheumatic (common)
  4. Supravalvular obstruction ( narrowing of asc aorta or a fibrous diaphragm just above- rare. Characteristic facies of broad forehead, wide set eyes,pointed chin. Loud A2 and thrill at sternal notch)
  5. Subvalvular obstruction (membranous diaphragm or fibrous ridge just below. Ass w/ a until regurg)
  6. Aortic sclerosis in elderly (no periph signs)
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50
Q

Peripheral Pulse in aortic regurg?

A

Collapsing, water hammer pulse (bounding) - raise pt arm

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51
Q

Carotid pulse in aortic regurg

A

Prominent pulsations

If severe or combined w/ stenosis, bisferiens pulse (2 beats per cycle)

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52
Q

Head sign of aortic regurg

A

De Musset sign: head bobbing due to hyperdynamic circulation

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53
Q

Hands sign of aortic regurg

A

Quincke’s sign: capillary beds of fingernails pulsate

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54
Q

Chest palpation findings of aortic regurg (2)

A

Apex beat displaced and hyper kinetic (thrusting)

Diastolic thrill at left eternal edge when pt sit up and expirate

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55
Q

Auscultation findings of aortic regurg (6)

A
  • A2 soft
  • Decrescendo high-pitched (blowing) early diastolic murmur (diaphragm of steth ) at apex/LLSB
  • Loudest at LLSB (radiate)Y
  • Loudest on expiration and sit forward, squat/leg raise, hand grip
  • softer on valsalva
  • RADIATE to carotids
    Usually systolic ejection murmur present: associated aortic stenosis/torrential flow

Austin-flint murmur may be present: low pitched rumbling mid-diastolic and pre - systolic murmur at apex from shuddering of mitral value due to regurgitant “jet”. NOT mitral stenosis bc s1 not loud and no opening snap.

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56
Q

Causes of aortic regurg (5)

A

CREAM

Chronic
- congenital eg bicuspid value and VSD; CTDs - aortic root dilatation: marfan’s syndrome, aortitis (RA); Calcified valve
• Rheumatic,
seronegative anthropathy esp ankylosing spondylitis
• Aortic root dilatation: idiopathic, aortitis (eg seroneg arthropathies, rheumatoid arthritis, tertiary syphilis!) dissecting aneurysm

Acute
• Endocarditis
• Marfan’s, Dissecting aneurysm.

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57
Q

Anatomical changes to heart in aortic stenosis and resulting complications (5)

A

LV hypertrophy

Asc aorta dilatation

3 complications = HHH

  • Haemolytic anaemia due to high shear forces from valve
  • HF
  • Heyde’s syndrome (triad AS, GI bleed, acquired von Willebrand syndrome)
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58
Q

Anatomical changes to heart in aortic regurg

A

LV hypertrophy causing HF

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59
Q

JVP of tricuspid regurg (2)

A

Raised if RVF

Large v wave

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60
Q

Palpation chest findings of tricuspid regurg

A

Parasternal impulse

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61
Q

Auscultation findings of tricuspid regurg (2)

A
  • Pansystolic high pitched blowing murmur at tricuspid area
  • Increase on inspiration, squat/leg raise, hand grip
  • decrease on valsalva
  • S3, S4
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62
Q

Abdomen signs of tricuspid regurg (3)

A

Ascites
Pulsating, large, tender liver
May cause right nipple to “dance” in time with heartbeat

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63
Q

Possible lung signs of tricuspid regurg

A

Pleural effusions

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64
Q

Feet and legs findings of tricuspid regurg (2)

A

Oedema

Dilated pulsatile veins

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65
Q

7 causes of tricuspid regurg

A
  1. Functional due to right ventricular failure
  2. Rheumatic (associated mitral disease)
  3. Infective endo ( IV drugs)! “Do you want to tri some drugs”
  4. Tricuspid valve prolapse
  5. Congenital - Eibstein’s anomaly, Marfan’s
  6. RV papillary muscle infarction (can’t anchor chordae tendinae)
  7. Trauma esp steering wheel injury to sternum; catheter injury ‘
  8. Pulmonary hypertension!
  9. Carcinoid syndrome,
  10. Myxomatous valve degeneration
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66
Q

How do diastolic bp and standing help in the diagnosis of HT? (2)

A

Rise in diastolic on standing: essential HT

Fall: secondary cause or antihypertensives

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67
Q

What is found in grade 1 hypertensive retinopathy?

A

“Silver wiring” of arteries only (sclerosis of vessel wall reduces its transparency so that the central light streak becomes broader and shinier)

68
Q

What is found in grade 2 hypertensive retinopathy?

A
  1. “silver wiring” of arteries and

2 arteriovenous nipping or nicking (indentation or deflection of the veins where they’re crossed by the arteries)

69
Q

What is found in grade 3 hypertensive retinopathy?

A
  1. “Silver wiring” of arteries
  2. Anteriovenous nipping or nicking
  3. Flame - shaped haemorrhages and exudates (soft cotton-wool spots due to ischaemia; or hard-lipid residues from leaking vessels )
    Also known as malignant (accelerated) HT
70
Q

What is found in grade 4 hypertensive retinopathy?

A

1 “silver wiring” of arteries

  1. Arteniovenous nipping or nicking
  2. Flame-shaped haemorrhages and exudates
  3. Papilloedema
71
Q

Name 5 types cardiomyopathy

A
  • Dilated (systolic heart failure: pump failure → decreased flow )
  • restrictive (diastolic hf: small chamber → decreased vol→ decreased flow)
  • hypertrophic / obstructive (diastolic: asymmetrical thickening of wall → blockage → reduced flow)
  • arrythmogenic rv CMO
  • unclassified: peripartum induced, tachyarrythmia induced, takotsubo (broken heart syndrome)
72
Q

Name 5 causes dilated cardiomyopathy

A

ID BIG MAPS

Primary genetic: Duchenne’s muscular dystrophy, haemochromatosis

Secondary

  • viral infection: coxsackie B
  • toxins: alcohol, cocaine, thiamine (B1) deficiency (beri beri ), chemo (doxorubicin)
  • pregnancy
  • idiopathic

Nb IHD, VHD not causes. They cause 2’ heart failure not DCMO

ID BIG MAPS Idiopathic, drugs/doxorubicin, beri beri, infection, genetic, myocarditis, alcoholism, peripartum, sarcoidosis

73
Q

Symptoms dilated cardiomyopathy?

A

Same as heart-failure: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea

74
Q

Exam findings dilated cardiomyopathy? (3)

A
  • s3 gallop
  • cardiomegaly - displaced, diffuse apex
  • raised JVP
75
Q

Definitive diagnosis cardiomyopathy?

A

Echo

76
Q

Name 3 complications dilated cardiomyopathy

A
  • Systolic heart failure
  • mitral, tricuspid valve regurgitation
  • arrhythmia
77
Q

Which condition will have tapping apex beat

A

Mitral stenosis. = palpable S1

78
Q

Name 6 causes restrictive cardiomyopathy

A

Fibrosis (scarring)

  • radiation
  • idiopathic

Infiltration

  • amyloidosis (protein)
  • sarcoidosis (granuloma)
  • inborn errors of metabolism
  • haemachromatosis (Iron)
79
Q

Name 2 specific features restrictive cardiomyopathy

A
  • Raised JVP
  • S4 (atria contract and push blood against non-compliant ventricular wall)
80
Q

Name 3 causes hypertrophic cardiomyopathy

A

Primary (this is the most common type of 1° cardiomyopathy

  • autosomal dominant mutation in genes that code for sarcomere proteins

Secondary

  • chronic ht
  • aortic stenosis
  • Friedrich’s ataxia
  • Fabry’s disease
81
Q

Presentation hypertrophic cardiomyopathy? (3)

A
  • Asymptomatic or
  • heart failure symptoms or
  • sudden death!
82
Q

Name 2 types obstructive cardiomyopathy

A
  • Obstructive type: most common. Interventricular septal hypertrophy blocks aortic outflow. Characterised by tachy
  • non-obstructive type: left ventricular hypertrophy. Ejection fraction preserved in early stages
83
Q

Name 5 specific heart exam findings in hypertrophic cardiomyopathy

A
  • S4 gallop
  • late ejection systolic crescendo-decrescendo murmur at llsb + apex due to obstruction ( maneuvers give it away)
  • louder with valsalva (bc this decreases preload,), nitrates (decrease after load)
  • softer on hand grip (increases after load) / squat (increase preload)
  • diffuse apex
84
Q

Treatment obstructive (hypertrophic) cardiomyopathy? (3)

A

Treat pump failure

  • beta blocker ( slow heart rate → heart has more time to fill → increase outflow → decrease symptoms )
  • consider: septal reduction with alcohol injection/ surgery; heart transplant

Amiodarone for arrhythmia
Anticoagulant for paroxysmal Afib or systemic emboli

Nb: digoxin contraindicated (may increase inotropy [beat with force] → exacerbate symptoms and worsen disease)

85
Q

Treatment dilated cardiomyopathy (5)

A

Treat back up of blood:

  • low salt diet, bed rest
  • diuretics
  • ace - inhibitor (also decreases outflow resistance)

Treat pump failure

  • beta blockers / CCB (decrease oxygen demand of heart )
  • digoxin ( increase contractile strength to overcome pump failure )
  • consider: pacemaker, heart transplant

Anticoagulant

86
Q

Treatment restrictive cardiomyopathy? (3)

A

Treat back up of blood:

  • low salt diet, bed rest
  • diuretics
  • ace - inhibitor (also decreases outflow resistance)

Treat pump failure

  • consider: pacemaker, heart transplant
87
Q

How grade systolic murmurs

A
  1. Faint, heard by expert
  2. Soft, heard in all positions
  3. Moderately loud
  4. Loud + thrill
  5. Very loud heard with stethoscope partly off chest + thrill
  6. Loud heard with stethoscope entirely off chest + thrill
88
Q

How grade diastolic murmurs

A
  1. Barely audible
  2. Soft
  3. Moderately loud
  4. Loud + thrill
89
Q

Peripheral smear in microcytic anaemia?

A
  • Anisocytosis (different size erythrocytes)
  • hypochromasia
90
Q

Peripheral smear in macrocytic anaemia?

A
  • Hypersegmented neutrophils
  • Large immature RBCs
91
Q

Name 4 systolic murmurs

A

PASS = pulmonary + aortic stenosis systolic

  • PS
  • AS
  • tricuspid regurg
  • mitral regurg
  • vSD
92
Q

Name 4 diastolic murmurs

A

PAID = pulmonary + aortic insufficiency diastolic

  • AR
  • PR
  • tricuspid stenosis
  • mitral stenosis
93
Q

How does expiration and inspiration make murmurs louder/softer

A

RILE

  • R sides murmurs = louder in inspiration
  • L = expiration
94
Q

Which manoeuvres make murmurs louder (3)

A
  • all louder: Squat/leg raise (EXCEPT hypertrophic obstructive CMO and mitral prolapse) bc increase preload
  • regurg louder: left hand grip/squeeze (increase afterload)
  • HOCM + MVP louder: nitrate (decrease afterload)
95
Q

Which manoeuvres make murmurs softer (2)

A
  • all murmurs except HOCM + MVP: Valsalva (decrease preload)
  • softer HOCM + MVP: L hand grip/squeeze (increase afterload)
96
Q

Name 3 types split S2 and causes

A
  • Normal splitting on inspiration / wide splitting: pulmonary stenosis, right BBB (“wpr”)
  • Fixed splitting (during inspiration+ expiration): ASD (“FA”)
  • paradoxical/reversed splitting (P2 heard first, caused by delayed av closure): AS, L BBB (“PAL”)
97
Q

Name 2 causes decreased /absent x descent on JvP wareform

A
  • Tricuspid regurg
  • right heart failure
98
Q

Name causes increased y descent on JvP wareform

A

Constrictive pericarditis

99
Q

Name causes absent y descent on JvP wareform

A

Cardiac tamponade
(Atria not emptying)

100
Q

How does JvP waveform correspond to heart sounds

A

JvP has 2 visible pulsations normally per heartbeat cycle.

a wave (most prominent): with S1
X descent: after S1
C: with carotid pulse (only seen if pathology )
V: with s2 (second, less prominent waveform seen)
Y descent: after s2

101
Q

Which JvP pulsations are clinically visible

A

2 pulsations per heartbeat cycle.

A wave: first pulsation with s1
V wave: second with s2.

C only seen (with carotid pulse) if pathology.

102
Q

Name 2 mimickers of mitral stenosis

A
  • left atrial myxoma
  • bacterial endocarditis vegetations
103
Q

Name 6 peripheral signs of aortic regurg

A
  • Hill’s sign: wide pulse pressure (foot:arm SBP >20)
  • water hammer/collapsing/bounding pulse
  • De musset sign (head nod)
  • Quincke sign (pulsating nail bed)
  • traube’s sign (pistol shot sounds over femoral)
  • prominent carotid pulse
104
Q

Causes mitral prolapse? (4)

A

“To win MVP your team has to click”

  • MVP: Myxomatous valve disease from connective tissue diseases: Ehlers Danlos, marfans, PCKD
  • Rheumatic fever
  • IE
  • Familial: young women
105
Q

Name 6 complication mitral valve prolapse

A
  • sudden death!
  • HF
  • arrythmia
  • systemic emboli
  • cardioembolic stroke
  • chordal rupture
106
Q

Heart auscultation in mitral valve prolapse?

A

“To win MVP, your team has to click”

  • midsystolic click!
  • late systolic crescendo murmur
107
Q

Name the ACCF / AHA stages of heart failure

A
  • stage A: high risk for developing CHF eg smoking but no structural heart disease or symptoms
  • B : structural disorder but never any symptoms (= class 1 nyha)
  • c: past or current symptoms of hf. Symptoms associated with underlying heart disease (= class 2-4 nyha)
  • D : end stage. (= class iv nyha )

Can’t improve stage

108
Q

Name the NYHA functional classification of heart failure

A
  • Class 1: No limitation of physical activity,
  • 2: slight limitation but comfortable at rest
  • 3a: marked limitation but comfortable at rest with no dyspnoea
  • 3 b: marked limitation but comfortable at rest with recent dyspnoea at rest
  • 4: can’t carry out any physical activity without discomfort and symptoms persist at rest.
109
Q

Name 5 most common causes CHF

A

Myocardium

  1. Coronary artery disease (ihd/mi → dilation),
  2. Hypertensive heart disease (hypertrophy → dilation)
  3. Idiopathic, often dilated cardiomyopathy’s
  4. Alcohol → dilated cardiomyopathy

Endocardium
4. Valvulopathy

110
Q

Anatomical changes and complications of tricuspid regurg ?

A

Rv hypertrophy which worsens regurg

  • Hf (increased preload)
111
Q

Name 4 causes pulmonary regurg

A
  • Congenital malformation of leaflets: TOF , NooNan’s syndrome, congenital rubella
  • ie
  • rheumatic
  • Pht
112
Q

Anatomical changes in pulmonary regurg and complications?

A

Rv hypertrophy

  • RHF
113
Q

Heart signs of pulmonary regurg (3)

A
  • High pitched blowing crescendo-decrescendo diastolic murmur at LUSB
  • louder on inspiration, squat/leg raise, hand grip
  • softer with valsalva
114
Q

Name 2 causes pulmonary stenosis

A
  • Congenital: WARNED (Williams, allagille = fewer bile ducts, rubella, Noonan’s, ehlers-danlos )
  • systemic disease: carcinoid syndrome
115
Q

Heart signs of pulmonary stenosis? (5)

A
  • ejection click
  • harsh ejection systolic murmur at LUSB
  • louder with inspiration, squat/leg raise
  • softer with valsalva
  • May have s4 ( ra hypertrophy)
116
Q

Peripheral signs pulmonary stenosis

A
  • JVP: giant a waves (ra hypertrophy)
  • RHF signs
117
Q

Anatomical change and complications in pulmonary stenosis?

A

Rv hypertrophy, later also ra

  • RHF
118
Q

Cause tricuspid stenosis?

A

Rare.

Rheumatic fever!

119
Q

Anatomical changes and complications of tricuspid stenosis?

A

Ra dilation

  • afib
120
Q

Heart signs tricuspid stenosis

A

Diastolic rumble at llsb

121
Q

Peripheral signs tricuspid stenosis

A

Raised JVP with giant A waves and slow y descent

122
Q

Name 2 peripheral signs hypertrophic obstructive cardiomyopathy

A
  • Pulse sharp rising or jerky, may be double (bisferiers)
  • JvP large A wave
123
Q

Name the 5 acyanotic congenital heart diseases

A

Cardiac VAPE

  • coarctation
  • VSD
  • ASD
  • PDA
    (Eisenmenger)
124
Q

Heart signs vSD? (2)

A
  • Pansystolic harsh murmur at llsb
  • louder on expiration, smaller defect (disappear eventually)
  • May have S3 s4

Sometimes associated Mr

125
Q

Anatomical defect in PDA?

A

Aorta→ pulmonary artery

126
Q

Name 3 heart signs PDA

A
  • Continuous machinery murmur! @Lusb
  • paradoxical splitting of s2
  • hyperkinetic apex
127
Q

Name 2 peripheral signs PDA

A
  • Collapsing pulse!
  • low DBP
128
Q

Treatment heart failure? (6)

A

Non-pharms: treat exacerbates and causes, avoid NSAIDs (fluid retention) + verapamil (negative inotrope), stop smoking, low salt, weight.

  1. Ace-inhibitor or arb
  2. Diuretic: loop (furosemide) for symptoms. Add potassium sparing diuretic (spironolactone eg aldactone ) if low potassium, arrhythmia predisposition, concurrent digoxin therapy, or still oedema. If refractory oedema, add thiazide (hctz)
  3. Beta blocker cardioselective eg carvedilol - start low go slow
  4. Digoxin if arrhythmia risk (tachycardia) or sinus rhythm but still symptoms.
  5. Vasodilators: hydralazine + Isosorbide dinitrate if intolerant of ace-i/arb or to reduce mortality in black patients
129
Q

Which troponin is cardiac specific

A

Troponin I

130
Q

What causes heaving apex

A

Outflow obstruction:

  • aortic stenosis
  • systemic ht
131
Q

What causes thrusting apex

A

Volume overload

  • mitral regurg
  • aortic regurg
132
Q

What causes diffuse apex

A
  • Lv failure
  • DCMO
133
Q

What causes double impulse apex

A

Hypertrophic obstructive cardiomyopathy

134
Q

Name 3 causes bounding arterial pulses

A
  • Aortic regurgitation!
  • anaemia
  • Co2 retention
  • liver failure
  • sepsis
135
Q

Name 3 causes small volume pulses

A
  • Sepsis
  • aortic stenosis
  • pericardial effusion
136
Q

Name 3 causes collapsing pulses

A
  • Aortic regurgitation
  • PDA
  • hyperthyroid
  • av malformations
137
Q

Name causes anacrotic (slow rising) pulses

A

Aortic stenosis

138
Q

Name 4 features Ebstein’s anomaly

A
  • Tricuspid valve set lower in r heart towards apex, very long and tethered so not good flow, degree of stenosis (if stenosis severe, need PDA)
  • arterialisation of rv (smaller) → poor flow to pulmonary vessels
  • dependent on ASD shunt → mixing blood to La → deoxygenated blood → cyanosis
  • associated with wolf Parkinson white Syndrome
139
Q

Management angina? (7)

A
  • Lifestyle: stop smoking, exercise, weight loss. Modify RFs: ht, diabetes
  • aspirin 75 - 150 mg/24h reduces mortality
  • beta blockers
  • nitrates GTN spray / sublingual tabs: for symptoms, up to every half hour. Or for prophylaxis
  • CCB
  • statin
  • consider K channel activator eg nicorandil
140
Q

JVP in cor pulmonale?

A

Prominent a and V waves

141
Q

Treatment cor pulmonale? (7)

A
  • Treat underlying cause eg COPD, pulmonary infection
  • treat respiratory failure: give oxygen
  • treat cardiac failure: furosemide / spironolactone, ace - I, beta blocker, digoxin, vasodilators if indicated
  • pulmonary vasodilators: CCB, long acting prostacyclin/ analogue, phosphodiesterase 5 inhibitors!(sildenafil!), endothelin -r analogues (bosentan)
  • dobutamine (inotrope to strengthen contractions ) if in cardiOgenic shock
  • consider venesection if haematocrit > 55% ‘
  • consider heart- lung transplant in young because poor prognosis.
142
Q

Treatment hypertensive urgency?

A

2 po agents to decrease DBP to 100 over 48 -72h, not fast bc cerebral autoregulation poor so risk stroke.

  • CCB: amlodipine
  • ace -i: enalapril
  • bb: atenolol
143
Q

Treatment hypertensive emergency? (3)

A

First 30 min - 2 h iv treatment. Don’t drop by > 25%

  • labetalol 2mg/min (max dose (1-2mg/kg)
  • If mi, CCf: glyceryl trinitrate 5-10 mcg/min + furosemide 40 - 80mg

Next 2-6 h: iv /oral

  • enalapril 2,5 mg po, increase according to response.
  • monitor renal function.

Never use sublingual nifedipine to drop bp! Drops it too quick → risk stroke

144
Q

Diagnoses acute heart failure?

A

BNP > 400 or nt- pro BNP > 900

145
Q

Treatment stemi? (8)

A

Oh bring BATMAN

  • Resuscitate: oxygen face mask, draw bloods, brief assessment
  • Beta blocker atenolol 5 mg iv
  • start best medical therapy: statin, stop smoking etc. Not CCB
  • aspirin 300mg po
  • Thrombolysis! (streptokinase 1,5 million u in 100 ml ns over 1 h. ) or primary angioplasty PCI (this is best but rarely possible)
  • Morphine 5-10mg iv+ metoclopramide 10mg iv (dopamine receptor antag)
  • ace-i even if normotensive.
  • sublingual GTN 1 tab as required unless hypotensive
146
Q

Name 4 indications thrombolysis in acute mi

A

Presentation within 12h chest pain with:

  • St elevation > 2mm 2 or more chest leads
  • > 1 mm 2 or more limb leads
  • posterior infarct (dominant r waves and St depression v1 -v3)
  • new onset lbbb

Presentation within 12 - 24h if continuing chest pain and or St elevation

147
Q

Criteria for infective endocarditis? (7)

A

Duke criteria: 2 major or 1 major + 3 minor or 5 minor

Major

  • positive blood culture:
    → typical organism (strep viridans, staph aureus or epidermis, enterococci, diptheroids, icroaerophilic strep) in 2 separate cultures or
    → persistently positive cultures eg 3 > 12h apart or majority > 4
  • endocardium involvement
    → positive echo: vegetation, abscess, dehiscence of prosthetic valve or
    → new valvular regurgitation

Minor

  • predisposition: cardiac lesion, iv drug use
  • fever >38
  • vascular/immunological sign: haematuria, glomerulonephritis + acute renal failure. Roth spots, splinter haemorrhages, Osler nodes, janeway lesions
  • positive blood culture that don’t meet major criteria
  • positive echo that doesn’t meet major
148
Q

Treatment infective endocarditis?

A

BAD GERM

  • Empirical: benzylpenicillin 1,2 g/4h iv + gentamicin 1mg / kg/8h iv for four weeks. If suspect staph, add flucloxacillin
  • enterococcus: amoxicillin + gentamicin
  • strep: benzoyl penicillin then amoxicillin + gentamicin
149
Q

Diagnosis rheumatic fever?

A

Jones criteria: 2 major or 1 major + 2 minor
+ evidence strep infection: throat culture gahbs or high anti-streptolysin o titers

JONES CAFE PAL

Major

  • joint involvement: migratory, “flitting” polyarthritis, usually larger joints
  • carditis: conduction defects, murmurs, tachycardia, pericardial rub, ccf…
  • nodules subcutaneous: small, mobile, painters on extensor surfaces and spine
  • erythema marginatum
  • Sydenham’s chorea

Minor

  • CRP raised
  • arthralgia
  • fever
  • ESR raised
  • prolonged p-r interval
  • anamnesis (history) of rf
  • leukocytosis
150
Q

Treatment rheumatic fever?

A

Very BAD

  • Benzylpenicillin 0,6 - 1,2g IM stat then
  • penicillin V 250 mg/6h po
  • aspirin
  • haloperidol/diazepam for chorea
151
Q

Name 9 causes atrial fibrillation

A

I HAVE AFIB

  • IHD, idiopathic
  • hyperthyroidism
  • anaemia; age; autonomic; apnoea OSA
  • valvular heart disease: mitral stenosis
  • elevated BP; electrocution; embolism PE
  • atrial septal defect
  • failure (chf)
  • infection (sepsis)
  • booze
152
Q

Name the 5 cyanotic congenital heart diseases

A

5 Ts

  • Truncus arteriosus
  • tetralogy of fallot
  • transposition of the great arteries
  • Tricuspid atresia
  • total anomalous pulmonary venous return
153
Q

Name 4 features tetralogy of fallot

A

PROVe

  • pulmonary stenosis
  • RVH
  • overriding aorta
  • vSD
154
Q

Name 10 causes secondary hypertension

A

Abcdef

  • apnoea (OSA); acromegaly; accuracy (incorrect measurement); adrenal phaeochromocytoma
  • Birth control
  • coarctation of the aorta; Cushing’s syndrome; Conn’S syndrome; catecholamines; kidney
  • drugs: alcohol, nasal decongestants, estrogen
  • endocrine disorders; erythropoietin
  • fibromuscular dysplasia
155
Q

Name 4 complications myocardial infarction

A

CRAP

  • congestive heart failure;cardiogenic shock; CVA (lv thrombus)
  • RV infarct ; rupture LV causing tamponade
  • acute MR, acute vSD, aneurysm, arrhythmia
  • pericarditis (from infarct or Dressler’s syndrome = inflammation )
156
Q

What is Kussmaul’s sign and name 3 causes

A

Paradoxical rise in JVP occurring during inspiration (usually inspiration sucks blood into RH and out of jugular veins )
Caused by constrictive pericarditis, cardiac tamponade, right heart failure

157
Q

Which score do for atrial fibrillation stroke risk?

A

Chads 2VASC score

To determine if need warfarin

Has bled score for bleeding risk on warfarin

158
Q

Which valve defect is S3 a sign of

A

Aortic / mitral regurgitation - hear blood hit ventricular wall

159
Q

Which valve defect is s4 a sign of

A

Aortic stenosis

160
Q

Name cause of slow-rising, weak, delayed arterial pulse

A

Aortic stenosis

161
Q

Cardiac output equation

A

Co= Sv x HR

Sv = preload, afterload, contractility

162
Q

Name 6 mechanisms of heart failure with examples

A
  • Reduced ventricular contractility: MI, myocarditis, cardiomyopathy
  • ventricular outflow obstruction (pressure overload): ht, aortic stenosis (lhf), pulmonary ht, pulmonary valve stenosis (rhf)
  • ventricular inflow obstruction: mitral + tricuspid stenosis (afib common)
  • ventricular volume overload: lv volume overload (mitral/aortic regurgitation), VSD, RV overload (asd), increased metabolic demand (high output)
  • arrhythmia: afib, tachycardia, complete heart block
  • diastolic dysfunction: constrictive pericarditis, restrictive cardiomyopathy, LV hypertrophy +fibrosis, cardiac tamponade
163
Q

Name 5 signs LHF

A
  • Raised JVP
  • pulmonary edema ( dyspnoea, inspiratory crepitations lung bases )
  • cardiomegaly
  • pleural effusion
  • pitting oedema
164
Q

Name 8 complications heart failure

A
  • Renal failure: poor perfusion, ace-i, arb
  • hypo K: hyperaldosteronism from RAAS activation , diuretics
  • hyper k: renal failure, ace-i, arb
  • hypo Na: severe, poor prognostic sign. From high vasopressin causing water retention, failure cell membrane ion pump, diuretic
  • impaired liver function: hepatic venous congestion, poor arterial perfusion,
  • thromboembolism: low output
  • arrhythmia: electrolyte changes, underlying cardiac disease, sympathetic activation
  • sudden death: V fib
165
Q

Treatment atrial fibrillation? (3)

A
  • Rhythm control: electrical/ pharmacological cardioversion - amiodarone
  • rate control: Beta blocker , digoxin
  • thromboprophylaxis: do scores for warfarin
166
Q

Treatment torsades de pointes

A

IV magnesia

Internal Medicine (20 decks)

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