Cardiovascular Flashcards
1
Q
Most common organism in infective endocarditis
A
Staphylococcus Aureus (Especially in acutely presenting patients and IVDUs)
2
Q
Most common organism in acute presentation of infective endocarditis
A
Staphylococcus Aureus (Especially in acutely presenting patients and IVDUs)
3
Q
Risk factors for Infective Endocarditis
A
Previous episode of infective endocarditis
Past Rheumatic fever or Rheumatic valve disease (30%)
Damaged or Prosthetic valves
Structural Congenital heart defects
IV Drug Users (typically causes tricuspid lesions)
Permanent pacemaker or ICD
Hypertrophic cardiomyopathy
4
Q
Septic signs of infective endocarditis
A
Fever Night sweats Weight loss Malaise Anaemia
5
Q
New onset murmur and fever is what until proven otherwise
A
Infective endocarditis
6
Q
Urinalysis in infective endocarditis
A
Haematuria +/- proteinuria
7
Q
Signs in the hands of infective endocarditis
A
Splinter haemorrhages
Osler’s nodes
Janeway lesions
8
Q
Osler’s nodes
A
Painful lesions on tips of fingers and toes due to immune complex deposition in IE
9
Q
Janeway lesions
A
Painless lesions on palms and soles due to embolic phenomena in IE
10
Q
ECG changes in infective endocarditis
A
PR prolongation
AV block
11
Q
First line imaging in infective endocarditis
A
Transthoracic echocardiogram
12
Q
Patient presents acutely with temperature >38 and a new onset murmur.
They have no history of cardiac disease.
They are diagnosed with infective endocarditis.
Which antibiotics are given?
A
Vancomycin and Gentamicin
13
Q
Management of Angina
A
Lifestyle modifications
Statin & Aspirin
Sublingual GTN
Beta blocker or CCB (verapamil, diltiazem)
14
Q
Management of NSTEMI
A
Aspirin 300mg AND Clopidogrel 300-600mg
Oxygen if hypoxia
Analgesia: GTN +/- Morphine
Beta Blockers (diltiazem or verapamil if contraindicated) should be continued indefinitely → Metoprolol
PCI may be indicated
15
Q
Management of STEMI
A
Oxygen if O2 sats < 94%
Analgesia: IV Morphine + Sublingual GTN
Antiemetic - Metoclopramide (or cyclizine if LV function is not compromised)
Dual antiplatelet therapy: Aspirin 300mg and Clopidogrel 300-600mg
Restore patency of occluded vessel: PCI or thrombolysis
16
Q
Secondary Prevention of MI
A
Lifestyle modification
Dual Antiplatelet therapy:
STEMI - Aspirin 75mg and Clopidogrel for 12 months
NSTEMI - clopidogrel for 12 months
ACE-I or ARB - start within 24 hours and continue for 5-6 weeks
Beta blocker (if contraindicated CCB e.g. verapamil or diltiazem)
Statin (Atorvastatin 80mg is given for secondary prevention)
17
Q
Dressler’s syndrome
A
Pericarditis 2-6 weeks after MI due to autoimmune reaction against antigenic proteins produced as heart recovers.
Treated with NSAIDs
18
Q
Auscultation: Aortic Area
A
Right sternal edge
2nd intercostal space
19
Q
Auscultation: Pulmonary area
A
Left sternal edge
2nd intercostal space
20
Q
Auscultation: Mitral area
A
Left midclavicular line
5th intercostal space
21
Q
Auscultation: Bicuspid area
A
Left sternal edge
4th intercostal space
22
Q
Most common cause of mitral stenosis
A
Rheumatic Fever
23
Q
ECG changes in Mitral Stenosis
A
Bifid P wave
AF
RV hypertrophy - right axis deviation, tall R waves in V1
24
Q
Signs of Mitral Stenosis
A
Mid diastolic murmur (opening snap, loud S1)
Malar flush
Raised JVP
25
Symptoms of mitral stenosis
Asymptomatic until severe.
Dyspnoea, fatigue, weakness if right sided heart failure
Palpitations if AF
26
Management of mitral stenosis
Diuretics for mild dyspnoea
Management of AF
Surgery if pulmonary hypertension occurs
27
Signs of mitral regurgitation
Pansystolic murmur with midsystolic click, radiating to axilla.
Signs of right heart failure in late disease - ascites, pulmonary oedema
28
ECG changes in mitral regurgitation
Bifid P waves
LV hypertrophy (tall R waves in lateral leads I and V5)
29
Symptoms of mitral regurgitation
Dyspnoea and orthopnoea due to reduced cardiac output
Signs of right sided heart failure in late disease
30
Which murmur is associated with increased risk of VTE?
Mitral stenosis (causes AF)
31
Which murmurs are associated with increased risk of infective endocarditis ?
Aortic stenosis
| Mitral regurgitation
32
Most common cause of aortic stenosis
Calcific Aortic Valvular Disease
33
Signs of aortic stenosis
Ejection systolic murmur (crescendo, decrescendo), loudest in aortic area. Radiates to carotids.
Narrow pulse pressure
Slow rising pulse
34
ECG changes in aortic stenosis
LV hypertrophy: tall R waves in lateral leads I and V5
35
Management of Aortic stenosis
Observation if asymptomatic
Surgery if symptomatic or reduced ejection fraction
Prophylaxis of infective endocarditis
36
Signs of Aortic Regurgitation
Early diastolic murmur, decrescendo
Collapsing pulse
Signs of hyperdynamic pulse:
- Quincke's sign = pulsation in nail beds
- de Musset's sign = head nodding with each beat
- Pistol shot femorals = sharp bang on auscultation of femoral arteries
37
ECG changes in aortic regurgitation
LV hypertrophy - tall R waves in lateral leads
38
Symptoms of aortic regurgitation
Angina - LV hypertrophy causes increased O2 demand
| Dyspnoea if left heart failure
39
Management of aortic regurgitation
Treat underlying cause
ACE-I and beta blockers if CHF
Surgery if symptomatic or reduced ejection fraction
40
ECG changes in tricuspid stenosis
Causes right atrial enlargement - tall P waves in lead II
41
Signs of tricuspid regurgitation
Pansystolic murmur which does not radiate to axilla
Signs of right heart failure if severe
42
Management of tricuspid regurgitation
Treat underlying cause e.g. IVDU
Management of heart failure
Surgery if severe
43
Organism causing Rheumatic Fever
Group A beta-haemolytic streptococci
44
Effects of Rheumatic Fever on the heart
Murmurs
Pericarditis - pericardial rub
Cardiomegaly - murmurs resulting in CHF
Conduction defects
45
Management of rheumatic fever
Bed rest until CRP normal
Benzylpenicillin then phenoxymethylpenicillin
NSAIDs for carditis and arthrtitis
Haloperidol & diazepam for chorea
46
In order of preference, valves affected by Rheumatic Fever
Mitral > Aortic > Tricuspid > Pulmonary
47
Non cardiac effects of rheumatic fever
Arthritis
Subcutaneous nodules
Erythema marginatum
Sydenham's chorea - movement disorder, emotional lability
48
Paroxysmal AF
2 or more episodes, terminate spontaneously
49
Persistent AF
2 or more episodes which do not self terminate
| May last for more than 7 days
50
Permanent AF
Continuous AF which cannot be cardioverted or not appropriate to cardiovert
51
Presentation of AF
Palpitations
Chest pain
Irregularly irregular pulse
52
75 year old patient with a history of ischaemic heart disease is diagnosed with AF.
Rate or rhythm control?
Rate control - beta blockers of rate limiting CCB e.g. Diltiazem
53
Rate control methods for AF
First line: Beta blocker or rate-limiting CCB e.g. Diltiazem, Verapamil
Second line: Combination therapy of any 2 of the following:
- Beta blocker
- CCB (NOT Verapamil - risk of AV block)
- Digoxin
54
50 year old patient with no significant PMH is diagnosed with AF which started the previous evening.
Rate or rhythm control?
Rhythm control
55
Rhythm control methods for AF
DC cardioversion OR
Drugs: Sotalol, Amiodarone, Flecainide
Anticoagulants - should be anticoagulated beforehand as the moment where patient switches from AF to sinus rhythm is high risk for embolism leading to stroke)
56
CHADSVASc
```
Congestive Heart Failure - 1
HTN - 1
Age > 75 - 2
Age 65-74 - 1
Diabetes 1
Prior stroke or TIA - 2
Vascular disease - 1
Sex (female) - 1
```
0 - offer no treatment
1 - consider treatment if male
2 - offer anticoagulation
57
HASBLED
```
Hypertension (>160) - 1
Abnormal renal or liver function - 1 for each
Stroke history - 1
Bleeding history - 1
Labile INRs - 1
Elderly > 65 yrs - 1
Drugs & Alcohol - 1 for each
```
High risk > 3
58
Presentation of atrial flutter
Often, worsening heart failure or pulmonary symptoms due to new-onset flutter
Palpitations or lightheadedness
59
Management of Atrial Flutter
Unstable: Synchronised cardioversion
Stable: Treat as AF
Ongoing: Catheter ablation of tricuspid valve isthmus
60
Young patient presents with sudden onset palpitations.
ECG shows a regular, narrow complex, tachycardia.
AVNRT supraventricular tachycardia
61
Causes of supraventricular tachycardia
Catecholamine excess e.g. cocaine use
Digoxin toxicity
Cardiomyopathy/Congenital heart disease
62
Management of AVNRT
Vagal manoeuvres
IV Adenosine 6mg THEN 12mg THEN 12mg (contraindicated in asthmatics - consider verapamil)
Long term: Catheter ablation
63
Pathology of Wolff-Parkinson-White Syndrome
Conduction from the atrium reaches the adjacent ventricle earlier via an accessory pathway (the bundle of Kent).
Most commonly associated with Ebstein’s anomaly.
64
Management of Wolff-Parkinson-White Syndrome
In acute setting, follow protocil for periarrest rhythms.
Ongoing: Catheter ablation of Bundle of Kent (accessory pathway)
65
Intrinsic causes of AV block
Degenerative processes
Congenital abnormality
Direct tissue damage, inflammation or infiltration
Infection e.g. rheumatic fever
66
Extrinsic causes of AV block
Toxins e.g. lead, TCA overdose
Drugs e.g. digoxin, Beta blockers, CCB
Electrolyte abnormalities
67
1st degree heart block
Fixed PR prolongation > 0.2s
68
Mobitz type I heart block
Progressive prolongation of PR interval with eventual loss of QRS
69
Mobitz type II heart block
Fixed PR intervals with occasional loss of QRS complex
70
Management of AV block
1st degree and Type I 2nd degree:
Monitor if asymptomatic
Discontinue AV-blocking medications if symptomatic
2nd degree type II or 3rd degree:
Discontinue AV-blocking medications
Usually, Dual chamber Pacemaker
If LVEF < 35%: Biventricular pacemaker + ICD
71
Causes of long QT syndrome
Congenital e.g. LQT1 or LQT2
Drugs
- Amiodarone
- Haloperidol,
- TCAs and SSRIs
- Methadone
- Chloroquine
- Erythromycin
Electrolyte abnormalities (low Ca2+, low K+, low Mg2+)
Acute MI
Myocarditis
Hypothermia
SAH
72
Management of long QT syndrome
If acquired, treat underlying cause or precipitating factor.
Pharmacotherapy: Beta blockers usually Propranolol NOT Sotalol
ICD - indicated if there has been a previous cardiac event, therefore risk of arrest OR high risk of arrest due to inherited disease OR QTc > 500ms
73
Management of tachycardia with adverse features e.g. shock, syncope, myocardial ischaemia, heart failure
SYNCHRONISED DC SHOCK (up to 3 attempts)
THEN Amiodarone 300mg IV over 10-20 mins
THEN Amiodarone 900mg over 24 hrs
74
Definition of broad complex
QRS > 0.12s or 3 small squares
75
Definition of narrow complex
QRS < 0.12s or 3 small squares
76
Management of regular, broad complex tachycardia
Assume VT until proven otherwise:
THEN Amiodarone 300mg IV over 10-20 mins
THEN Amiodarone 900mg over 24 hrs
77
Differentials for Irregular, broad complex tachycardia
AF + BBB
| Polymorphic VT e.g. Torsades de Pointes
78
Management of Torsades de Pointes
DC cardioversion and amiodarone if adverse features
IV Mg2+ 2g over 10 mins
79
Effect of Adenosine
Inhibits conduction through AVN
80
Management of bradycardia with adverse features e.g. shock, syncope, myocardial ischaemia, heart failure
Atropine 500mcg IV
81
Management of bradycardia with a risk of asystole
```
Atropine 500mcg IV repeat to maximum 3mg (x6)
OR
Transcutaneous pacing
OR
Adrenaline 2-10mcg min-1 IV
```
82
Risk Factors for AAA
Smoking
Hypertension
Family history
Age > 55
Male sex (female sex is a risk factor for rupture)
Syphilis
Connective tissue disease e.g. Ehlers Danlos Type I and Marfan’s Syndrome
83
Features of AAA
Diameter of infrarenal aorta > 3cm (Normally 1.5cm in females and 1.7cm in males)
Normally asymptomatic - discovered incidentally
Abdominal, back or groin pain
Palpable pulsatile abdominal mass
Hypotension if AAA is ruptured
84
Diagnosis of AAA
USS
85
Management of ruptured AAA
ABCDE approach
Withhold fluids prior to surgery
Urgent surgical repair: Endovascular > open
Perioperative antibiotic therapy - prevention of graft infection
86
Management of symptomatic, non ruptured AAA
Urgent surgical repair - new onset symptoms are predictive of impending rupture
Preop CV risk reduction - low dose aspirin and antihypertensives
Perioperative broad spectrum antibiotics
87
Indication for surgery in asymptomatic AAA
> 5.5cm
88
Management of asymptomatic AAA
Lifestyle modifications - smoking cessation, exercise
CV risk factor reduction: low dose aspirin, antihypertensives, statin
Elective surgical repair if > 5.5cm
89
Screening for AAA
One off USS of all males at 65 years
90
Differentials for acute pericarditis
Infectious (usually viral)
Post MI
Malignant - associated with carcinoma of bronchus, breast and Hodgkin's lymphoma)
Uraemia - common in patients with advanced kidney disease
91
Features of pericarditis
Sharp, central chest pain - worse lying down, relieved by sitting forwards
Pericardial friction rub - heard at the end of expiration
+/- Fever/Leukocytosis/Lymphocytosis
Dyspnoea
92
ECG changes in pericarditis
Saddle shaped ST elevation
93
Risk of relapsing or intermittent pericarditis following first presentation
20%
94
Clinical features of pericardial effusion
Quiet heart sounds
Pericardial rub
Signs of cardiac tamponade
95
Signs of cardiac tamponade
Raised JVP with sharp rise and y decent
Kussmaul’s sign (rise in JVP on inspiration)
Pulsus paradoxus
Reduced cardiac output
96
Management of cardiac tamponade
Pericardiocentesis
97
Causes of constrictive pericarditis (thickened, fibrous pericardium)
```
TB
Haemopericardium
Bacterial infection
Rheumatic heart disease
Open heart surgery
Dopamine antagonists causing fibrosis
```
98
Post thrombotic Syndrome
Affects 30% of patients following VTE
```
Chronic pain
Oedema
Skin changes
Ulcers
4% of patients will have chronic pulmonary hypertension following PE
```
99
Clinical Features of DVT
```
Pain/tenderness
Unilateral pitting oedema
Erythema
Warm leg
Presence of risk factors - cancer, obesity, age, recent trauma inc surgery, hormone therapy
```
100
Clinical features of PE
Pleuritic chest pain, worse on deep inspiration
Dyspnoea
Haemoptysis
Cough
```
Tachypnoea > 16
Tachycardia > 100
Hypoxia
Lung crackles on auscultation
Fever > 37.8*
```
101
Wells Scoring assesses probability of...
PE or DVT
102
Investigations in DVT
Low suspicion (Wells < 2) - D dimer
High suspicion (Wells 2+) - Proximal duplex USS
103
Investigations in PE
Low suspicion (Wells <4) - D dimer
High suspicion (Wells 4+) - CTPA
104
D dimer
Fibrin degradation product
105
ECG changes in PE
```
S1Q3T3 - seen in only 20% of patients
Large S wave in lead I
Large Q wave in lead III
Inverted T wave in lead III
May also show RBBB, R axis deviation and sinus tachycardia.
```
106
Investigation of PE in patients with renal failure
V/Q Scan
107
Management of PE/DVT
Anticoagulation
LMWH for at least 5 days. Can be stopped when INR is >2 for >24 hours
Warfarin:
- 3 months if precipitated +/- distal
- >3 months if idiopathic or proximal
- Long term if recurrent or occurred whilst on warfarin with therapeutic INR
108
Complications of PE
```
Sudden cardiac death
Obstructive shock
Arrhythmias
Secondary pulmonary arterial hypertension
Cor Pulmonale
Severe Hypoxia
Right to left intracardiac shunt
Lung infarction
HIT
Thrombophlebitis
```
109
Complications of DVT
PE
| Post thrombotic syndrome - calf pain, swelling, rash, ulceration
110
First line treatment of hypertension
Lifestyle advice - low salt diet, reduce caffeine
ACE-I if < 55 yrs
CCB if > 55 yrs of Afro-Caribbean
111
Second line treatment of hypertension
ACE-I and CCB
112
Third line treatment of hypertension
ACE-I + CCB + Thiazide diuretic
| Indapamide or Chlorthalidone > Bendroflumethiazide
