Cardiovascular Flashcards
What are some features of an innocent murmur?
Common 1 in 3
Systolic, quiet, no radiation, not continuous, no thrill, postural variation, intensifies on increased CO (exercise, illness), rest of exam is normal
What is Eisenmenger syndrome?
When there is a congenital heart lesion such as VSD, ASD or PDA and the pulmonary pressure rises beyond the systemic causing a R-L shunt and so cyanosis
A patient who has a DVT has had a large stroke. What underlying defect might they have had?
Asymptomatic ASD
DVT is in the venous system and a stroke is in the arterial system - if it stayed n the venous - PE
What defects may cause ASD?
Patent foramen ovale (not technically one)
Ostium Secundum
Ostium Primum
What other conditions may be linked to PFO?
Migraine with aura
What signs might indicate a ASD?
Mid-systolic crescendo-decrescendo murmur, loudest at the upper left sternal border
Fixed split second heart sound (doesn’t vary with resp)
What murmur may be heard in VSD?
Pansystolic murmur heard at left lower sternal edge
May be systolic thrill
What are the components of tetraolgy of fallot?
VDS, PS, Overriding aorta, RVH
What is a tet spell?
tetraolgy of fallot
An intermittent symptomatic period where the R-L shunt gets temporarily worse precipitating cyanosis.
Brough on by physical exertion or crying - Inc PVR or dec SVR. ?inc CO2 (vasodilates)
Management - Child can squat
Infant - bring knees up to chest
What is the medical management of a tet spell in tetraolgy of fallot?
O2, IV fluids?, Beta blockers?, Morphine?, sodium bicarbonate?, Phenylephrine infusion?
What are the stages of the cardiac cycle?
Diastole - 1. Isovolumetric relaxation 2. Passive ventricular filling/ rapid filling 3. Diastasis 4. Atrial contraction Systole - 1. Isovolumetric contraction 2. Ejection
What might you suspected if a child has a persistent fever for >5 days?
RED FLAG
Kawasaki’s disease?
When is one of the few scenarios you would give a child Aspirin?
Kawasaki’s disease to reduce the risk of thrombosis
Aspirin can cause Reye’s syndrome
What is Kawasaki’s disease?
A systemic, medium vessel vasculitis
Affects children < 5
No clear cause or trigger
What are some features of Kawasaki’s disease?
Persistent high fever >5 days
Widespread erythromatous maculopapular rash, with desquamation (skin peeling) on palms and soles
Strawberry tongue (red with large papillae)
Cracked lips
Bilateral conjunctivitis, cervical lymphadenopathy
What is a key complication of Kawasaki’s disease?
Coronary artery aneurysm
Give IVIg to try reduce risk and echo monitoring
What might bloods show in Kawasaki’s disease?
Anaemia, leukocytosis, thrombocytosis, elevated LFTs, raised ESR
What is rheumatic fever?
A multisystem autoimmune condition triggered by a streptococcal infection
Commonly Group A beta haemolytic strep (e.g. strep pyogens) causing tonsilitis
What causes rheumatic fever?
Recent strep infection
Body makes ab to bacteria but it targets bodys antigen - type 2 hypersensitivity reaction
Delayed by 2-4 weeks post infection
What are some clinical features of rheumatic fever?
Delayed - 2-4 weeks after initial infection
Joints - migratory arthritis - large joints. Red, hot and swollen
Skin - SC nodules on extensor surfaces, or Erythema marginatum (pink rings on torso and prox limbs)
Cardiac - inflammation - carditis - murmur? tachy or brady? pericardial rub? HF?
CNS - Chorea
JONES criteria is used to diagnose Rheumatic fever, what is it?
Evidence of a recent strep infection (ASO ab titre) + 2 Major or 1 Major and 2 minor
Major - JONES
Joint arthritis, Organ inflammation (carditis), Nodules, Erythema marginatum, Sydenhams chorea
Minor - FEAR
Fever, ECG changes without carditis (prolonged PR?), Arthralgia without arthritis, raised inflammatory markers
How would you investigate for Rheumatic fever?
Throat swab
Anti-steptococcal antibody titre
Echo, ECG, CXR
How would you manage a patient with Rheumatic fever?
Antibiotics for strep infections - Phenoxymethylpenicillin (penicillin V) 10d
Refer to a specialist -
NSAIDs - joint pain
Aspirin and steroids - carditis
Prophylactic abx
Monitoring and management of complications - Recurrent rheumatic fever, mitral stenosis *, chronic HF
What are some characteristic of turners syndrome (45 XO)?
Short stature Broad chest with widely spaced nipples Webbed neck High arched palate Cubitus valgus (exaggerated angle at the elbow away from body) Late or incomplete puberty Infertile
Associated with - Coarctation of aorta, recurrent UTIs and Otitis media, hypothyroid, HTN, diabetes, obesity, LD?
What are the management options in Turners?
GH - to help with height
Oestrogen and progesterone - puberty
Fertility treatment
What is cardioplegia?
A K rich solution used in coronary artery surgery. It is injected into the coronary arteries and it arrests the heart without causing ischaemia. It allows for a static operatig field
What vessels can be used in CABG?
Long saphenous VEIN (aorta to diatal occlusion)
Left internal mammary artery (detach one side then attach to LAD)
What are some vascular phenomenons in IE?
Septic emboli, IC haemorrhage, conjunctival haemorrhage, Janeway lesions
What are some immunological phenomenons in IE?
Roth spots, Oslers nodes, RF, glomerulonephritis
What abx might you give for IE caused by Strep?
Benzylpenicillin ± gentamicin
Prosthetic? 6 weeks IV
Native? 4 Wks IV
What abx might you give in IE due to MRSA?
Vancomycin ± Gentamicin
Give an example of some ACEi that are given first line for HTN in a patient < 55 or diabetic pt.
Captopril, Enalopril, ramipril
1.25/2.5mg OD (up to 10mg)
Contraindicated - pregnancy, renal artery stenosis, angioedema, hypotension
SE - cough, hypotension, angioedema
What is the mechanism of ACEi in HTN?
Reduce aldosterone secretion, reduces ADH –> reducing fluid volume
Reduces sympathetic activity and vasoconstriction
Give an example of a CCB used in HTN in >55 or black African patients.
Amlodipine 5mg OD
Interactions - CYP3A4
SE - peripheral oedema *, gingival hyperplasia, constipation, dizzy
What is the mechanism of action of amlodipine?
Inhibits L type Ca channels, reducing IC ca
Relaxes vascular smooth muscle, reduces contractility and reduces SAN rate
What thiazide diuretic can be given in HTN?
Indapamide 2.5mg OD
SE - erectile dysfunction, hyponatraemia and hypokalaemia, maculopapular rash, exacerbate gout
Monitor - U&Es, Na, K
How does Indapamide work?
Inhibits Na/ Cl co-transporter at DCT, inhibiting water reabsorption allowing more to be excreted
Peripheral vasodilation
Beta blockers can be used after A + C + D if HTN is still not effectively controlled, give an example and some cautions and SE.
Bisoprolol 5mg OD
CAUTION- Asthma, COPD, don’t give with CCB
SE - erectile dysfunction, cool peripheries, bradycardia, headache
How do beta blockers work?
Strong for beta 1 - reduce HR (negatively Chronotropic) and contractility (negatively Inotrophic), reduces renin release
Low affinity for beta 2 - vasodilation of vascular and bronchial sm
What dose of furosemide can you give?
20-40mg OD but can give up to BD
Monitoring of U&Es
What are some side effects of furosemide?
Acute gout, renal failure, electrolyte abnormalities
What is the MoA of furosemide?
Acts of Na/Cl/K on the loop of henle - reducing water reabsorption
Monitor U&Es (K!)
What spironolactone dose can you give?
25mg PO OD, up to 400mg MAX
CONTRAINDICATIONS - Hyperkalaemia, Addisons disease
What advice should you give to someone with HOCM
Try and avoid doing bursts of activity or heavy lifting
What medications should you AVOID in HOCM?
Digoxin, dilators, diuretics
What is HOCM?
LV outflow tract obstruction due to asymmetrical sepatal myomectomy
AD? or mutation to myosin, alpha tropomyosin or troponin I
FHX of sudden cardiac death
May not have sx until strain is put on the heart
What murmur may be heard in HOCM?
Harsh ejection systolic crescendo-decrescendo
Dute to diastolic dysfunction
What is used in the immediate management of a STEMI?
MONAD
Morphine - pain relief
O2 if sats <94%
Nitrates to improve blood flow to myocardium
Antiemetics - metaclopromide
Dual antiplatlete - 300mg Aspirin + 180mg ticagrelor/ 300mg clopidogrel
What reperfusion therapy is used in STEMI?
Within 120min of ECG diagnosis - Percutaneous coronary intervention - balloon angioplasty and stenting
Thrombolysis
What is the long term management after an NSTEMI or STEMI?
Risk factor modifications
Cardiac rehabilitation - education, improving quality of life and psychological well being
ACEi, statin, BB, Aspirin (+ for 6-12m Clopidogrel or ticagrelor)
How can you estimate the 6 month mortality from an NSTEMI?
GRACE score - Can help decide if to intervene with catheterisation or stenting
What dose of morphine would you give in acute management of STEMI and what does it do?
5-10mg IV
Rapid pain relief ~5min
Acts on mu receptors to reduce neuronal excitability and pain transmission
What are some contraindications to morphine?
Acute respiratory depression
Head injury
What does of antiplatelets should be given for long term after a STEMI?
75mg aspirin life long
90mg ticagrelor for ~3 months
What is the MoA of digoxin?
Negatively chronotrophic (reduces HR), positively inotropic (increased force of contraction) Reduces AVN conduction and so reduces Ventricular rate
Due to digoxin toxicity, you need to check a serum level, what time should you do this after a loading dose?
6 hours take a serum level
Loading ~500micrograms, then maintenance ~125-250micrograms daily
What does Warfarin do?
Vitamin K antagonist - inhibits formation of vit K dependent factors - 2,7,9,10 and also protein C and S
What do you need to consider when prescribing warfarin?
INR monitoring (2-3)
It is reversible!
Has lots of interactions
Bleeding risk!!
What criteria fits with a transudate?
High glucose, high pH (alkaline), low LDH, low protein, low cells
Due to increased hydrostatic pressure
What criteria fits with exudate?
Low glucose, low pH, high protein, high LDH, lots of cells
Due to inflammation and so increased capillary permeability
What is lights criteria?
IF any are true its an exudate:
Pleural fluid: serum LDH >0.6
Pleural fluid : serum protein >0.5
Pleural fluid LDH>2/3 the upper limit of normal
What is the MoA of beta 2 agonists?
Salbutamol, terabutaline
Salmeterol, formeterol
Specific for pulmonary beta 2
Stimulate adenyl cyclase
Increases IC cAMP
Relaxing bronchial smooth muscles
Give some SE of beta 2 agonists.
Hypokalaemia, tremor, hyperglycaemia, muscle cramps
What is the MoA of ICS?
Suppress multiple pro-inflammatory genes
Budesonide, fluticasone
What is the action of Muscarinic antagonists?
Bind to M1 and M3
M1 - directly counteracts bronchoconstriction
M3 - increased NO, causing vasodilation
What are some SAMAs and LAMAs?
SAMA - Ipratropium bromide
LAMA - Tiotropium, glycopyrronium
What are Methylxanthines Moa?
Non-selective inhibitors of phosphodiesterase, increasing IC cAMP relaxing bronchial smooth muscle
Immunomodulatory - improving mucociliary clearance and anti-inflammatory effects
What is the MoA of magnesium sulphate?
Relaxes smooth muscle, inhibits release of histamine from mast cells and acetylcholine release from nerve endings
What are some SE of magnesium sulphate?
Hypermagnesaemia, muscle weakness, respiratory failure
What drugs can be used in prophylaxis for exercise induced asthma or allergic rhininitis?
Used for MAINTENANCE not acute!!!
Leukotriene receptor antagonists - Montelukast, Zifirlukast
Reduce airways oedema and smooth muscle contraction
What is the MoA of omalizumab?
4wkly SC
Monocloncal Anti-IgE
SE - hypersensitivity reaction
What is the MoA of mepolizumab?
4wkly SC
Anti-IL5 monoclonal antibody, reducing eosinophil production
SE - headache
What criteria must be reached before discharging a patient who had an asthma exacerbation?
Been stable on discharge medication for 24 hours Had inhaler technique checked PEF >75% predicted Steroids and bronchodilator therapy Their own PEF meter and management plan GP appointment within 1 week Resp appointment within 4 weeks
What is the MoA of Roflumilast?
It is used to reduce COPD exacerbations
It selectively inhibits phosphodiesterase 4 and increases IC cAMP. This reduces the release of proinflammatory mediators and cytokines.
What is the MoA of Azithromycin?
Reduces exacerbations of COPD
macrolide antibiotic
Inhibits proinflammatory cytokines and mucin release
What is the MoA of carbocystine?
Reduces exacerbations of COPD
mucolytic
Reduces mucous viscosity and improves mucociliary clearance
What is the management in COPD?
Smoking cessation Saba or sama Laba or lama Laba + lama or laba + ics Laba + lama + ics \+ macrolide or theophylline
