Cardiovascular Flashcards
1
Q
What does JVP measure
A
Pressure in right atrium (indirectly)
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;
3
Q
Path of constrictive pericarditis
A
Pericardium thickens and scars leading to decreased elasticity
4
Q
Def of cardiac tamponade
A
Accumulation of pericardial fluid under pressure in pericardial sac, leading to compression of heart
5
Q
How to tell difference between JVP and carotid pulse
A
JVP has 2 pulses, carotid 1
JVP pulse not palpable, carotid is.
6
Q
Normal JVP?
A
3Cm
7
Q
Draw JVP waveform
A
See picture 1 internal medicine folder
8
Q
What does A wave on JVP waveform represent
A
A for Atrial contraction
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
10
Q
What does C wave on JVP waveform represent
A
Start of systolic Contraction
C for Closure of tricuspid
11
Q
What does V wave in JVP waveform represent?
A
Atrial relaxation, tricuspid still closed. Maximal atrial filling
V for villing (filling)
12
Q
What does y descent in JVP waveform represent?
A
Tricuspid opening and emptYing of atrium
13
Q
What can cause an absent A wave in the JVP waveform?
A
Atrial fibrillation
Bc a wave = atrial contraction. Not contracting properly.
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
15
Q
What can cause large V waves in JVP waveform?
A
Tricuspid regurgitation.
Bc makes atria super full
16
Q
5 symptoms of LHF
A
Exertion dyspnoea Orthopnoea Paroxysmal nocturnal dyspnoea Cough W/ white frothy or pink sputum Fatigue
17
Q
3 vital signs of LHF
A
Tachypnea
Hypotension
Tachycardia
18
Q
Breathing pattern of LHF
A
Cheyne-stokes breathing
(Deep breathing then apnea)
19
Q
JACCOLD signs of LHF
A
Peripheral and central cyanosis
Periph oedema due to associated RHF
20
Q
Pulse of LHF
A
Tachycardia
Low pulse pressure
Pulsus alterans - rare
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)
22
Q
Auscultate LHF ( 2)
A
Left ventricular s3 best heard at apex.
Functional mitral regurg secondary to valve ring dilatation
23
Q
Lung findings LHF
A
Basal inspiratory crackles due to pulmonary congestion
Crackles and wheezes throughout due to pulmonary oedema
24
Q
JVP signs LHF
A
Increased
Positive abdominojugular reflux test
25
4 broad causes of LHF and examples
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
26
Symptoms of RHF (4)
Ankle/sacral/abdominal swelling
Anorexia
Lethargy
Dyspnea (poor pulmonary perfusion)
27
JACCOLD of RHF
Peripheral cyanosis
| Pitting ankle and sacral oedema
28
Pulse in RHF
Low volume
29
JVP in RHF (3)
Raised
Kussmaul's sign (increase on inspiration)
Large v waves (functional tricuspid regurg)
30
Chest palpation RHF
Right ventricular heave = RV hypertrophy = LLSB heave
If severe, epigastric heave
31
Auscultate RHF heart ( 2)
Right ventricular s3 best heard at lower left sternal edge but soft.
Pansystolic murmur of functional tricuspid regurg
32
Abdomen signs RHF (3)
Tender hepatomegaly - raised venous hepatic pressure
Pulsatile liver if tricuspid regurg
Ascites
33
5 broad causes and examples of RHF
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
34
3 broad complications of mitral stenosis and examples of symptoms
Increased LA pressure (paroxysmal nocturnal dyspnoea )
Ruptured bronchial Veins (haemoptysis )
Pulmonary HT (oedema, fatigue)
Atrial fibrillation → thrombus
35
Face and neck signs of mitral stenosis (3)
Mitral faces
| Normal JVP but prominent a wave if pulmonary HT, loss a wave if Afib
36
Vitals of mitral stenosis (4)
Tachypnea
HR+ BP may be normal or reduced volume
May be a-fib present due to LA enlarge
37
Chest palpation findings on mitral stenosis (3)
Apex beat tapping (short duration)
Palpable P2 if pulmonary HT
R ventricular heave
38
Findings on auscultation of mitral stenosis (5)
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
39
2 causes of mitral stenosis
- Rheumatic fever!
- connective tissue disease: SLE, RA
- Congenital parachute valve (all chordae insert into one papillary muscle)
40
Chest palpation of mitral regurg findings (5)
Apex displaced, diffuse, hyperdynamic (forceful but ill sustained) - due to ventricular dilatation due to volume overload
Pansystolic thrill at apex
Parasternal impulse
41
How will anatomy of heart change in mitral stenosis and how will this complicate (5)
Left atrial dilatation
- leads to Afib → thrombus, embolism
- back flow to lungs → pulmonary congestion + oedema
- PHT
- RHF
- dysphagia: oesophagus compressed by dilated atrium
42
How will anatomy of the heart change in mitral regurg and how will this complicate
Left atrial (and ventricular) dilatation → cardiomegaly
Complications same as stenosis: lung and R heart pathology
43
Findings in auscultation of mitral regurg (7)
- 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.
44
7 causes of mitral regurg
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
45
Symptoms of aortic stenosis (3)
SAD
Exertion all chest pain (angina) , dyspnoea and syncope.
46
Pulse in aortic stenosis
```
Slow rising ("anacrotic/late peaking” ) = pulsus parvus et tardus
Small volume
```
47
Chest palpation aortic stenosis
Systolic thrill at heart base (2nd-3rd intercostal space)
Apex beat bounding
48
Auscultation aortic stenosis findings (6)
- 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)
49
6 causes of aortic stenosis
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)
50
Peripheral Pulse in aortic regurg?
Collapsing, water hammer pulse (bounding) - raise pt arm
51
Carotid pulse in aortic regurg
Prominent pulsations
| If severe or combined w/ stenosis, bisferiens pulse (2 beats per cycle)
52
Head sign of aortic regurg
De Musset sign: head bobbing due to hyperdynamic circulation
53
Hands sign of aortic regurg
Quincke's sign: capillary beds of fingernails pulsate
54
Chest palpation findings of aortic regurg (2)
Apex beat displaced and hyper kinetic (thrusting)
Diastolic thrill at left eternal edge when pt sit up and expirate
55
Auscultation findings of aortic regurg (6)
- 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.
56
Causes of aortic regurg (5)
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.
57
Anatomical changes to heart in aortic stenosis and resulting complications (5)
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)
58
Anatomical changes to heart in aortic regurg
LV hypertrophy causing HF
59
JVP of tricuspid regurg (2)
Raised if RVF
| Large v wave
60
Palpation chest findings of tricuspid regurg
Parasternal impulse
61
Auscultation findings of tricuspid regurg (2)
- Pansystolic high pitched blowing murmur at tricuspid area
- Increase on inspiration, squat/leg raise, hand grip
- decrease on valsalva
- S3, S4
62
Abdomen signs of tricuspid regurg (3)
Ascites
Pulsating, large, tender liver
May cause right nipple to "dance" in time with heartbeat
63
Possible lung signs of tricuspid regurg
Pleural effusions
64
Feet and legs findings of tricuspid regurg (2)
Oedema
| Dilated pulsatile veins
65
7 causes of tricuspid regurg
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
66
How do diastolic bp and standing help in the diagnosis of HT? (2)
Rise in diastolic on standing: essential HT
Fall: secondary cause or antihypertensives
67
What is found in grade 1 hypertensive retinopathy?
"Silver wiring" of arteries only (sclerosis of vessel wall reduces its transparency so that the central light streak becomes broader and shinier)
68
What is found in grade 2 hypertensive retinopathy?
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
What is found in grade 3 hypertensive retinopathy?
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
What is found in grade 4 hypertensive retinopathy?
1 "silver wiring" of arteries
2. Arteniovenous nipping or nicking
3. Flame-shaped haemorrhages and exudates
4. Papilloedema
71
Name 5 types cardiomyopathy
- 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
Name 5 causes dilated cardiomyopathy
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
Symptoms dilated cardiomyopathy?
Same as heart-failure: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea
74
Exam findings dilated cardiomyopathy? (3)
- s3 gallop
- cardiomegaly - displaced, diffuse apex
- raised JVP
75
Definitive diagnosis cardiomyopathy?
Echo
76
Name 3 complications dilated cardiomyopathy
- Systolic heart failure
- mitral, tricuspid valve regurgitation
- arrhythmia
77
Which condition will have tapping apex beat
Mitral stenosis. = palpable S1
78
Name 6 causes restrictive cardiomyopathy
Fibrosis (scarring)
- radiation
- idiopathic
Infiltration
- amyloidosis (protein)
- sarcoidosis (granuloma)
- inborn errors of metabolism
- haemachromatosis (Iron)
79
Name 2 specific features restrictive cardiomyopathy
- Raised JVP
- S4 (atria contract and push blood against non-compliant ventricular wall)
80
Name 3 causes hypertrophic cardiomyopathy
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
Presentation hypertrophic cardiomyopathy? (3)
- Asymptomatic or
- heart failure symptoms or
- sudden death!
82
Name 2 types obstructive cardiomyopathy
- 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
Name 5 specific heart exam findings in hypertrophic cardiomyopathy
- 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
Treatment obstructive (hypertrophic) cardiomyopathy? (3)
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
Treatment dilated cardiomyopathy (5)
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
Treatment restrictive cardiomyopathy? (3)
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
How grade systolic murmurs
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
How grade diastolic murmurs
1. Barely audible
2. Soft
3. Moderately loud
4. Loud + thrill
89
Peripheral smear in microcytic anaemia?
- Anisocytosis (different size erythrocytes)
- hypochromasia
90
Peripheral smear in macrocytic anaemia?
- Hypersegmented neutrophils
- Large immature RBCs
91
Name 4 systolic murmurs
PASS = pulmonary + aortic stenosis systolic
- PS
- AS
- tricuspid regurg
- mitral regurg
- vSD
92
Name 4 diastolic murmurs
PAID = pulmonary + aortic insufficiency diastolic
- AR
- PR
- tricuspid stenosis
- mitral stenosis
93
How does expiration and inspiration make murmurs louder/softer
RILE
- R sides murmurs = louder in inspiration
- L = expiration
94
Which manoeuvres make murmurs louder (3)
- 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
Which manoeuvres make murmurs softer (2)
- all murmurs except HOCM + MVP: Valsalva (decrease preload)
- softer HOCM + MVP: L hand grip/squeeze (increase afterload)
96
Name 3 types split S2 and causes
- 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
Name 2 causes decreased /absent x descent on JvP wareform
- Tricuspid regurg
- right heart failure
98
Name causes increased y descent on JvP wareform
Constrictive pericarditis
99
Name causes absent y descent on JvP wareform
Cardiac tamponade
(Atria not emptying)
100
How does JvP waveform correspond to heart sounds
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
Which JvP pulsations are clinically visible
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
Name 2 mimickers of mitral stenosis
- left atrial myxoma
- bacterial endocarditis vegetations
103
Name 6 peripheral signs of aortic regurg
- 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
Causes mitral prolapse? (4)
“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
Name 6 complication mitral valve prolapse
- sudden death!
- HF
- arrythmia
- systemic emboli
- cardioembolic stroke
- chordal rupture
106
Heart auscultation in mitral valve prolapse?
“To win MVP, your team has to click”
- midsystolic click!
- late systolic crescendo murmur
107
Name the ACCF / AHA stages of heart failure
- 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
Name the NYHA functional classification of heart failure
- 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
Name 5 most common causes CHF
Myocardium
1. Coronary artery disease (ihd/mi → dilation),
2. Hypertensive heart disease (hypertrophy → dilation)
3. Idiopathic, often dilated cardiomyopathy's
5. Alcohol → dilated cardiomyopathy
Endocardium
4. Valvulopathy
110
Anatomical changes and complications of tricuspid regurg ?
Rv hypertrophy which worsens regurg
- Hf (increased preload)
111
Name 4 causes pulmonary regurg
- Congenital malformation of leaflets: TOF , NooNan's syndrome, congenital rubella
- ie
- rheumatic
- Pht
112
Anatomical changes in pulmonary regurg and complications?
Rv hypertrophy
- RHF
113
Heart signs of pulmonary regurg (3)
- High pitched blowing crescendo-decrescendo diastolic murmur at LUSB
- louder on inspiration, squat/leg raise, hand grip
- softer with valsalva
114
Name 2 causes pulmonary stenosis
- Congenital: WARNED (Williams, allagille = fewer bile ducts, rubella, Noonan's, ehlers-danlos )
- systemic disease: carcinoid syndrome
115
Heart signs of pulmonary stenosis? (5)
- ejection click
- harsh ejection systolic murmur at LUSB
- louder with inspiration, squat/leg raise
- softer with valsalva
- May have s4 ( ra hypertrophy)
116
Peripheral signs pulmonary stenosis
- JVP: giant a waves (ra hypertrophy)
- RHF signs
117
Anatomical change and complications in pulmonary stenosis?
Rv hypertrophy, later also ra
- RHF
118
Cause tricuspid stenosis?
Rare.
Rheumatic fever!
119
Anatomical changes and complications of tricuspid stenosis?
Ra dilation
- afib
120
Heart signs tricuspid stenosis
Diastolic rumble at llsb
121
Peripheral signs tricuspid stenosis
Raised JVP with giant A waves and slow y descent
122
Name 2 peripheral signs hypertrophic obstructive cardiomyopathy
- Pulse sharp rising or jerky, may be double (bisferiers)
- JvP large A wave
123
Name the 5 acyanotic congenital heart diseases
Cardiac VAPE
- coarctation
- VSD
- ASD
- PDA
(Eisenmenger)
124
Heart signs vSD? (2)
- Pansystolic harsh murmur at llsb
- louder on expiration, smaller defect (disappear eventually)
- May have S3 s4
Sometimes associated Mr
125
Anatomical defect in PDA?
Aorta→ pulmonary artery
126
Name 3 heart signs PDA
- Continuous machinery murmur! @Lusb
- paradoxical splitting of s2
- hyperkinetic apex
127
Name 2 peripheral signs PDA
- Collapsing pulse!
- low DBP
128
Treatment heart failure? (6)
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
Which troponin is cardiac specific
Troponin I
130
What causes heaving apex
Outflow obstruction:
- aortic stenosis
- systemic ht
131
What causes thrusting apex
Volume overload
- mitral regurg
- aortic regurg
132
What causes diffuse apex
- Lv failure
- DCMO
133
What causes double impulse apex
Hypertrophic obstructive cardiomyopathy
134
Name 3 causes bounding arterial pulses
- Aortic regurgitation!
- anaemia
- Co2 retention
- liver failure
- sepsis
135
Name 3 causes small volume pulses
- Sepsis
- aortic stenosis
- pericardial effusion
136
Name 3 causes collapsing pulses
- Aortic regurgitation
- PDA
- hyperthyroid
- av malformations
137
Name causes anacrotic (slow rising) pulses
Aortic stenosis
138
Name 4 features Ebstein's anomaly
- 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
Management angina? (7)
- 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
JVP in cor pulmonale?
Prominent a and V waves
141
Treatment cor pulmonale? (7)
- 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
Treatment hypertensive urgency?
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
Treatment hypertensive emergency? (3)
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
Diagnoses acute heart failure?
BNP > 400 or nt- pro BNP > 900
145
Treatment stemi? (8)
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
Name 4 indications thrombolysis in acute mi
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
Criteria for infective endocarditis? (7)
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
Treatment infective endocarditis?
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
Diagnosis rheumatic fever?
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
Treatment rheumatic fever?
Very BAD
- Benzylpenicillin 0,6 - 1,2g IM stat then
- penicillin V 250 mg/6h po
- aspirin
- haloperidol/diazepam for chorea
151
Name 9 causes atrial fibrillation
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
Name the 5 cyanotic congenital heart diseases
5 Ts
- Truncus arteriosus
- tetralogy of fallot
- transposition of the great arteries
- Tricuspid atresia
- total anomalous pulmonary venous return
153
Name 4 features tetralogy of fallot
PROVe
- pulmonary stenosis
- RVH
- overriding aorta
- vSD
154
Name 10 causes secondary hypertension
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
Name 4 complications myocardial infarction
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
What is Kussmaul's sign and name 3 causes
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
Which score do for atrial fibrillation stroke risk?
Chads 2VASC score
To determine if need warfarin
Has bled score for bleeding risk on warfarin
158
Which valve defect is S3 a sign of
Aortic / mitral regurgitation - hear blood hit ventricular wall
159
Which valve defect is s4 a sign of
Aortic stenosis
160
Name cause of slow-rising, weak, delayed arterial pulse
Aortic stenosis
161
Cardiac output equation
Co= Sv x HR
Sv = preload, afterload, contractility
162
Name 6 mechanisms of heart failure with examples
- 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
Name 5 signs LHF
- Raised JVP
- pulmonary edema ( dyspnoea, inspiratory crepitations lung bases )
- cardiomegaly
- pleural effusion
- pitting oedema
164
Name 8 complications heart failure
- 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
Treatment atrial fibrillation? (3)
- Rhythm control: electrical/ pharmacological cardioversion - amiodarone
- rate control: Beta blocker , digoxin
- thromboprophylaxis: do scores for warfarin
166
Treatment torsades de pointes
IV magnesia
