Cardiovascular Flashcards
What is angina pectoris?
Symptomatic reversible myocardial ischaemia
What are the features of angina pectoris?
- Constricting/heavy discomfort to chest, jaw, neck, shoulder or arms
- Symptoms brought on by exertion
- Symptoms relieved within 5min by rest or GTN
All 3 = typical angina
2 = atypical angina
0-1 = non-anginal chest pain
What are the causes of angina?
Atheroma
Rarely: Anaemia Coronary artery spasm Aortic stenosis Tachyarrhythmias Hypertrophic obstructive cardiomyopathy Arteritis/small vessel disease
What are the different types of angina?
Stable = induced by effort, relieved by rest; good prognosis
Unstable = angina of increasing frequency or severity; occurs on minimal exertion or at rest; increased MI risk
Decubitus = precipitated by lying flat
Variant = caused by coronary artery spasm - rare
What is stable angina?
Chest pain resulting from myocardial ischaemia induced by exertion, relieved by rest
Good prognosis
Most common cause = atherosclerotic disease
What is unstable angina?
Angina of increasing frequency or severity
Occurs on minimal exertion or at rest
Increased MI risk
What is decubitus angina?
Angina precipitated by lying flat
What is variant angina?
Angina caused by coronary artery spasm
Rare
What are the risk factors for angina?
Age (M≥ 45, W≥55) Smoking DM Dyslipidemia Family history of premature cardiovascular disease (M<55, F<65) HTN Kidney disease (microalbuminuria or GFR<60 mL/min) Obesity (BMI ≥ 30 kg/m2) Physical inactivity Prolonged psychosocial stress
How is angina investigated?
- ECG - normal, may be ST depression, flat or inverted T waves, signs of past MI
2. BLOODS: FBC U+Es TFTs - high ?thyrotoxicosis Lipids - high HbA1c - may be high in DM
- ECHO
- CXR
- EXERCISE ECG - ST depression or elevation
- ANGIOGRAPHY - using cardiac CT w contrast or transcatheter
How is angina managed?
- Address exacerbating factors: anaemia, tachycardia (eg fast AF), thyrotoxicosis
- Secondary prevention of CVD
- Stop smoking, exercise, dietary advice, optimise HTN and diabetes control
- Daily aspirin
- Address hyperlipidaemia
- Consider ACEis eg if diabetic - PRN symptom relief = GTN spray or sublingual tabs
- Advise patient to repeat dose if pain not gone in 5m and to call ambulance if still pain after 2nd dose
- SE: headache, hypotension - Anti-anginal medication
1st line - B blocker + CCB (atenolol + amlodipine - Revascularisation
- Considered when optimal medical therapy proves inadequate
- Percutaneous coronary intervention
- CABG
What is PCI?
Percutaneous coronary intervention
Balloon inflated inside stenosed vessel, opening the lumen
Stent usually inserted to reduce risk of re-stenosis
Dual antiplatelet therapy (aspirin + clopidigrel) for 12 months+ after stent insertion to reduce risk of in-stent thrombosis
When is revascularisation (PCI/CABG) indicated?
Angina
Considered when optimal medical therapy proves inadequate
What is CABG? Compare it to PCI
Coronary artery bypass graft
vs PSI
Open heart surgery
Slower recovery
2 large wounds - sternal + vein harvesting
Less likely to need revascularisation
Better outcomes for those with multivessel disease
What is acute coronary syndrome?
A constellation fo symptoms caused by sudden reduced blood flow to the heart muscle
Unstable angina + MIs
What is myocardial infarction?
Myocardial cell death, releasing troponin
What causes ACS?
Plaque rupture -> thrombosis -> inflammation
Rarely: emboli, coronary spasm, vasculitis in normal coronary arteries
What is the biochemical difference between MIs and unstable angina?
MIs have a rise in troponin
Unstable anginas do not
What are the risk factors for ACS?
Non-modifiable: age, male, FHx of IHD (MI in 1st-degree relative <55)
Modifiable: smoking, HTN, DM, hyperlipidaemia, obesity, sedentary lifestyle, cocaine use
What are the presenting symptoms of ACS?
Acute-onset central, crushing chest pain lasting>20m
Radiates to arms/neck/jaw
Pallor
Sweating
How might ACS present in elderly and diabetic patients?
'Silent' ACS No chest pain Syncope Pulmonary oedema Epigastric pain Vomiting Post-operative hypotension or oliguria Acute confusional state Stroke Diabetic hyperglycaemic state
What are the signs of ACS?
Distress Anxiety Pallor Sweatiness Pulse up or down BP up or down S4
Signs of HF: raised JVP, S3, basal creps
Pansystolic murmur: papillary muscle dysfunction/rupture, VSD
Low-grade fever
Later: pericardial friction rub, peripheral oedema
How is ACS investigated?
ECG: STEMI - tall T waves, ST elevation or new LBBB within hours; T-wave inversion + pathological Q waves over hours-days
NSTEMI/unstable angina: ST depresson, T wave inversion, non-specific changes or normal
CXR: Cardiomegaly, pulmonary oedema, widened mediastinum
BLOODS: FBC, U+Es, glucose, lipids, high troponin
ECHO: regional wall abnormalities
How is STEMI managed acutely?
- Attach ECG monitor and record a 12-lead ECG
- IV access - bloods for FBC, U+E, glucose, lipids, troponin
- Brief assessment:
- Hx of CVD, RFs for IHD
- Examination: pulse, BP both arms, JVP, murmurs, signs of CCF, upper limb pulses, scars from previous cardiac surgery, CXR if will not delay Rx
- CIs to PCI or fibrinolysis? - Aspirin: 300mg PO (unless already given by GP/paramedics) + tricagrelor 180mg (or other antiplatelet)
- Morphine: 5-10mg IV + metoclopramide 10mg IV (anti-emetic) w 1st dose
STEMI on ECG and PCI available within 2h?
YES - primary PCI - further management
NO - fibrinolysis –> transfer to PCI centre for either rescue PCI if fibrinolysis unsuccessful or for angiography
What is the prognosis of ACS?
50% of deaths occur with 2h of symptom onset
Up to 70% die before discharge
Worse prognosis: elderly, LVF, ST changes
How is ACS without ST-elevation managed acutely?
- Monitor closely; record ECG while in pain
- If SaO2<90% or brethless, low-flow O2
- Analgesia: morphine 5-10mg IC + metoclopramide 10mg IV
- Nitrates: GTN spray or sublingual tablets as required
- Aspirin: 300mg PO; consider need for 2nd antiplately agent
- Measure troponin and clinical parameters to risk assess, eg GRACE score
Invasive strategy (HIGH-RISK PT):
- Rise in troponin OR
- Dynamic ST or T-wave changes
- Secondary criteria - DM, CKD, LVEF<40%, early angina post MI, recent PCI, prior CABG, intermediate to high-risk GRACE score)
1. Fondaparinux or LMWH
2. 2nd antiplatelet agent - ticagrelor, clopidogrel, prasugrel
3. IV nitrate if pain continues
4. Oral B blocker - bisoprolol
5. Prompt cardiologist review for angiography
Conservative strategy (LOW-RISK PT):
- No recurrence of chest pain
- No signs of HF
- Normal ECG
- -ve baseline (+-repeat) troponin
1. May be discharged
2. Further outpatient investigation, eg stress test
What are the possible complications of IHD?
Cardiac arrest Cardiogenic shock LVF Bradyarrhythmias Tachyarrhythmias RVF/infarction - fluids Pericarditis - NSAIDs Systemic embolism - warfarin 3 months Cardiac tamponade - pericardial aspiration, surgery Mitral regurgitation - treat LVF, ?valve replacement Ventricular septal defect - surgery Late malignant ventricular arrhythmias Dressler's syndrome - NSAIDs, steroids Left ventricular aneurysm - anticoagulate, ?excision
What is infective endocarditis?
Infection of the endocardium, usually the valves, usually caused by a bacterial infection, but less commonly a fungal infection
What are the risk factors for infective endocarditis?
- Artificial heart valves
- Intracardiac devices
- Unrepaired cyanotic congenital heart defects
- Hx of IE
- Chronic rheumatic heart disease (AI response to repeated Streptococcus pyogenes infection)
- Age-related degenerative valvular lesions
- Haemodialysis (in renal failure)
- Coexisting conditions, especially ones that suppress immunity - DM, alcohol abuse, HIV/AIDS, IVD
What are the presenting symptoms of infective endocarditis?
Fever Malaise Fatigue Weight loss Coughing
What are the causes of infective endocarditis?
Bacteraemia –> heart valves
Strep. viridans (usually subacute)
Staph. aureus
Strep. bovis
Enterococci + Coxiella burnetii
Rarely: HACEK Gram -ve bacteria: Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella
Diphtheroids
Chlamydia
Fungi: usually in IVD, immunocomp, prosthetic valves
Candida
Aspergillus
Histoplasma
Other:
SLE (Libman-Sacks endocarditis)
Malignancy
What are the signs of infective endocarditis?
Septic signs: fever, rigors, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing
Cardiac lesions: any new murmur, or change in old murmur
Immune complex deposition: Roth spots on retina, splinter haemorrhages, Osler’s nodes
Embolic phenomena: Janeway lesions
How is infective endocarditis investigated?
Modified Duke criteria
Blood cultures: 3 sets at different times from different sites at peak of fever
Blood tests: normochromic, normocytic anaemia, neutrophilia, high ESR/CRP, RF positive
Also check U+E, Mg, LFT
Urinanalysis: microscopic haematuria
CXR: cardiomegaly, pulmonary oedema
ECG: ?heart block
Echocardiogram: vegetations, mitral lesions + aortic root abscess
CT: emboli (spleen, brain, etc)
What is hypertension?
Blood pressure over 135/85mmHg
What are the presenting symptoms of hypertension?
Usually asymptomatic
How is hypertension investigated?
To confirm diagnosis: ABPM or week of home BP monitoring
To help quantify overall risk: fasting glucose, cholesterol
To look for end-organ damage:
- Urinanalyis: protein, blood
- ECG or echo (any LV hypertropgy? past MI?
To exclude secondary causes: U+E (eg low K in Conn’s); Ca (high in hyperPT)
Special tests: Renal US/arteriography (RAS); 24h urinary meta-adrenaline; urinary free cortisol; renin; aldosterone; MR aorta (coarction)
How is hypertension managed conservatively?
Lifestyle changes: Reduce concomitant RFs Stop smoking Low-fat diet Reduce EtOH and salt intake Increase exercise Reduce weight if obese
What are the complications of hypertension?
CVD
Death
What is mitral regurgitation?
Backflow through the mitral valve during systole
What causes mitral regurgitation?
Functional - LV dilatation Annular calcification (elderly) Rheumatic fever Infective endocarditis Mitral valve prolapse Ruptured chordae tendinae Papillary muscle dysfunction/rupture (eg post-MI) Connective tissue disorders (E-D, Marfan's) Cardiomyopathy Congenital
Which drugs can cause mitral regurgitation?
Appetite suppressants - fenfluramine, phentermine
What are the presenting symptoms of mitral regurgitation?
Dyspnoea Fatigue Decreased exercise tolerance Palpitations Symptoms of causative factor (eg fever)
What are the signs of mitral regurgitation?
Holosystolic (between S1 and S2), blowing murmur at apex that radiates to axilla
Laterally displaced apical impulse
Dimished S1
How is mitral regurgitation investigated?
Transthoracic echocardiogram:
determine presence, severity + mechanism of flail, as well as evaluating LV size + function, LA size, other valvular abnormalities, and RV systolic pressure
CXR: big LA and LV, mitral valve calcification, pulmonary oedema
Transoesophageal echocardiogram: to assess LV function and MR severity and aetiology
ECG: AF, P-mitrale if in sinus rhythm (may mean increased LA size), LVH
Cardiac catheterisation to confirm Dx, exclude other valve disease and assess CAD
What can be seen on a CXR of a patient with mitral regurgitation?
Big LA and LV
Mitral valve calcification
Pulmonary oedema
What can be seen on an ECG of a patient with mitral regurgitation?
AF
P-mitrale if in sinus rhythm (may mean increased LA size)
LVH
What are the risk factors for mitral regurgitation?
Mitral valve prolapse Hx of rheumatic heart disease Infective endocarditis Hx of cardiac trauma Hx of MI Hx of congenital heart disease Hx of IHD LV systolic dysfunction hypertrophic cardiomyopathy Anorectic/doapminergic drugs
What is the worldwide prevalence of mitral regurgitation?
> 5 million
What causes mitral regurgitation?
Mitral valve apparatus = anterior + posterior leaflets, chordae tendineae, anterolateral, and posteromedial papillary muscles + mitral annulus, atrial + ventricular myocardium
Mitral valve dysfunction may result from aberrations of any portion of the mitral valve apparatus, due to mechanical, traumatic, infectious, degenerative, congenital, or metabolic causes. MR can be either acute or chronic.
Typical causes of acute MR: infective endocarditis, ischaemic papillary muscle dysfunction or rupture, acute rheumatic fever, acute dilation of LV due to myocarditis or ischaemia
Common causes of chronic MR include those already listed as well as myxomatous degeneration of the mitral leaflets or chordae tendineae, mitral valve prolapse, and mitral annular enlargement.
What is mitral stenosis?
Narrowing of the mitral valve orifice
Explain the aetiology of mitral stenosis
Cause in >95% of cases: rheumatic fever leading to rheumatic heart disease
Rarer causes: congenital deformity of the valve, carcinoid syndrome, use of ergot and/or serotogenic drugs such as fenfluramine, SLE, mitral annular calcification due to ageing, and amyloidosis.
Theory:
- Some M antigens are held in common by heart and some strains of group A streptococci
- Streptococcal M protein may bind directly to valvular collagen, inciting an inflammatory response
- The endocardium containing heart valves receives the most inflammatory damage
- During an attack of acute rheumatic fever, the mitral valve becomes thickened and retracted leading to mitral regurgitation
- However, years later, fusion of mitral leaflet commissures and thickening of leaflets and sub-valvular apparatus cause mitral stenosis
What are the risk factors for mitral stenosis?
Streptococcal infection (usually pharyngitis) Female (3x)
Weak:
Ergot medications (for migraine) - methysergide, ergotamine
Serotogenic medications (appetite suppressants) - fenfluramine
SLE
Amyloidosis
Bronchial carcinoid syndrome
What are the presenting symptoms of mitral stenosis?
Dyspnoea
Orthopnoea
What are the signs of mitral stenosis?
Malar flush Low-volume pulse Tapping, non-displaced apex beat Palpable S1 RV heave Loud S1 Opening snap Rumbling mid-diastolic murmur (heard best on expiration w patient on left side) Loud P2 (L parasternal 2nd ICS) Raised JVP
How is mitral stenosis investigated?
ECG: AF, LA enlargement, RVH
CXR: double right heart border –> enlarged LA, prominent pulmonary artery, Kerley B lines
What are varicose veins?
Subcutaneous, permanently dilated veins 3mm or more in diameter when measured in a standing position
Long, tortuous and dilated veins of the superficial venous system
Explain the aetiology of varicose veins
Usually caused by venous valve incompetence
Blood pools when valves do not function properly, leading to increased pressure and distension of the veins
Also
Progesterone is believed to lead to passive venous dilation, which may then lead to valvular dysfunction.
Oestrogen produces collagen fibre changes and smooth muscle relaxation, which both lead to vein dilation.
What are the risk factors for varicose veins?
Increasing age Female Hx of DVT FHx Pregnancy Prolonged standing Obesity
What are the presenting symptoms of varicose veins?
'My legs are ugly' Leg fatigue or aching with prolonged standing Pain Cramps Tingling Heaviness Restless legs
What are the signs of varicose veins?
Haemosiderin deposition Oedema Eczema Ulcers Haemorrhage Phlebitis Atrophie blanche (white scarring at site of healed ulcer) Lipodematosclerosis
How are varicose veins investigated?
Duplex ultrasound: assesses for reversed flow
Roughly, valve closure time >0.5 second = reflux in superficial system
Valve closure time >1.0 second = reflux in deep system
How are varicose veins managed?
Graducated compression stockings
Phlebectomy or sclerotherapy
Ablative procedures
Perforator surgery
What are the possible complications of varicose veins?
Chronic vein insufficiency Haemorrhage Venous ulceration Lipodermatosclerosis Haemosiderin deposition
What is the prognosis for varicose veins?
Symptom resolution in >95% of patients
Patients need to be counselled that new varicosities will very likely occur with time
What is pericarditis?
Inflammation of the pericardium
What is acute pericarditis?
New-onset inflammation of the pericardium lasting <4-6 weeks
What is constrictive pericarditis?
Inflammation of the pericardium that impedes normal diastolic filling
The heart is encased in a rigid pericardium
What are the risk factors for pericarditis?
Male 20-50yo Transmural MI Cardiac surgery (CABG) Neoplasm Viral and bacterial infections Uraemia or on dialysis Systemic AI disorders - RA, SLE
What are the presenting symptoms of pericarditis?
Central chest pain worse on inspiration or lying flat +- relief by sitting forward
Trapezius ridge pain
Fever
Myalgias
Malaise
RHF: fatigue, ankle oedema
What are the signs of pericarditis?
Pericardial rub - high-pitched, squeaky, heard best at L sternal edge w patient leaning forward at end-expiration
Signs of RHF: ankle oedema, ascites
How is pericarditis investigated?
ECG: concave (saddle-shaped) ST elevation globally w PR depressions
Bloods: elevated serum troponin, elevated ESR, elevated CRP, elevated urea (if uraemic cause), elevated WCC
Pericardiocentesis: positive pericardial fluid culture
Blood culture: positive
CXR: cardiomegaly (-> pericardial effusion)
Echo: pericardial effusion, absence of LV wall motion abnormalities
CMR/CT: localised inflammation
How is pericarditis managed?
Ibuprofen/aspirin w omeprazole for 1-2 weeks
+ Colchicine for 3 months to reduce recurrence risk
Treat cause
Exercise restriction
If not improving or AI, consider steroids or other immunosuppressants
What causes constrictive pericarditis?
Often unknown in UK
Elsewhere - TB
Or after any pericarditis
What are the possible complications of pericarditis?
Pericardial effusion +- cardiac tamponade
Chronic constrictive pericarditis
What is the prognosis for pericarditis?
Depends on underlying cause and disease severity
Major poor prognostic factors: - Evidence of large pericardial effusion - High fever >38 Sub-acute course - Failure to respond within 7 days to NSAID
What is vasovagal syncope?
A syndrome characterised by a relatively sudden, temporary and self-terminating loss of consciousness, associated with the inability to maintain postural tone, with rapid and spontaneous recovery due to
What is heart failure?
Failure of heart to maintain CO required to meet body’s requirements
What is the equation for CO?
CO = HR x SV
Compare chronic and acute HF
Chronic:
Develops and progresses slowly
Arterial pressure maintained until later/decompensation
Acute: Decompensation/exacerbation of chronic disease, or can be new onset Develops and progresses quickly Needs urgent Tx Evidence of peripheral hypo-perfusion Peripheral/pulmonary oedema
What causes left HF?
- Heart valves: AR, AS, MR
- Heart muscle: IHD, MI, cardiomyopathy (eg HOCM), myocarditis, arrhythmias (eg AF)
- Systemic: HTN, amyloidosis
- Drugs: alcohol, cocaine
What causes right HF?
- Heart valves: tricuspid regurg, pulmonary valve disease
- Lungs: pulmonary HTN, PE, pulmonary fibrosis, ILD, CF
- Cor pulmonale: enlargement and failure of RV due to increased pressure in lungs/vascular resistance
What causes a high-output state and what does it lead to?
NAP MEALS Nutritional - B1/thiamine Anaemia Pregnancy Malignancy - multiple myeloma Endocrine - hypothyroidism AV malformation Liver cirrhosis Sepsis
Can lead to HF
What are the risk factors for heart failure?
Older men PMH of HD - especially MI DM FHx of HD Dyslipidaemia Drug abuse
What are the signs and symptoms of LHF?
LHF -> fluid congestion in lungs -> resp symptoms: Exertional dyspnoea Orthopnoea Paroxysmal noctural dyspnoea Fatigue Nocturnal cough +- pink frothy sputum Wheeze (cardiac asthma)
Heart O/E: high HR, high RR, irregularly irregular heart beat, displaced apex beat, gallop rhythm (S3), murmur (AS, MR)
Lungs O/E: bibasal crackles, wheeze
What are the signs and symptoms of RHF?
RHF -> fluid congestion in system -> peripheral symptoms: Swelling - ankles, face, abdomen Fatigue Weight gain Decreased exercise tolerance Anorexia Nausea Nocturia
Face/neck: raised JVP, facial swelling
Chest: Parasternal heave, TR murmur, high HR, high RR
Abdo: ascites, hepatomegaly
Other: pitting oedema
What are the appropriate investigations for HF?
Bedside:
History and examination
ECG
Bloods: FBC - anaemia is cause U&E LFTS - abdominal congestion TFTs - hyperthyroidism is cause Glucose - DM is RF BNP - high
Imaging:
Transthoracic echocardiogram - EF<40% = systolic HF, over 50%=HF w preserved EF
CXR
What are the features of HF on a CXR?
Alveolar oedema ('bat wing' appearance)
B-lines (Kerley) (interstitial oedema)
Cardiomegaly (CTR>50%)
Dilated upper lobe vessels (pulmonary venous HTN)
Effusion (pleural)How is chronic HF managed?
Treat underlying cause
Conservative:
Smoking cessation
Weight management - exercise
Diet - reduce salt intake
Medical:
- ACE-Is: enalapril, perindopril, ramipril
- can use ARB if cough
- must monitor K - B blockers: bisoprolol, carvedilol
- Diuretics
- aldosterone antagonist - spironolactone
- loop diurectics - furosemide
- thiazide - hydrochlorthiazide
How is acute HF managed?
- Sit patient up
- Oxygen - SpO2 target 94-98% - 15L via non rebreathe mask
- IV access and ECG (arrhythmia?)
- Furosemide IV
- GTN spray 2 puffs sublingual
- Morphine 2.5mg (but do not give routinely)
What are the possible complications of HF?
Pleural effusion
Renal failure
Acute exacerbations
Death
What is the prognosis for HF?
50% severe HF patients die within 2 years
What are the different types of valvular heart disease?
Tricuspid regurgitation Mitral regurgitation Mitral stenosis Aortic regurgitation Aortic stenosis
What does S1 signify?
Closure of AV valves: tricuspid and mitral
What does S2 signify?
Closure of aortic and pulmonary valves
What does valvular heart diseases often produce on examination?
Murmurs
Heart sounds produced when blood flows over the valves
Which valvular heart diseases cause systolic murmurs?
Aortic stenosis
Mitral regurg
Tricuspid regurg
A systolic murmur, really tiring respiration
Which valvular disease cause diastolic murmurs?
Aortic regurg
Mitral stenosis
What is tricuspid regurgitation?
Backflow of blood from RV to RA
What is aortic stenosis?
Narrowing of LV outflow at aortic valve
What is mitral regurgitation?
Backflow of blood from LV to LA
What are the symptoms of AS, MR and TR?
Dyspnoea - SOB Syncope on exertion Angina HF signs Palpitations
Also may be asymptomatic
What are the signs of aortic stenosis?
Ejection systolic murmur (aortic area = 2nd-3rd right ICS)
Radiating to carotids and apex
Ask pt to hold breath on expiration
BP - narrow pulse pressure
Pulse - slow-rising
Palpation - thrill (palpable heart murmur)
What are the signs of mitral regurgitation?
Pan-systolic murmur at apex
Radiates to axilla
Pulse - normal/irregularly irregular
Palpation - laterally displaced apex beat
What are the signs of tricuspid regurgitation?
Pan-systolic murmur
Ask pt to hold breath on inspiration
Tricuspid area - L lower sternal border
Inspection - raised JVP
Palpation - parasternal heave
Signs of RHF - pleural effusion, hepatomegaly, ascites, pitting oedema
How are AS, MR and TR investigated?
ECG:
AS - signs of LV hypertrophy - enlarged R waves, inverted T waves, L axis deviation
TR - signs of LVH - tall p-wave
CXR:
- enlargement of ascending aorta
- aortic valve calcification (AS)
- right-sided enlargement (TR)
- cardiomegaly (MR)
How can valvular disease be classified?
Systolic - AS, MR, TR
Diastolic - AR, MS
What is aortic regurgitation?
Reflux of blood from aorta to LV during diastole
What is mitral stenosis?
Narrowing of mitral valve, obstructing blood flow from LA to LV
What causes diastolic murmurs - AR and MS?
Infection - rheumatic HD (MS), infective endocarditis
Congenital - bicuspid aortic valve
Dilation of aorta - HTN, aortitis
CTD
When do people usually get diastolic murmurs?
late 50s-80s
What percentage of mitral stenosis if caused by rheumatic heart disease?
90%
What are the symptoms of AR and MS?
Dyspnoea - SOB Syncope on exertion Angina HF signs Palpitations Orthopnoea
May be asymptomatic
What are the signs of AR?
Early diastolic murmur (2nd to 3rd R ICS) - lub pssssh
Radiates to carotids and apex
Ask pt to sit forward and hold breath on expiration
Wide pulse pressure
Collapsing pulse
Displaced apex beat
What are the signs of MS?
Mid-diastolic murmur
Loud S1 with opening snap
Bell of stethoscope
Apex
Malar flush
Thready or irregularly irregular pulse
Tapping apex
Parasternal heave
How are AR and MS investigated?
ECG:
Signs of LV hypertrophy - enlarged R waves, inverted T waves, L axis deviation
MS - broad bifid p wave, AF
CXR:
Dilation of ascending aorta
Cardiomegaly
What do ECG changes in leads II, III and aVF indicate?
Inferior (right coronary artery) infarct
What do the ECG changes in different leads indicate?
Inferior (right coronary artery): II, III, aVF
Anterior (left anterior descending): V1-V5
Lateral (left circumflex): I, aVL, V5/6
Posterior (posterior descending): tall R wave + ST depression in V1-3
What do ECG changes in leads V1-V5 indicate?
Anterior (left anterior descending) infarct
What do ECG changes in leads I, aVL and V5/6 indicate?
Lateral (left circumflex) infarct
What do ECG changes in leads V1-3 indicate?
Posterior (posterior descending) infarct
How is ACS managed generally?
Morphine Oxygen Nitrates Antiplatelets (aspirin + clopidogrel) Beta-blockers ACE inhibitors Statins Heparin
What are the complications of ACS?
Darth Vader
Death Arrhythmia Rupture Tamponade Heart failure Valve disease Aneurysm Dressler's syndrome Embolism Reinfarction
What is atrial fibrillation?
Characterised by rapid, chaotic and ineffective atrial electrical conduction
What are the causes of AF?
Absolutely loads
Pneumonia PE Hyperthyroidism IHD Alcohol Pericarditis
What are the symptoms and signs of Af?
Palpitations
Syncope
Symptoms of underlying causes
Irregularly irregular pulse
How do you investigate AF?
ECG:
absent P waves
Irregular QRS complexes
Irregularly irregular tachycardia
Bloods: U+E, cardiac enzymes, TFTs
Echo: LA enlargement, mitral valve disease, poor LV function, other structural abnormalities
How do you manage AF?
If the patient is haemodynamically unstable - DC CARDIOVERSION
Rhythm contol:
<48h since onset of AF:
DC cardioversion
or chemical cardioversion (flecainide (CI if IHD Hx) or amiodarone)
>48h:
anticoagulate for 3-4 weeks before cardioversion
Rate control:
Verapamil
B blockers
Digoxin
Treat the cause
Stroke Risk Stratification
CHADS-Vasc score
Low risk -> aspirin or none
High risk -> warfarin
What is in the CHADS-VASc score?
Anticoagulate in AF?
Congestive HF - 1 Hypertension - 1 Age 65-74 -1/>74 - 2 Diabetes - 1 Stroke/TIA/Thromboembolism - 2 Vascular disease - 1 Sex Category - female - 1
More than 1 = should be considered
What is supraventricular tachycardia?
A regular, narrow-complex tachycardia with no p waves and a supraventricular origin
What are the symptoms of SVT?
Palpitations
Syncope
Dyspnoea
Chest discomfort
What are the complications of AF?
Stroke MI Congestive HF Bradycardia Hypotension
What are the types of SVT?
Atrioventricular nodal re-entry tachycardia (AVNRT) - local circuit forms around AV node
Atrioventricular re-entry tachycardia (AVRT) - re-entry circuit forms between atria and ventricles due to presence of accessory pathway (Bundle of Kent)
How do you investigate SVT?
ECG:
Regular
Narrow complex tachycardia
Absent p waves
ECG after termination of SVT:
AVNRT = normal
AVRT = delta wave - slurred upstroke on QRS complex
Test for causes: cardiac enzymes, electrolytes, TFTs, digoxin level
What does the presence of an accessory pathway resulting in a delta wave on ECG indicate?
Wolff-Parkinson-White Syndrome
How do you manage SVT?
STEP 1: is the patient haemodynamically stable?
NO –> Synchronised DC cardioversion
YES –> STEP 2
STEP 2: Vagal Manoeuvres (carotid body massage) – did it work?
YES –> Good Job
NO –> STEP 3
STEP 3a: IV Adenosine 6 mg – did it work?
YES –> Good Job
NO –> Step 3b, if that fails, Step 3c, then, Step 4
STEP 3b: IV Adenosine 12 mg
STEP 3c: IV Adenosine 12 mg (again)
STEP 4: Choose from: IV b-blocker (e.g. metoprolol) IV amiodarone IV digoxin Synchronised DC cardioversion
NOTE: if adenosine is CI eg asthma, use verapamil
How does WPW syndrome lead to AVRT?
Accessory pathway allows early depolarisation of the ventricles (ie pre-excitation)
Gives rise to slurred QRS upstroke
If a wave of DP travels retrograde back into atria, it can set up a re-entry circuit between atria and ventricles
AVRT
