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Clinical Medicine > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Most common organism in infective endocarditis

A

Staphylococcus Aureus (Especially in acutely presenting patients and IVDUs)

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2
Q

Most common organism in acute presentation of infective endocarditis

A

Staphylococcus Aureus (Especially in acutely presenting patients and IVDUs)

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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

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4
Q

Septic signs of infective endocarditis

A 
Fever
Night sweats
Weight loss 
Malaise 
Anaemia
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5
Q

New onset murmur and fever is what until proven otherwise

A

Infective endocarditis

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6
Q

Urinalysis in infective endocarditis

A

Haematuria +/- proteinuria

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7
Q

Signs in the hands of infective endocarditis

A

Splinter haemorrhages
Osler’s nodes
Janeway lesions

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8
Q

Osler’s nodes

A

Painful lesions on tips of fingers and toes due to immune complex deposition in IE

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9
Q

Janeway lesions

A

Painless lesions on palms and soles due to embolic phenomena in IE

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10
Q

ECG changes in infective endocarditis

A

PR prolongation

AV block

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11
Q

First line imaging in infective endocarditis

A

Transthoracic echocardiogram

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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

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13
Q

Management of Angina

A

Lifestyle modifications
Statin & Aspirin
Sublingual GTN
Beta blocker or CCB (verapamil, diltiazem)

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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

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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

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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)

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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

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18
Q

Auscultation: Aortic Area

A

Right sternal edge

2nd intercostal space

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19
Q

Auscultation: Pulmonary area

A

Left sternal edge

2nd intercostal space

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20
Q

Auscultation: Mitral area

A

Left midclavicular line

5th intercostal space

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21
Q

Auscultation: Bicuspid area

A

Left sternal edge

4th intercostal space

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22
Q

Most common cause of mitral stenosis

A

Rheumatic Fever

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23
Q

ECG changes in Mitral Stenosis

A

Bifid P wave
AF
RV hypertrophy - right axis deviation, tall R waves in V1

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24
Q

Signs of Mitral Stenosis

A

Mid diastolic murmur (opening snap, loud S1)
Malar flush
Raised JVP

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25
Q

Symptoms of mitral stenosis

A

Asymptomatic until severe.

Dyspnoea, fatigue, weakness if right sided heart failure

Palpitations if AF

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26
Q

Management of mitral stenosis

A

Diuretics for mild dyspnoea

Management of AF

Surgery if pulmonary hypertension occurs

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27
Q

Signs of mitral regurgitation

A

Pansystolic murmur with midsystolic click, radiating to axilla.

Signs of right heart failure in late disease - ascites, pulmonary oedema

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28
Q

ECG changes in mitral regurgitation

A

Bifid P waves

LV hypertrophy (tall R waves in lateral leads I and V5)

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29
Q

Symptoms of mitral regurgitation

A

Dyspnoea and orthopnoea due to reduced cardiac output

Signs of right sided heart failure in late disease

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30
Q

Which murmur is associated with increased risk of VTE?

A

Mitral stenosis (causes AF)

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31
Q

Which murmurs are associated with increased risk of infective endocarditis ?

A

Aortic stenosis

Mitral regurgitation

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32
Q

Most common cause of aortic stenosis

A

Calcific Aortic Valvular Disease

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33
Q

Signs of aortic stenosis

A

Ejection systolic murmur (crescendo, decrescendo), loudest in aortic area. Radiates to carotids.
Narrow pulse pressure
Slow rising pulse

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34
Q

ECG changes in aortic stenosis

A

LV hypertrophy: tall R waves in lateral leads I and V5

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35
Q

Management of Aortic stenosis

A

Observation if asymptomatic

Surgery if symptomatic or reduced ejection fraction

Prophylaxis of infective endocarditis

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36
Q

Signs of Aortic Regurgitation

A

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
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37
Q

ECG changes in aortic regurgitation

A

LV hypertrophy - tall R waves in lateral leads

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38
Q

Symptoms of aortic regurgitation

A

Angina - LV hypertrophy causes increased O2 demand

Dyspnoea if left heart failure

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39
Q

Management of aortic regurgitation

A

Treat underlying cause

ACE-I and beta blockers if CHF

Surgery if symptomatic or reduced ejection fraction

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40
Q

ECG changes in tricuspid stenosis

A

Causes right atrial enlargement - tall P waves in lead II

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41
Q

Signs of tricuspid regurgitation

A

Pansystolic murmur which does not radiate to axilla

Signs of right heart failure if severe

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42
Q

Management of tricuspid regurgitation

A

Treat underlying cause e.g. IVDU

Management of heart failure

Surgery if severe

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43
Q

Organism causing Rheumatic Fever

A

Group A beta-haemolytic streptococci

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44
Q

Effects of Rheumatic Fever on the heart

A

Murmurs
Pericarditis - pericardial rub
Cardiomegaly - murmurs resulting in CHF
Conduction defects

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45
Q

Management of rheumatic fever

A

Bed rest until CRP normal
Benzylpenicillin then phenoxymethylpenicillin

NSAIDs for carditis and arthrtitis
Haloperidol & diazepam for chorea

46
Q

In order of preference, valves affected by Rheumatic Fever

A

Mitral > Aortic > Tricuspid > Pulmonary

47
Q

Non cardiac effects of rheumatic fever

A

Arthritis
Subcutaneous nodules
Erythema marginatum
Sydenham’s chorea - movement disorder, emotional lability

48
Q

Paroxysmal AF

A

2 or more episodes, terminate spontaneously

49
Q

Persistent AF

A

2 or more episodes which do not self terminate

May last for more than 7 days

50
Q

Permanent AF

A

Continuous AF which cannot be cardioverted or not appropriate to cardiovert

51
Q

Presentation of AF

A

Palpitations
Chest pain
Irregularly irregular pulse

52
Q

75 year old patient with a history of ischaemic heart disease is diagnosed with AF.

Rate or rhythm control?

A

Rate control - beta blockers of rate limiting CCB e.g. Diltiazem

53
Q

Rate control methods for AF

A

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
Q

50 year old patient with no significant PMH is diagnosed with AF which started the previous evening.

Rate or rhythm control?

A

Rhythm control

55
Q

Rhythm control methods for AF

A

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
Q

CHADSVASc

A 
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
Q

HASBLED

A 
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 &amp; Alcohol - 1 for each

High risk > 3

58
Q

Presentation of atrial flutter

A

Often, worsening heart failure or pulmonary symptoms due to new-onset flutter

Palpitations or lightheadedness

59
Q

Management of Atrial Flutter

A

Unstable: Synchronised cardioversion

Stable: Treat as AF

Ongoing: Catheter ablation of tricuspid valve isthmus

60
Q

Young patient presents with sudden onset palpitations.

ECG shows a regular, narrow complex, tachycardia.

A

AVNRT supraventricular tachycardia

61
Q

Causes of supraventricular tachycardia

A

Catecholamine excess e.g. cocaine use
Digoxin toxicity
Cardiomyopathy/Congenital heart disease

62
Q

Management of AVNRT

A

Vagal manoeuvres

IV Adenosine 6mg THEN 12mg THEN 12mg (contraindicated in asthmatics - consider verapamil)

Long term: Catheter ablation

63
Q

Pathology of Wolff-Parkinson-White Syndrome

A

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
Q

Management of Wolff-Parkinson-White Syndrome

A

In acute setting, follow protocil for periarrest rhythms.

Ongoing: Catheter ablation of Bundle of Kent (accessory pathway)

65
Q

Intrinsic causes of AV block

A

Degenerative processes
Congenital abnormality
Direct tissue damage, inflammation or infiltration
Infection e.g. rheumatic fever

66
Q

Extrinsic causes of AV block

A

Toxins e.g. lead, TCA overdose
Drugs e.g. digoxin, Beta blockers, CCB
Electrolyte abnormalities

67
Q

1st degree heart block

A

Fixed PR prolongation > 0.2s

68
Q

Mobitz type I heart block

A

Progressive prolongation of PR interval with eventual loss of QRS

69
Q

Mobitz type II heart block

A

Fixed PR intervals with occasional loss of QRS complex

70
Q

Management of AV block

A

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
Q

Causes of long QT syndrome

A

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
Q

Management of long QT syndrome

A

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
Q

Management of tachycardia with adverse features e.g. shock, syncope, myocardial ischaemia, heart failure

A

SYNCHRONISED DC SHOCK (up to 3 attempts)

THEN Amiodarone 300mg IV over 10-20 mins

THEN Amiodarone 900mg over 24 hrs

74
Q

Definition of broad complex

A

QRS > 0.12s or 3 small squares

75
Q

Definition of narrow complex

A

QRS < 0.12s or 3 small squares

76
Q

Management of regular, broad complex tachycardia

A

Assume VT until proven otherwise:

THEN Amiodarone 300mg IV over 10-20 mins

THEN Amiodarone 900mg over 24 hrs

77
Q

Differentials for Irregular, broad complex tachycardia

A

AF + BBB

Polymorphic VT e.g. Torsades de Pointes

78
Q

Management of Torsades de Pointes

A

DC cardioversion and amiodarone if adverse features

IV Mg2+ 2g over 10 mins

79
Q

Effect of Adenosine

A

Inhibits conduction through AVN

80
Q

Management of bradycardia with adverse features e.g. shock, syncope, myocardial ischaemia, heart failure

A

Atropine 500mcg IV

81
Q

Management of bradycardia with a risk of asystole

A 
Atropine 500mcg IV repeat to maximum 3mg (x6)
OR
Transcutaneous pacing 
OR
Adrenaline 2-10mcg min-1 IV
82
Q

Risk Factors for AAA

A

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
Q

Features of AAA

A

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
Q

Diagnosis of AAA

A

USS

85
Q

Management of ruptured AAA

A

ABCDE approach
Withhold fluids prior to surgery
Urgent surgical repair: Endovascular > open
Perioperative antibiotic therapy - prevention of graft infection

86
Q

Management of symptomatic, non ruptured AAA

A

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
Q

Indication for surgery in asymptomatic AAA

A

> 5.5cm

88
Q

Management of asymptomatic AAA

A

Lifestyle modifications - smoking cessation, exercise

CV risk factor reduction: low dose aspirin, antihypertensives, statin

Elective surgical repair if > 5.5cm

89
Q

Screening for AAA

A

One off USS of all males at 65 years

90
Q

Differentials for acute pericarditis

A

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
Q

Features of pericarditis

A

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
Q

ECG changes in pericarditis

A

Saddle shaped ST elevation

93
Q

Risk of relapsing or intermittent pericarditis following first presentation

A

20%

94
Q

Clinical features of pericardial effusion

A

Quiet heart sounds
Pericardial rub
Signs of cardiac tamponade

95
Q

Signs of cardiac tamponade

A

Raised JVP with sharp rise and y decent
Kussmaul’s sign (rise in JVP on inspiration)
Pulsus paradoxus
Reduced cardiac output

96
Q

Management of cardiac tamponade

A

Pericardiocentesis

97
Q

Causes of constrictive pericarditis (thickened, fibrous pericardium)

A 
TB
Haemopericardium 
Bacterial infection
Rheumatic heart disease
Open heart surgery 
Dopamine antagonists causing fibrosis
98
Q

Post thrombotic Syndrome

A

Affects 30% of patients following VTE

Chronic pain
Oedema 
Skin changes 
Ulcers 
4% of patients will have chronic pulmonary hypertension following PE
99
Q

Clinical Features of DVT

A 
Pain/tenderness 
Unilateral pitting oedema 
Erythema 
Warm leg 
Presence of risk factors - cancer, obesity, age, recent trauma inc surgery, hormone therapy
100
Q

Clinical features of PE

A

Pleuritic chest pain, worse on deep inspiration
Dyspnoea
Haemoptysis
Cough

Tachypnoea > 16
Tachycardia > 100
Hypoxia 
Lung crackles on auscultation
Fever > 37.8*
101
Q

Wells Scoring assesses probability of…

A

PE or DVT

102
Q

Investigations in DVT

A

Low suspicion (Wells < 2) - D dimer

High suspicion (Wells 2+) - Proximal duplex USS

103
Q

Investigations in PE

A

Low suspicion (Wells <4) - D dimer

High suspicion (Wells 4+) - CTPA

104
Q

D dimer

A

Fibrin degradation product

105
Q

ECG changes in PE

A 
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
Q

Investigation of PE in patients with renal failure

A

V/Q Scan

107
Q

Management of PE/DVT

A

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
Q

Complications of PE

A 
Sudden cardiac death 
Obstructive shock
Arrhythmias 
Secondary pulmonary arterial hypertension
Cor Pulmonale
Severe Hypoxia 
Right to left intracardiac shunt 
Lung infarction 
HIT
Thrombophlebitis
109
Q

Complications of DVT

A

PE

Post thrombotic syndrome - calf pain, swelling, rash, ulceration

110
Q

First line treatment of hypertension

A

Lifestyle advice - low salt diet, reduce caffeine

ACE-I if < 55 yrs
CCB if > 55 yrs of Afro-Caribbean

111
Q

Second line treatment of hypertension

A

ACE-I and CCB

112
Q

Third line treatment of hypertension

A

ACE-I + CCB + Thiazide diuretic

Indapamide or Chlorthalidone > Bendroflumethiazide

Clinical Medicine (9 decks)

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