Cardiovascular Flashcards
HF diagnosis
BNP
Echo if prev MI
CXR Alveolar shadowing - oedema B Kerley B lines Cardiomegaly Dilated vessels Effusion
heart failure presentation and examination
SOBOE, PND, orthopnoea
o/e pulmonary oedema pleural effusion cardiomegaly S3 JVP, neck veins hepatomeg, ankle swelling
quick weight loss on starting diuretic (4.5kg in 3d)
MAJOR pnd neck vein distend acute pulm oedema creps cardiomegaly weight loss>4.5 in 5 days w diuretic S3 gallop incread CVP
MINOR
ankles, nocturnal cough, hepato, dysp on exert, tachy>120, pleural eff, dec VC
heart fail mgmt
0) loop diuretic vs fluid
1) ace and b block
2) spironalact
hydralazine w/ nitrate
3) digoxin if AF
cardaic resynch
also: vaccines (anual flu, 1xpneumococ)
aortic stenosis
TRIAD: c.p, syncope, dyspnoe
narrow pp, slow rising 'crescendo decrescendo' ejec murmur, S4, sustained heave radiateto apex/carotid lvh on ecg
severe (gradient>5mmHg) or symptomatic get AVR
calcify (>65), bicuspid (<65), williams, rheumat
mitral regurg
pan systolic, rad to axilla thrusting apex, ?displaced sob, fatigue, palp *AF common* LVH - post mi (papillary muscle) - dilated cardiomyop - IE - Marfan's
aortic regurgitation
high pitch early diastolic, lean forward
may be closer to LSE
DISPLACED APEX BEAT, may be thrusting
backflow signs
- corrigans - carotid pulse
- de musset - head
- durosier - femoral
- quinke - nail pulsation
like HF: dyspnoe, orthopnoea, pnd
also palpitations
collapsing pulse, wide pp
Marfans, AS, RA, syphilis
acuutely w dissection, IE
Mx: vs htn ACE-i
aortic regurgitation
assoc: connective tissue dis, arthritides
high pitch early diastolic
like HF: dyspnoe, orthopnoea, pnd
also angina, palp, syncope
collapsing pulse, wide pp
pulsations signs (corrigan, de musset, quinke)
Mx: vs htn ACE-i
mitral stenosis
mid diastolic - roll to enhance
CP, sob, palp, fatigue
may see haemoptysis
AF common
mala flush
TAPPING apex
low vol pulse
left atrial enlarge (p mitrale), pulmonary HTN and RHF
management mitral valve probs
- rate control vs AF (b-block or CCB)
- anticoagulate (warfarin)
- diuretics
- ab proph w procedures
?balloon valvuloplasty, valvotomy, replacement
tricuspid regurg
pan systolic, lower lse
louder on inspiration
signs of systemic backflow
- jvp - big v wave
- pulsatile hepatomegaly
- ascites
caused by RHF which is due to LHF or cor pulmonale
see rh strain on ecg
AF
problem
1 - impair output
2 - risk clots
3 - angina
causes w no structural disease - hyperthyroid - alcohol otherwise - mi, htn, hf, - valve disease
AF causes mnemonic
MATCH V
M - MI A - ALCOHOL T - THYROTOX C - CCF H - HTN V - VALVE PROB
acute AF
- new, symptomatic
heparin
cardiovert - shock or amiod
CCB for rate control (verap diltiaz)
- bblock, digoxin also used
chronic AF
anticoag if score on chadsvas (inr 2-3)
rate: b block or CCB
- digoxin only if sedentary ie HF
rhythm control if under 65, symptomatic, CCF
- sotalol, flec (no structural disease), amiod
HTN treat
target 140,90
or 150,90 if over 80
or 130,90 if DM with end organ damage
under 55: ACE or ARB (switch if intol)
over 55 or black: CCB (amlod, nifed)
(thiazide-like if HF)
2) a+c
3) a+c+tld
htn classif
1) 140,90 clinic
135/85 home/amb
2) 160/100 clinic
150/95 home/amb
3) 180s or 110d clinic
treat stage 1 if over 40, target organ damage, cvd, dm, renal, Q score>20%
secondary htn
RENAL 80%
gn, pyelo, cystic, stenosis
ENDOCRINE cush (cortisol), conn (aldosterone), congen adren hyp, phaeo, acromeg hyperparathyroid PREGNANCY
VASCULAR
- coarctation
- renal artery stenosis
alcohol
rare: MAO-i (depression) with cheese
renal artery stenosis
resistant to htn treatment
get worse with ace/arb if bilat
FLASH pulmonary oedema
US: show renal asym
angina (stable chest pain) diagnosis
get percentage CAD score
typical angina plus 90% score =diagn below 90% need investigation before managing as angina -over 60: angiogram -30-60: functional - mps/stress echo -below 30: ca score ct
angina mgmt
aspirin and statin
atenolol is first line anti-anginal
(ccb if pvd/asthma/heart block)
nitrate (can devel tol)
nicornadil
PCI
STEMI
MONAC
PCI or thrombolysis
B blocker IV
ACE
longterm: Aspirin, B block, aCe-i
NTSEMI and unstable angina
acute ASPIRIN 300 NITRATE MORPHINE ? oxygen if hypoxic
LMWHep
B blocker IV
calculate 6 month mortality
if over 1.5: clopidog for12m
if over 3: tirofiban, angiogram
mi ecg territories
inferior (RCA): ii, iii, avf
anteroseptal (LAD): V1 - V4
anterolateral (LC): V4 - V6
ecg territories
AS - v1/4 - LAD
AL - V4/6,I,aVL - LAD or LC
L - I, aVL, V5/6 - LC
Inf - II,III,aVF - RC (see bradycardia and vom)
posterior - tall r waves v1/2 - LC or RCA
pericardits
pleuritic pain - relieved by sitting
?cough dysp
percardial rub on ausc
tachycard/tachydysp
post virus - coxsackie b
post mi (dresslers)
bact is rarer - staph, tb
ecg - saddle ST elev widespread
pr depression
pericarditis ecg
widespread ST (saddle) elevation - across territories trop may be slightly raised
pericardial effusion
2dry to pericarditis
HF (sob, jvp, pleural effusion, ascites)
low voltage ecg
pericardiocentesis
if accumulates–>tamponade (low bp, high pulse)
constrictive pericarditis
2dry to pericarditis
RHF signs
CXR: calcification
t: surgical excision
aortic dissec
sudden severe - max at onset
rad to back
pulse deficit and bp difference
may get neuro/cog impair
may get inferior mi (take out rca)
cxr may show small pleural eff, wide mediastinum
I: ct angiogram
M: control blood pressure, refer to sugery
PE
haemoptysis
dyspnoea
tachycardia
pleuritic pain
see respiratory alkalosis w low oxygen
wells score
CTPA, heparin
thrombolysis
anticoag
ventricular ectopics
missed beats
disappear w exercise
if symptomatic investigate - echo, exercise ecg
ventric tachy VT
broad complex tachy (>120)
- stable - amiod
- unstable - shock
correct hypokal/hypomag
QT elongation
can be inherited syndrome
torsade de pointes
risk of getting VT
drugs: tca, ssri amiodarone methadone TERFEADINE (ant hist) chloroquine (anti malaria) erythromycin
- hypo cal,kal,mag,thermia
svt
narrow complex (<120 - 3 small)
flutter (sawtooth, w 2:1 block gives 150)
junctional
compromised - cardioversion
stable - VAGAL
- ADENOSINE (ci in asthma)
prevention - b-block
ablation
*SEE POLYURIA AFTER DUE TO ANP RELEASE
torsade de pointes
polymorphic wide complex tachy
causes
- electrolytes - hypomag, hypokal
- post mi
- drugs - amiod, methadone
- congenital
- aut dom: romano ward
- aut recess: lange nielsen
M: replace electrolytes Mg then K
heart block
1st degree - prolonged pr
2nd degree
type 1 successive increases until dropped beat
type 2 2:1 or 3:1
3rd degree total - no relation
cardiomyopathy
ISCHAEMIC
post MI
DILATED - test BNP
alcohol
htn
autoimmune
HYPERTROPHIC
hocm - autosomal dominant
t: bblock, implan defib, amiod for arryth
RESTRICTIVE/INFILTRATIVE
amyloid, haemochromatosis, sarcoidosis, scleroderma
acute myopathy
post viral or bact infect
drugs: cyclophosphamide, herceptin
causes acute HF, cp, palp
troponin slight
may cause chronic HF
infective endocarditis
FEVER
MURMUR
EMBOLI
systemic symptoms
risk: heart defect, valve prob, iv drug, new valve, dental
50% normal vlaves, acute, HF, staph A
50% abn valves, subacute, strep viridans (alpha haem)
95% left
right (tricuspid) with drug users
d: 3 blood cultures, echo (veg,regurg)
t: iv gent and benzylpen
congenital heart disease
in order of freq in adults
bicuspid aorta - AS
ASD (L to R shunt)
- pulm htn. hf
- eisenmenger (pulm htn reverse shunt; cyanoisis sob, infec, rhf)
VSD
- pulm htn, hf
COARC
- turners
PULM STEN
tetralogy of fallot
VSD
overriding aorta
pulm stenosis
RVH
right to left shunt
CYANOTIC
vsd
young patient - it is congenital
monitor for eissenmenger’s
loud pan systolic murmur
loudest at lse but widespread
ASD
fixed splitting of second heart sound
PFO
DVT can lead to stroke instead of PE
Rheumatic fever features
follows infection w group A beta haemolytic (pyogenes)
carditis (tachy, murmur, rub, ccf, arrhth) arthritis subcutaneous nodules erythema marginatum sydenhams chorea
rheumatic fever treat and prog
rest
penicillin
high dose aspirin for carditis/arthritis
acute attck can take 3m to clear
60% chronic heart disease
can recur
hypo/hyperkalaemia ecg
hyperkal (spiro, ace, renal fail, addisons, acidosis)
- tall tented T
- small P
- wide QRS
hypokal (diuretics, vom/diar, alk, conns)
- U
- small T
- long pr
breathlessness - new york classification
1 - heart disease but no dysp
2 - dysp not at rest but on ordinary activity - walking/stairs
3 - dysp on basic activities - making tea
4 - dysp at rest
atrial myxoma
throws off clots –> stroke
cause of clubbing
cardiac myxoma pres
like endocard: fever, clubbing
like m stenosis: af, congestion
s3 and s4
s3 - heart failure
s4 - AS, hocm, htn
thiazide
hyponatraemia is main se
avoid in gout
K depletion
-u waves, no T, long qt/pr
j waves
hypothermia
delta waves
wolf parkinson white
cause of rentry tachycardia
bundle of kent
–> ablate
digoxin
can cause heart block
can cause down sloping ST, T inversion
se - any arryth, yellow vision, nausea, gynecomast
antidote: digoxin immune fab (digibind)
stop exercise testing
symptoms ST > 1mm ST downsloping is diagnostic fall in bp arryth reach max hr (220-age)
driving
MI w angioplast 1 week
pacemaker 1 week
MI no angioplast - 4 weeks
CABG - 4 weeks
libman sacks endocarditis
afebrile endocarditis
just new murmur and emboli –> stroke
assoc w SLE (ana) and other connective tisssues
ACE se
cough
first dose hypo
hyperkal
rarer - tongue and face swelling
- can last up to 6m once stopped
amlodipine se
oedema - ankles
flushing
in overdose - pulmonary oedema
nitrate se
headache
can devel tolerance
dilitazem/verap se
constipation
b blocker se
slow hr
peripheral vasoconst
- cold peripheries
- erectile dysf
ci: asthma
spironalactone se
hyperkalaemia
swanz gatz catheter
sits in pulmonary artery
used mostly in critical care - continual monitoring
diagnostic info
- hf - ie post mi, cardiogenic shock
- pulm htn (wedge pressure)
- assess therapy response
- assess fluid need
central line uses
sits in internal jugular
- sometime femroal or subclavian
deliver drugs
- amiod, chemo
monitoring
- central venous oxygen sat
- central venous pressure
sometimes in haemodialysis
AAA
risk: smoke, htn, age, male, fh
Defined when diam > 3cm
Usually above umbilicus
- after renal arteries
Screening programme for men aged 65
Once over 6cm risk of rupture outweighs risk of surgery (endovascular stent)
- 10% annual risk of rupture
- surgery mortality is 2-7%
Symptomatic if enlarging/leaking
- constant/severe abdo pain (epigastric) rad to back
Rupture - collapse and death
svt vs vt
svt
- often young no underlying heart disease
- palpitation +/- syncope
- vagal then adenosine or dc
vt
- stronger symptoms - syncope
- often underlying heart disease
- dc or amiod (or ligno)
