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MSRA Exam Preperation > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

A patient has malar flush and rumbling mid-diastolic murmur (loudest on exp on left side). What is the Dx?

A

Mitral stenosis

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2
Q

Pan systolic murmur following MI with features of heart failure - what is the murmur?

A

Mitral regurgitation - due to ischaemic to papillary muscles

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3
Q

Most common heart defect in Down’s?

A

AVSD (others - VSD, ASD, PDA, ToF)

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4
Q

How does a thrombolytic/fibrinolytic agent work? What different types exist?

A

Plasminogen activators - dissolve IV clots to Tx acute MI, DVT/PE, acute ischaemic stroke, occlusion of indwelling catheter etc.

During thrombosis platelets activate prothrombin to form thrombin. This converts fibrinogen to fibrin forming a matrix.

This is counterbalanced by plasmin derived from plasminogen. tPA is a natural fibrinolytic in epithelial cells. All thrombolytic agents are proteases cleaving plasminogen to plasmin.

Agent types:
1. Fibrin-specifc agents - need fibrin present for conversion and work best for STEMI/PE/acute ischaemic stroke. E.g. alteplase
2. Non-fibrin-specific agents - act systemically as don’t require fibrin present e.g. streptokinase (less efficacy but reduced risk of IC haemorrhage, increased risk of allergy, no repeat use for 6 months), urokinase (used for indwelling catheters/PV thrombosis)

TXA can be used to reverse action of these agents.

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5
Q

ECG findings based on electrolyte abn?

A

K:
* Hyperkalaemia - ECG tall tented T-waves, wide QRS, prolonged PR - causes cardiac toxicity/muscle weakness - caused by drugs (k-sparing diuretics, ACEi/ARB, digoxin), Addison’s.
* Hypokalaemia - ECG U-waves (V2/3), T-waves wide/flat, ST depression - causes muscle weakness/resp failure - caused by diarrhoea/vom, malnutrition, aldosteronism, drugs (insulin, corticosteroids)

Ca:
* Hypercalcaemia - ECG short ST, wide T-wave - causes thrones, stones, bones, grones, and psychic moans - caused by primary hyperparathryoidism, malignancy
* Hypocalcaemia - long ST, long QT - causes neuro Sx - caused by pancreatitis, rhabdomyolysis etc

Na - no effect on ECG:
* Hypernatremia - causes thirst/neuro Sx - caused by dehydration, diabetes insipidus, hyperaldosteronism
* Hyponatremia - causes neuro Sx - caused by diuretics, SIADH, heart/liver/renal disease, diarrhoea

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6
Q

Summarise ACS guidelines

A
  1. For all ACS (STEMI/NSTEMI/UA) - give aspirin life-long
  2. STEMI within 12hrs Sx-onset & can do PCI within 120 mins - corronary angio + PCI, if not:
    - If within 12hrs - fibrinolysis
    - If not within 12hrs but myocardial ischaemia/cardio shock - angio
    - Otherwise add Ticagrelor (Clopidogrel if high bleed risk)
    - After angio add prasugrel (if no previous anticoag, otherwise clopi), if done via radial route give unfr heparin, femoral give bivalirudin (either with bailout GPI)
  3. NSTEMI/UA - give fondaparinux (if low bleed risk, CR >265 consider unfr heparin) –> do GRACE/HEART score:
    - If low risk add Ticagrelor
    - If high risk/young for angio
  4. Secondary prevention - ACEi, DAPT (12m), B-blocker (12m or forever if rLVEF, if CI for diltiazem/verapamil), Statin
  5. IF heart failure with rLVEF start aldosterone antag e.g. spironolactone (3-14d post-MI, after ACEi)
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7
Q

Give an overview of pericarditis

A
  • Inflam of pericardium
  • Acute form - new onset inflam lasting under 6-weeks
  • Triad - chest pain, pericardial friction rub on auscultation, ECG widespread ST elevation (other Ix - bloods inflam, echo - pericardial effusion)
  • Tx - NSAIDs + Colchicine
  • Complications - recurrence, tamponade, constrictive pericarditis
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8
Q

Give an overview of aortic dissection

A
  • Seperation in aortic wall intima –> blood flow into false channel (inner & outer layers of media)
  • > 50yrs, sudden tearing substernal/intrascapular pain (+/- syncope, heart/renal failure, mesenteric/limb ischaemia)
  • Ix with CT/MRI/ECHO
  • If ascending aorta/arch - URGENT repair, otherwise b-blocker (or surgery if complicated), needs lifelong surveillance
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9
Q

After how long do trop levels peak after MI? Other causes of raised trop?

A
  1. rise 2-4hrs, peak 18-24hrs, last several days
  2. PE, other heart issue, renal failure, sepsis, rhabdomyolysis
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10
Q

Driving rules for MI

A
  • Cease for 1wk if - successful angioplasty (incl in STEMI)/PPM-insertion
  • Cease 4wk if - CABG/MI
  • Cease completely if unstable angina uncontrolled
  • Notify DVLA if AAA ≥6cm (disqualified if ≥6.5cm) or arrythmia (incapacitated)

Other to note - no sex for 1/12, return to work after 2/12 (stop if pilot/air traffic control)

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11
Q

ECG changes depending on STEMI location? How long for ECG changes to resolve?

A

Lateral leads - left circumflex/LAD
Inferior leads (or posterior) - RCA/LCx
Anterior/septal - LAD

ST-T changes resolve in days-weeks (longer if ischaemia causes infarction)
QRS including pathological Q-wave - PERMANENT

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12
Q

What are the complications of MI by time period after the event?

A
  • Arrythmias - VF/VT (20%), AF (15%)
  • Ischaemia (high CK) - re-occlusion, postinfarct angina –> angio + corronary revasc
  • Mechanical:
  • LVSD/HF - Killip’s classification (severity of HF post-MI)
  • 24h-7d: 1) Ventricular septal - angina/pul oedema, new pansystolic murmur LLSB -> surgery. 2) free wall rupture - bleeding into pericardium (-> tamponade) -> needs pericardiocentesis/surgery
    NOTE: pseudoaneurysm = contained left ventricular free walk rupture
  • Acute MR (normally inf/posterior infarct from isch/necrosis/papillary muscle rupture) = pansystolic murmur
  • L. vent aneurysm, R vent failure, L vent outflow obstruction
  • Inflammatory - Dressler’s syndrome (pericarditis) - 2-4wks post-MI - self-limiting fever + pericardial/pleural pain –> Tx with NSAIDS/steroids/drainage
  • Systemic - PE/DVT, mural thrombosis & systemic embolism
  • Depression - suicide
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13
Q

Give an overview of chronic heart failure

A

Classification:
- LVEF (<40 low, 41-49 mild, 50 preserved)
- NYHC (1 - no limit on physical activity, 2 - slight, 3 - marked, 4 - Sx at rest)

NT-proBNP > 2000 - 2wk referral/echo, 400-2000 - 6wk referral/echo

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14
Q

Acute heart failure findings on CXR? Ix? Mx?

A
  1. Bat wing opacities 2. Kerley B lines 3. Cardiomegaly 4. Dilated upper lobe vessels 5. Pleural effusion

Sit upright and 15L NRM, consider IV dia/morphine, Furosemide IV (x2 oral dose), GTN IV 0.5mg/hr (only if BP >90), consider CPAP/NIV if acidotic

If BNP > 100 or NT-proBNP > 300 transthoracic echo

Acute severe MR - surgical replacement
Critical AS - surgical replacement/TAVI
LVSD - ACEi, Aldosterone antag, B-blocker (d/c after stable for 48hrs)

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15
Q

Hypertension Management

A

BP in clinic >140/90 —> repeat (both arms should be measured if >15 repeat then use measurement in higher arm)
BP 140/90-180/120 - AMBM (ambulatory - 2 measurements/hr requiring 14 measurements)/HBPM (Home - x2 measurements daily for 4-7d, discard 1st day) to confirm Dx
>180/120 with retinal haemorrhage/papilloedema/Sx - same day specialist R/V

Classification:
1 >140/90 with AMBM 135/85
2 >160/100 with AMBM 150/95
3 >180/120
Accelerated/malignant = signs of retinal haemorrhage/papilloedema

?secondary cause of HTN if: <40yrs, Low Na/High K, eGFR <60, Pro/Blood in urine
Most common secondary cause: Renal

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16
Q

Signs of cardiac tamponade? Possible ECG findings? Tx?

A
  • Beck’s triad - JVP, low BP, reduced HS
  • Pulsus paradoxus - >12mmHg/9% normal insp decrease in SBP (also caused by const pericarditis, restrictive CMO, severe obs pul disease, PE)
  • Kussmaul sign - increased venous pressure/distension on inspiration
  • Ewart/Pins sign - if large pericardial effusion, dullness/bronchial breath sounds/bronchophony below angle L scapula

ECG - sinus tachy, low voltage QRS, electrical alternans, PR segment depression

Pericardiocentesis

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17
Q

Mx of stable angina?

A
  1. B-Blocker and/or CCB (amlodipine/nifedipine)
  2. Add/switch to long-acting nitrate/nicorandil (risk of ulceration)
  3. Ivabradine/Ranolazine

Secondary prevention: consider Aspirin, Statins, ACEi

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18
Q

Cardiac tamponade - key finding on exam? Triad? Mx?

A

Pulsus paradoxus - BP variation between inspiration & expiration (≥10)

Beck’s triad (50%):

  • Raised JVP
  • Muffled heart sounds
  • Hypotension

Mx:

  • IV fluids (RV filling depends on venous pressure & effusion is constricting)
  • Echo –> refer to cardiology for pericardiocentesis
    • Coagulation profile (to prep for pericardiocentesis)
19
Q

Acute limb ischaemia - Def? Presentation? Ix? Mx?

A
  • Def: a sudden decrease in limb perfusion that threatens the viability of limb
    • AF = major RF for acute limb ischemia
  • Presentation - 6Ps:
    • Pale
    • Pulseless
    • Painful
    • Perishingly cold
    • NOTE: need immediate vascularisation (<6hrs) if:
      • Paralysis
      • Paraesthesia (esp worrying)
  • Ix (after initial Mx):
    • Bedside: ABPI (PAD), ECG (AF)
    • Bloods: FBC, U&E, clotting, HbA1c, lipid profile
    • Imaging: duplex USS, CT/MR angiography
  • Mx:
    • Initial:
      • A-E, IV access, analgesia
      • IV heparin infusion - reduces the chance of the clot getting worse
    • Limb viability:
      • Immediate - tender muscles, loss of power, loss of sensation
      • Urgent - pale, pulseless, painful, cold
      • Irreversible - fixed, mottled skin, woody, hard muscles
    • Refer to vascular surgery:
      • Thrombotic - local intra-arterial thrombolysis, angioplasty, bypass
      • Embolic - embolectomy/local intra-arterial thrombolysis/bypass
20
Q

Peripheral vascular (arterial) disease - Def? RFs? Spectrum? Ix? Special test?

A

Def: limb ischemia (chronic) from atherosclerosis in lower limb vasculature

RFs: male, older, smoker, HTN, DM

Spectrum:

  • Intermittent claudication (mild) - cramping leg pain after walking (& have to stop) + relieved by rest
    • NOTE: the equivalent of stable angina (worse on exertion)
    • Worse going uphill/upstairs
  • Critical limb ischemia (severe) - ulcers, gangrene, night pain & rest pain
    • ​NOTE: the equivalent of unstable angina (present at rest)

Ix:

  • Bedside:
    • Exam special test = Buerger’s angle - elevation pallor –> sudden drop feet down = sunset sign
    • exercise-treadmill ABPI (ankle-brachial pressure index) - <0.8 (<0.3 = CLI)
  • Bloods - FBC, U&E, LFTs, CRP, clotting
  • Imaging:
    • Arterial duplex USS
    • CT/MR angiography

Mx: dealt with by vascular surgeons –> optimise meds + surgery (bypass)

  • Conservative: smoking cessation
  • Medical: ACEi, clopidogrel, statin, DM control
  • Surgery: angioplasty/stent/bypass graft/amputation
21
Q

Chronic venous insufficiency & varicose veins - presentation? Ix? Mx? Complications of varicose veins?

A

Presentation:

  • Oedema, haemosiderin deposition, lipodermatosclerosis (inverted-champagne bottle), eczema, venous ulcers
  • Varicose veins - dilated tortuous, superficial veins
    • Pain, swelling, itching, restless legs, cramps
    • Feel for thrombosis (hard = thrombophlebitis)
    • Cough impulse at SFJ (for Saphena Varix - dilation of saphenous vein @junction w/ femoral vein)
    • Trendelenburg test
      • Lying flat, lift up leg & empty veins
      • Compression over SFJ –> stand up (maintain pressure) - if do not fill = competent valves below SFJ
      • If do fill = incompetent valves below SFJ (blood flow from deep to superficial vein via perforating veins)
      • Repeat with pressure lower down until filling stops
    • Perthe’s test - apply tourniquet to mid-thigh + walk for 5-mins –> compresses superficial vein
      • Less distended - normal deep veins as calf compression pushes blood into deep venous system
      • Remain distended - impaired deep veins
    • Doppler US for reflux
  • Warfarin - previous DVT
  • Abdo mass with compression

Ix: duplex USS (allow DVT to be ruled out)

Venous insufficiency Mx:

  • ABPI > 0.8 –> Compression bandaging
  • Varicose veins:
    • Conservative - weight loss, avoid standing for prolonged periods
    • Minimally invasive procedures - injection sclerotherapy, endovenous radiofrequency ablation
    • Surgical - vein ligation

Varicose Veins complications:

  • thrombophlebitis - Tx for superficial: NSAIDs
  • Eczema
  • Bleeding
  • Haemosiderin deposition
  • Lipodermatosclerosis (champagne bottle)
  • Ulceration
22
Q

AAA key Sx & ruptured Sx? Ix? Mx?

A

Sx:

  • Central abdo pain
  • Radiates to back
  • Bloating
  • Pulsatile mass on palpation (expansile - moves to sides)
  • NOTE: always consider if abdo pain + RFs (male, >65yrs, HTN, smoking etc.)

Ruptured AAA Sx:

  • Severe pain radiating to back
  • Visible pulsating abdo mass
  • Shock (circulatory compromise)

Ix:

  • Abdo duplex USS if part of national screening - male age 65yrs
  • CT angiography if stable but suspicious of rupture

Mx:

  • <5.5cm –> Conservative: monitor w/ USS + RF modification
    • <4.5cm –> yearly USS
    • 4.5≤x<5.5com –> 3 monthly USS
  • Medical: optimise BP control, statin, aspirin
  • Sx/>5.5cm/expanding >1cm/yr –> Surgical: endovascular (catheter into aorta to insert stent)/open repair
23
Q

How to calculate ABPI? ABPI value range?

A
  • BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler
  • Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure
  • Repeat procedure in arm using brachial artery signal to record the brachial pressure
  • ABPI = ankle pressure/brachial pressure

Range:

  • 0.8-1 = normal
  • 0.6-0.8 = claudication (may only drop to this with exercise)
  • Below 0.6 = critical limb ischaemia
24
Q

Aortic dissection - def? Sx? Ix? Mx?

A

Def: tear in tunica intima (inner layer of BV) –> blood collection between tunica intima and tunica media –> false lumen (can occlude blood flows through aorta) –> AR, myocardial ischaemia, stroke

Sx: sudden onset, central tearing chest pain –> radiating to between shoulder blades

  • Hx of intermittent claudication
  • Haemodynamic instability (high HR, low BP)
  • Before left subclavian artery - left arm smaller than right arm
  • After left subclavian artery - lower body less developed than upper body

Ix:

  • BP in both arms - radio-radial delay
  • ECG, CXR (widened mediastinum)
  • Gold-standard: CT-aortogram w/ contrast

Mx:

  • Stanford A (ascending aorta) - more WORRYING (compromise blood to brain, cause aortic regurg):
    • BP control - B-blockers & CCB (aim 100-120mmHg)
    • Immediate referral for vascular surgery
  • Stanford B (descending aorta)
    • BP control - B-blockers & CCB (aim 100-120mmHg)
    • Urgent referral to vascular surgery (repair likely if complicated)
25
Q

Comparing different types of vascular ulcers:

  • Hx
  • Location
  • Characteristics - ulcer & surrounding skin
  • Tx
A

Venous:

  • Hx: varicose veins, previous DVT, obesity, preg, recurrent phlebitis
  • Location: lower calf-medial malleolus
  • Characteristics: mild pain
    • Ulcer - shallow/flat margins, exudate, sloughing @base, granulation tissue
    • Surrounding skin - haemosiderin staining, eczematous, oedematous, thickening skin, (normal CRT)
  • Tx: compression bandaging, leg elevation, surgical Mx

Arterial:

  • Hx: HTN, DM, smoking, prev vascular disease
  • Location: pressure points, toes/feet, lateral malleolus, tibia
  • Characteristics: painful
    • Ulcer - punched-out/deep, irreg shape, necrosis, no exudate (unless inf)
    • Surrounding skin: thin, shiny, reduced hair, 6Ps (pallor, pain, perishingly cold, pulselessness, paraesthesia, paralysis)
  • Tx: revascularization (e.g. bypass), anti-platelet, manage RFs

Neuropathic:

  • Hx: DM (peripheral neuropathy), trauma, prolonged pressure
  • Location: plantar foot, tip of toe, lateral-fifth metatarsal
  • Characteristics: no pain
    • Ulcer - deep, surrounded by callus, insensate (no feeling)
    • Surrounding skin - dry, cracked, callus, insensate
  • Tx: off-loading pressure, topical GF

Pressure:

  • Hx: limited mobility
  • Location: bony prominence, heel
  • Characteristics:
    • Ulcer - deep, macerated (moist, wrinkly)
    • Surrounding skin - atrophic skin, lost muscle mass
  • Tx: off-loading pressure, reduced moisture, increased nutrition
26
Q

Hypertension BP targets? Ix? Mx?

A

BP targets:

  • <140/90
  • <150/95 for over 80yrs
  • Causes of hypertensive crisis ≥180/120: pregnancy, scleroderma, vasculitis, renovascular, endo, cocaine –> reduce BP slowly

Ix:

  • Bedside - ECG, urine dip
  • Bloods - FBC, U&E, lipids, BM, TFTs

Drug treatment:

  • Conservative management - diet (low salt), exercise, reduce alcohol
    1. a) <55yrs/DM –> ACEi (ramipril)/ANG-II receptor antagonist (Losartan)
    1. b) ≥55yrs/black –> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide)
    1. ACEi + CCB OR ACEi + thiazide diuretic
    1. ACEi + CCB + thiazide diuretic
    1. Add:
      * Spironolactone (or other diuretic)
      * Alpha-blocker
      * Beta-blocker
      * Specialist advice
27
Q

DVT - def? RFs? Presentation? Scoring & Ix? Mx?

A

Def: occlusion of deep vein in lower limb

RFs: SICC - Surgery, Immobility, Cancer, COCP

Presentation: pain, swelling (if extends proximally to iliacs –> bilateral swelling), pitting oedema, warmth, erythema

Scoring & Ix: Well’s score

  • 0-1= D-Dimer –sign raised–> as below
  • ≥2 = proximal leg vein USS + D-Dimer
  • Obtain baseline before starting anti-coag: FBC, U&E, LFTs, clotting screen

Mx:

  • Ongoing anticoagulation - DOAC/Warfarin
  • Provoked - 3 months (SICC)
  • Unprovoked - >6 months + thrombophilia testing
28
Q

IHD - RFs? Types? Definition? Dx? Mx? Complications?

A

RFs: HTN, DM, Smoking, FHx IHD, Hypercholesterolaemia

Stable angina - chest pain on exertion relieved by rest

  • Path - mismatch in O2 supply and demand to the myocardium
  • Ix: CT-angiogram
  • Mx:
    • B-blocker/CCB (e.g. verapamil) - reduces HR req for activity –> reduced likelihood of mismatch in O2 supply & demand
    • GTN spray - reduce myocardial preload + reduces strain
    • RF modification –> reduced risk of progression

Acute coronary syndrome - Sx caused by sudden reduced BF to the myocardium

  • Dx:
    • ​ST-elevation = STEMI
    • Troponin raised = NSTEMI (+ dynamic T-wave inversion, ST depression)
    • Unstable angina pectoris (pain at rest) = ischemia NOT infarct
  • Generic ACS Mx - MONA BASH
    • ALL immediate:
      • 5-10mg Morphine IV + Nitrates (GTN spray)
      • Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor)
    • ALL long-term:
      • Continue DAPT
        • 1 year: 75mg OD Aspirin + 75mg OD Clopidogrel (or 90mg BD Ticagrelor)
        • >1yr - 75mg OD Aspirin
      • B-blocker (1.25-10mg Bisoprolol OD)
      • ACEi (1.25-10mg Ramipril OD)
      • Statin (80mg Atorvastatin OD)
  • STEMI Mx: establish coronary reperfusion ASAP
    • Sx under 12hrs for PCI, BUT if no PCI within 2hrs Dx > thrombolysis (e.g. tPA - tissue plasminogen activator)
    • Sx >12hrs: invasive coronary angiography ± PCI if needed
    • PCI:
      • If having PCI give Prasugrel (instead of Clopi/Ticagrelor)
      • PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND IV unfractionated heparin during the procedure –> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) –> takes longer for endothelialization of stent so DAPT needed for 1yr
      • If PCI with stents inserted –> DAPT 12 months
  • NSTEMI Mx:
    • 2.5mg SC Fondaparinux (direct factor 10a inhibitor)
    • Risk stratify - GRACE criteria (& others)
    • High risk = invasive coronary angiography (within 48-72hrs)

Complications: FAP (failure, arrhythmias, pericarditis)

  • Heart failure, arrhythmias (incl. VF)
  • Pericarditis
    • Early - positional chest pain day after MI –> give NSAIDs
    • Late - Dressler’s syndrome - immune response @6wks (fever, pleuritic chest pain, pericarditis/pericardial effusion)
29
Q

Heart failure def? Causes? Pathophysiology? Categories & Causes? Classification? Ix? Mx?

A

Def: pumping of blood by heart insufficient to meet the demands of the body

Causes:

  • RVF:
    • Acute: MI, inf endocarditis, PE
    • Chr: Cor pulmonale, LVF
  • LVF:
    • Acute: ischaemic/hypertensive CMO, valvular HD
    • Chr: MI, inf endocarditis

Pathophysiology:

  • RHF - right side of the heart pumps deoxygenated blood from the body to the lungs to be reperfused - if the RH is not pumping effectively you get the fluid collection in the peripheries = PERIPHERAL OEDEMA
  • LHF - left side of the heart pumps oxygenated blood from the lungs to the body - if the LH is not pumping effectively you pooling of blood in the lungs = PULMONARY OEDEMA
  • Reduced CO –> shock, tachycardia, AKI
    • CO = SV*HR
    • Ejection fraction = SV/End-diastolic Volume

Categories:

  • HF w/ preserved ejection fraction (left ventricular >50%) = inadequate filling of ventricles during diastole (from ventricular stiffness)
    • Causes of ventricular stiffness:
      • Volume overload (valve regurg)
      • Pressure overload (HTN)
      • Decreased distensibility (constrictive pericarditis)
  • HF w/ reduced ejection fraction (left ventricular <40%) = inadequate emptying of ventricles during systoles (from outflow obstruction/impaired contractility)
    • Causes of outflow obstruction/impaired contractility:
      • MI, Cardiomyopathy, Arrythmia

NYHA classification:

  • 1 - no limitation on activity
  • 2 - comfortable at rest but dyspnoea on ordinary activity
  • 3 - marked limitation on ordinary activity
  • 4 - dyspnoea at rest

Ix:

  • Bedside: ECG - detects if anything precipitating HF (arrhythmia/ischaemic event)
  • Bloods: ABG (if resp compromise from pul oedema), troponin (ACS), BNP (HF screening)
  • Imaging: CXR (visualise pul oedema, cardiomegaly), ECHO (valvular abn/regional wall mov abn)

Mx: MON BA (out of MONA BASH)

  • Immediate:
    • Sit the patient up (reduce venous return to heart –> less strain)
    • O2 15L/min NRM
  • Medical:
    • IV furosemide (loop diuretic) - remove excess fluid + venous dilation (reduce preload)
    • Nitrates (GTN/Isosobide Mononitrate) AND Morphine - reduce preload on the heart
  • Long-term:
    • Reduced ejection fraction - prognostic benefit:
      • B-blocker (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them
      • ACEi - reduce strain on heart
        • After the above if LVEF <35% & Sx –> mineralocorticoid antagonist e.g. spironolactone
        • 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT
      • SGLT2 inhibitors (dapagliflozin)
    • RF modification - poor glycaemic control/high cholesterol
    • Sx (diuretics)

Complications:

  • Reduced CO (SV*HR) –> shock, tachycardia, AKI
  • Congestion –> pulmonary oedema + peripheral oedema
30
Q

Atrial fibrillation (AF)

  • Def? Causes? Ix? Mx?
A

Def: rapid, chaotic, and ineffective atrial electrical conduction

  • ECG def: irregularly irregular narrow complex tachycardia with no p waves

Causes: idiopathic, cardio (IHD, valvular disease, cardiomyopathy), resp (PE, pneumonia), hyperthyroidism, alcohol

Ix: ECG (absence of p-waves, irregularly irreg rhythm)

Mx:

  • Haemodynamically unstable (≤90 BP, chest pain, acute HF) –> DC Cardioversion

OR

  • Rate control –> B-blocker (bisoprolol) OR rate-limiting CCB (verapamil - asthma)

OR

  • Rhythm control - ONLY if clear reversible cause
    • Sx onset <48hrs –> DC/chemical cardioversion (amiodarone/flecanide)
      • NOTE: IV heparin started prior to cardioversion
    • Sx onset >48hrs –> anticoagulate for 3wks –> elective cardioversion (also anticoag for 4wks after)

AND

  • Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score –> DOAC (Apixaban)
    • If metallic heart valve –> warfarin INR 3-3.5
    • Otherwise DOAC
    • NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 –> anticoagulation not recommended
    • CHF, HTN, Age ≥75rs (2), DM, Stroke (2), Vascular disease, Age 65-74, Sex - female
      • Score 1 - consider; ≥2 - DOAC/Warfarin needed
      • Lifetime risk = annual risk x estimated years of life left (up to 80 yrs e.g. if 60 then x annual risk by 20)
31
Q

SVT - Def? Types? Presentation - case example? Mx?

A

Def: regular narrow-complex tachycardia with no p-waves + supraventricular origin

Junctional types:

  • AVNRT - local re-entry circuit within AV node
  • AVRT - re-entry circuit between atria and ventricles –> after SVT termination = delta wave = WPW syndrome:
    • ​Assoc w/ HOCM
    • Avoid digoxin, verapamil, amiodarone (reduce conduction down SAN –> worsen retrograde conduction –> risk of VT)
    • Can use B-blocker/flecainide instead

Case example: 23yrs, 1-hr palpitations + SoB, 2 similar episodes prev following alcohol, this time severe chest pain

Mx:

  • Unstable tachycardia (<90 BP/chest pain/acute heart failure) –> synchronised DC Cardioversion
  • Vagal manoeuvres (increase parasympathetic stim via vagus nerve to slow conduction via AV node)
    • Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe
  • Adenosine 6mg –> 12 mg –> 12mg
    • NOTE: if adenosine CI (e.g. asthma) –> VERAPAMIL (rate-limiting CCB)
  • Other:
    • IV B-blocker/amiodarone/digoxin
    • Synchronised DC Cardioversion
32
Q

Key heart murmurs?

Accentuation manoeuvres?

Causes?

Left vs right heart valve abn epidemiology?

Mx?

Complications of prosthetic heart valves?

A

Key murmurs:

  • AS = ejection systolic + radiates to carotids, slow rising pulse, narrow pulse pressure, heaving apex beat
    • Sound: Wooooshhh
    • Severe AS - absent/soft 2nd heart sound, reversed splitting of 2nd HS, heaving apex beat
      • A longer murmur is worse (small space for blood to pass through = takes longer)
  • MS = mid-diastolic + LLP, malar flush, AF, loud/palpable S1 “tapping” apex, pul HTN (loud P2 - pul thrill)
    • Sound: Wooosh de (loud S1) de (early diastolic snap)
  • AR = early diastolic + sitting forward (LLSE), collapsing pulse, wide pulse pressure, displaced apex
    • Sound: de woooshhhh
    • Severe AR –> Austin-flint murmur = ‘Rumbling mid-diastolic murmur’
      • Best heard at apex, caused by blood flowing back through aortic valve and over mitral valve
      • Shorter murmur is worse (quicker to flow back through large hole)
  • MR = pan-_systolic_ + radiates to left axilla, AF, displaced thrusting apex, LVF/pul HTN
    • Sound: Woooooshhh (holosystolic)
  • NOTE: same pattern for pulmonary & tricuspid (pul stenosis & tricuspid regurgitation = systolic)
    • TR - pulsatile liver
    • PS - radiates to back, assoc w/ Noonan’s (AD, webbed neck, wide-spaced eyes etc.)

Accentuation manoeuvres:

  • R-sided murmurs (tricuspid + pulmonary) –> louder on INspiration = blood goes IN to right-side of heart
  • L-sided murmurs (aortic + mitral) –> louder on EXpiration = blood EXits left-side of heart
  • AS radiates to the carotids + louder on leaning forward + listen on right sternal edge
  • MS louder on turning to the left, MR radiates to axilla

Causes:

  • AS (stenosis/sclerosis): senile calcification (aortic valve)
  • MR:
    • Acute: - IHD (papillary-muscle dysfunction post-MI), Infective endocarditis, cardiomyopathy, RHD
    • Chronic - myxomatous degeration
  • AR:
    • Acute (infective endocarditis, aortic dissection)
    • Chronic (CTD, RHD, HTN, congenital)
  • MS: rheumatic heart disease (RHD)

Left vs Right valve abn:

  • Left = more common as higher pressure system, more likely in damaged valves, commonly Strep Viridans
  • Right = more common in IV drug users –> tricuspid valve is first valve reached, commonly S. aureus

Management:

  • AS:
    • C: 6-monthly ECHO, exercise-stress test if asymptomatic
    • M: RF optimisation (statins, HTN, DM), HF Sx (diuretics, ACEi)
    • S: Based on severity/comorbid - STS-PROM (surgical risk calc)
      • If severe AS:
        • Medically fit (req midline sternotomy & cardiopul bypass) = Surgical aortic valve replacement (SAVR)
        • Not fit = Transcatheter aortic valve replacement (TAVR)
      • Acutely Sx/cardiogenic shock = Balloon valvuloplasty
  • MR:
    • M:
      • ACEi ± B-blockers (as HTN worsens MR)
      • Tx AF & anti-coagulate
      • Diuretic (if refractory to surgery)
    • S: for acute MR (post-MI, chordae tendinae rupture), asymptomatic LVEF <60%, symptomatic LVEF >30%
      • Valve _R_epair > _R_eplacement
  • AR:
    • M: asym + Reassurance (good prog)
      • Unfit for surgery/waiting - ACEi & vasodilators (e.g. hydralazine)
    • S: acute/Sx/severe = surgery
      • Valve _R_eplacement > _R_epair
  • MS:
    • C: asymptomatic - Monitor
    • M:
      • AF Tx, anti-coagulate & diuretics (if Sx/severe)
    • S: Sx/severe - can do balloon valvuloplasty/replacement
      • Valvuloplasty = lateral thoracotomy scar
      • Do not do percutaneously if persistent left atrial thrombus/rigid calcified valve –> need open heart surgery (CABG, concurrent severe MS)

Complications of prosthetic heart valves: FIBAT

  • Failure
  • Infection
  • Bleeding - MAHA
  • Anaemia
  • Thromboembolic phenomena
33
Q

Infective endocarditis - RFs? Ix? Dx criteria? Mx?

Acute vs subacute bacterial endocarditis - what hearts affected? who are commonly affected? What bacteria most likely?

A

Def: infection of heart valves (typically mitral/aortic or tricuspid in IVDU)

RFs: bacteraemia (long-term lines, IVDU, dental work), abn valves (prosthetic, RHD), prev endocarditis, VSD, piercings

Presentation: low-grade fevers, night sweats

  • Exam:
    • Splenomegaly
    • Splinter haemorrhages, osler’s nodes, Janeway lesions, petechiae, Roth spots (eyes)
    • Chronic = clubbing (rare, mostly acute now)

Ix:

  • Urine dip - haematuria
  • Serial BCs (x3 but start empirical abx), ESR
  • Transoesophageal Echo (TOE - vegetations)

Dx: DUKE’S CRITERIA (2 major OR 1 major + 3 minor OR 5 minor):

  • Major: +ve BC (typical organism), new regurg murmur/veg on echo
  • Minor: RF, fever (>38), embolic (vascular) phenomena, immune phenomena, +ve BC (another organism)
  • Mx: IV abx for 6wks – fluclox/vanc/gent

Acute in structurally normal heart – In IV drug user the first valve met is tricuspid valve, commonly S. aureus (also most common cause in prosthetic valve endocarditis)

Subacute in structurally abn heart – mitral & aortic valves more commonly affected as high pressure system, more likely damaged valves, commonly Strep Viridans (overall most common cause of endocarditis)

34
Q

3rd & 4th heart sounds - sounds & cause?

A

3rd = rapid ventricular filling = volume overload e.g. HF (reduced EF/systolic)

  • KEN…TU.CKY (deee. de.de)

4th = atrial contraction against stiff ventricles = pressure overload e.g. longstanding AS & other causes of left ventricular hypertrophy (HTN heart disease, HOCM, HF with preserved EF/diastolic)

  • TE.NE..SSEE (de.de.deee)
35
Q

2 days of chest pain following 4 days of generalised muscle aches

  • Worse on inspiration & lying flat
  • Low-grade fever
  • Exam: pericardial rub

Causes? Dx? Ix? Mx?

A

Pericarditis

Causes:

  • Viral (most common)
  • MI (can be Dressler’s syndrome)
  • TB (constrictive)
  • Uraemia (CKD where urea high –> pericarditis) = indication for haemodialysis (HUMP)
  • Hydralazine (AI pericarditis)
    • NOTE: also causes drug-induced lupus
  • SLE, RF, radiation

Presentation:

  • Pleuritic chest pain, worse lying flat
  • Exam: pericardial rub - “creaking/scratching”
    • Tip - put on all-fours, put stethoscope on sternal edge, hold inspiration

Ix:

  • ECG: ST elevation widespread
  • Only slightly raised/normal troponin

Mx: colchicine (3 months) + NSAIDs (ibuprofen, max 2wks)

36
Q

Causes of raised JVP (>4cm)?

A

JVP + hepatojugular pressure (RUQ), rockstar hand

PQRST:

  • Pul HTN/PE/Pericarditis/Pericardial effusion/PS
  • Quantity of fluid (fluid overloaded)
  • RHF
  • SVC obstruction
  • Tamponade/TR
37
Q

SVC obstruction - presentation? Tx?

A

Presentation: swollen face and neck and distended veins on her chest in background of cancer

Mx: dexamethasone to reduce tumour swelling

  • Insert EV stent if stridor (after intubation and steroids)
38
Q

Bradycardia arrhythmia with a palpable pulse (peri-arrest) - Mx?

A

Innitial: A-E

  • If unstable - 500mcg IV atropine (/5mins up to 3mg)
    • Also considered unstable if:
      • Recent asystole >3s/Mobitz T2 AV block/3rd degree heart block
    • Caution in acute MI, C/I if heart transplant
  • If persistent –> transcutaneous pacing + analgesia/sedation (very painful)
    • If can’t be achieved properly –> IV isoprenaline/adrenaline (specialist help)
  • Arrange transvenous pacing (temporary if recent asystole >3s/Mobitz T2 AV block/3rd degree heart block)
39
Q

Heart block causes? types? Ix? Mx? Complications?

A

Causes:

  • MI/IHD (MOST COMMON)
  • Inf (RHD, IE)
  • Drugs (digoxin)
  • Metabolic (hyperkalaemia)
  • Infiltration of conducting system (e.g. sarcoidosis)
  • Degeneration of conducting system

Types:

  • First Degree AV block - fixed prolonged PR interval (> 0.2 s) - ASYMPTOMATIC
  • Second degree AV block:
    • Mobitz TI (Wenckebach) - progressively prolonged PR interval –> P-wave NOT followed by a QRS complex = ‘going, going, gone’
      • Normally asymptomatic
    • Mobitz Type II - intermittently P wave NOT followed by a QRS
      • May be regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1)
      • Can cause:
        • Stokes-Adams Attacks (syncope caused by ventricular asystole)
        • Dizziness, palps, chest pain, HF
  • Complete AV heart block - no relationship between P waves and QRS complexes
    • Presentation as in Mobitz T2

Ix: ECG

  • Bloods: TFTs, Digoxin, cardiac enzymes (troponin, CK, BNP)
  • CXR (cardiac enlargement, pulmonary oedema)
  • Echo (wall motion abn, aortic valve disease, vegitations)

Mx:

  • Acute block - if clinical deterioration:
    • IV atropine
    • Consider temporary transcutaneous pacing
  • Chronic block:
    • 1st degree monitored
    • Permanent pacemaker in:
      • Symptomatic Mobitz T1
      • Advanced Mobitz T2
      • Complete heart block

Complications: asystole, cardiac arrest, HF, surgical complications of pacemaker insertion

40
Q

Types of pacemaker? When to use each type? Complications?

A

Types:

  • Implantable Cardioverter Defibrillator (ICD, has a thicker end)
  • Single-chamber pacemaker (right ventricle)
    • Used in permanent AF (no organised atrial contraction so atrial lead not required to sense contraction)
    • Rarely can have atrial lead only - if SA disease in young with good AV conduction
  • Dual-chamber pacemaker (right atrium & ventricle)
    • Can have ICD dual-chamber pacemaker
    • Used in paroxysmal AF/all other scenarios (there is sometimes organised atrial contraction - this is sensed by the atrial lead)
  • Cardiac Resynchronisation Therapy/Biventricular pacemaker (right ventricle, left ventricle ± right atrial lead)
    • Can have ICD biventricular pacemaker

When to use each type:

  • Atrial lead only → Sino-atrial disease in young people with good AV node conduction
  • RV lead only → Pacing whilst in permanent atrial fibrillation
  • Dual-lead → All other scenarios (paroxysmal AF, bradycardia)
  • CRT → LV dysfunction + broad QRS –> end-stage HF
  • Indications for ICD:
    • Primary prevention = @risk of serious ventricular arrhythmia
      • Familial cardiac conditions (hypertrophic cardiomyopathy, long QT)
      • Previous surgical repair of congenital HD
      • Previous MI + LVEF <35% + HF Sx
    • Secondary prevention = had previous serious ventricular arrhythmia wo/ treatable cause
      • Cardiac arrest from VT/VT
      • Spontaneous sustained VT AND:
        • Syncope/haemodynamic compromise OR
        • LVEF <35% + sign HF Sx (NYHA 3+)
      • NOTE: VT/VF from STEMI has treatable cause (open occluded vessel)

Complications:

  • Surgical complications - infection, bleeding, damage to underlying structures
  • Displacement (of lead)
  • Pacemaker syndrome (if ventricular lead with no atrial) –> AV node conducts in retrograde direction = mitral/tricuspid regurge + HF Sx
41
Q

Different pulse forms? Causes?

A

Pulsus paradoxus - greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration

  • severe asthma, cardiac tamponade

Slow-rising/plateau

  • AS

Collapsing

  • AR, PDA
  • hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

Pulsus alternans - regular alternation of the force of the arterial pulse

  • severe LVF

Bisferiens pulse - ‘double pulse’ - two systolic peaks

  • Mixed aortic valve disease
  • HOCM (also causes ‘Jerky’ pulse)
42
Q

Ventricular tachycardia - Dx? Presentation? Ix - appearance on ECG? Mx?

A

VT or SVT w/ aberrancy

  • SVT >200bpm, also often irregular
  • VT more likely if LAD
  • Acutely treat any broad complex tachy as VT until proven otherwise

Presentation: palpitations, light-headed, chest pain, syncope, seizure

  • Tachycardia, LVF
  • ACS most common cause
  • NEVER IGNORE palpitations & light-headedness

Ix: ECG - regular broad complex tachycardia

  • U&E (Mg, Ca, K), TFTs, Troponins

Mx:

  • Unstable tachycardia (BP <90, chest pain, acute cardiac failure) = DC cardioversion
  • Stable:
    • IV amiodarone, b-blocker –> prepare for DC cardioversion
43
Q

Cardiac tamponade - key finding on exam? Triad? Mx?

A

Pulsus paradoxus - BP variation between inspiration & expiration (≥10)

Beck’s triad (50%):

  • Raised JVP
  • Muffled heart sounds
  • Hypotension

Mx:

  • IV fluids (RV filling depends on venous pressure & effusion is constricting)
  • Echo –> refer to cardiology for pericardiocentesis
    • Coagulation profile (to prep for pericardiocentesis)

MSRA Exam Preperation (13 decks)

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