Cardiovascular Flashcards
Aortic regurgitation
Early diastolic crescendo/decrescendo
Left sternal edge on expiration sitting forwards
Caused by valvular damage (infective endocarditis, senile calcification) or aortic problems (dissection, aortitis, connective tissue disorders)
Associated signs e.g. de Musset (head bobbing), Corrigan’s (pulsating carotids), Traube (pistol shot femorals), waterhammer pulse (collapsing pulse), wide pulse pressure
+/- Austin Flint murmur
Austin Flint murmur
Mid diastolic murmur
Apex/mitral area
Associated with severe aortic regurgitation
Displacement of blood striking anterior mitral valve leaflet
Aortic stenosis
Ejection systolic murmur
Left sternal edge, radiates to the carotids
Soft S2 sound
Narrow pulse pressure, slow rising pulse
Most common cause is rheumatic heart disease
Bicuspid valve +ve ejection systolic click
Mitral regurgitation
Pansystolic murmur Loudest at the apex beat radiating to the axilla Soft S1 +/- S3 Post-MI Pulmonary oedema (L sided heart failure) Barlow syndrome
Barlow syndrome
Mitral valve prolapse
Mid-systolic click followed by late systolic murmur
Standing: click moves towards S1
Squatting: click moves away from S1
(similar to hypertrophic cardiomyopathy)
RF: connective tissue disorders, bicuspid valve
Mitral stenosis
Rumbling mid-diastolic murmur
Mitral area laying on the left on expiration
Loud S1 with opening snap
Signs: malar flush, AF,, undisplaced tapping apex beat, peripheral cyanosis
Most common cause is rheumatic heart disease
Graham Steell murmur
Graham Steell murmur
Early diastolic murmur
Left sternal edge on inspiration
Pulmonary regurgitation secondary to pulmonary hypertension/mitral stenosis
Tricuspid regurgitation
Pansystolic murmur
Lower left sternal edge on inspiration (Carvallo sign)
Loud P2 of S2 heart sound (splitting)
Giant V waves in JVP
Signs: headaches, epigastric pain worse with exercise
Pericardial effusion
Muffled heart sounds
Beck’s Triad
Lupus/malignancy
Beck’s Triad
Muffled heart sounds
Raised JVP
Low BP
HCM
Double apex beat Jerky carotid pulse Family hx sudden death Harsh ejection systolic murmur Louder with valsalva manouvres Treated with ß-blockers
Patent Ductus Arteriosus
Machine-like murmur
Bounding pulse, wide pulse pressure
Left subclavian thrill
Heart failure
Left: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, Cheyne-Stokes respiration, fine inspiratory crackles (pulmonary oedema)
Right: peripheral oedema, hepatomegaly, raised JVP
↑BNP, ECG changes
G: transoesophageal echo
CXR: Alveolar oedema, kerley B lines, Cardiomegaly, Dilated upper lobe diversion, pleural Effusions
ECG changes in left ventricular hypertrophy
Deep S V1/2
Tall R V5/6
Inverted T lead I/aVL/V5-6
Left axis deviation
Infective endocarditis
IVDU
Tricuspid murmur/right sided heart failure
Petechiae, microvascular haematuria
FROM JANE C: fever, Roth’s spots, Osler’s nodes (painful), murmur, Janeway lesions (palm), anaemia, nail (splinter haemorrhages), emboli, clubbing
Modified Duke Criteria
Modified Duke Criteria
Infective endocarditis (2M/1M3m/5m)
Major:
1) typical cultures x2 separate occasions or continuously positive cultures
2) positive echo or new heart murmur
Minor:
1) Fever >38
2) Predisposing heart condition or IV drug user
3) Vascular phenomenon: emboli, infarcts, signs in hands etc
4) positive cultures not meeting major criteria
5) positive echo not meeting major criteria
Management for infective endocarditis
- empirical
- native valve
- prosthetic valve
- staph
- entero
- culture negative
- surgical management
Empirical (streptococcus): benzylpenicillin + gentamicin
Native valve: benzylpenicillin (beta-lactams) + gentamicin
Prosthetic valve/resistant: vancomycin + gentamicin + rifampicin
Staph: flucloxacillin/vancomycin + gentamicin
Entero: amoxicillin + gentamicin
Culture -ve: vancomycin + gentamicin
Surgical: replace valve
Atrial fibrillation
Irregularly irregular pulse
Absent P waves in ECG
Absent A waves in JVP
Old, palpitations, SOB, fatigue, syncope
Atrial flutter
Narrow complex tachycardia
150 bpm ventricular rate with 2:1 block (atrial rate = 250-350 bpm)
Saw-toothed appearance on ECG
Ventricular tachycardia
Broad complex (tall waves) Previous MI
Management of VT
Pulseless: non-synchronised DC cardioversion + ALS protocol
Pulse: 1) synchronised cardioversion 2) treat cause/electrolyte imbalances 3) anti-arrhythmics: amiodarone
Torsades de Pointes
Polymorphic VT
Management: 1) IV magnesium sulphate 2) treat cause/electrolyte imbalances 3) isoprenaline infusion
Ventricular fibrillation
Irregular broad complex tachycardia
Pulseless
Management of VF
Pulseless: defibrillation
Implantable cardioverter defibrillator (ICD)
Empirical beta-blockers
Management of acute/unstable AF
Rhythm: 1) high flow oxygen 2) correct electrolytes 3) DC cardioversion 4) Chemical cardioversion: IV amiodarone or flecainide *Flecainide contraindicated in ischaemic heart disease Rate: 1) verapamil (CCB) or ß-blocker 2) digoxin or amiodarone
Management of chronic/stable AF
Rate:
1) bisoprolol (ß-blocker) or verapamil (CCB) *combination is contraindicated (2nd line digoxin or amiodarone)
2) anti-coagulate 3/52 with warfarin or NOACs (dabigatran, apixaban, rivaroxaban)
Rhythm:
1) elective chemical cardioversion with flecainide or amiodarone +/- 4/52 sotalol or amiodarone
Management of paroxysmal AF
Pill-in-pocket
1) sotalol or flecainide PRN
2) anticoagulation with warfarin or NOACs
Wolff-Parkinson White syndrome
Delta wave on ECG
Predisposition to SVT
Accessory pathway (radiofrequency ablation)
First degree heart block
Physiological
Prolonged PR interval > 0.2s
Second degree heart block
Mobitz type I:
Gradually prolonging PR interval and dropped QRS
Mobitz type II: Regular prolonged PR interval with dropped QRS
(may have regular P:QRS ratio e.g. 2:1/3:1)
*requires consideration of ICD
Third degree/complete heart block
Broad QRS Bradycardia Disassociation between P and QRS waves Cannon A waves in JVP Management: ICD
Aortic dissection
Collapsed whilst exercising Radio-radial/femoral delay Tearing pain radiating to the back Hx of connective tissue disorder Type A: ascending aorta Type B: descending aorta (after subclavian vein)
Pericarditis
Pericardial friction rub ‘snow crunching sound’
Pain better on leaning forwards
Sudden onset pleuritic chest pain
Male, post-MI (Dressler’s syndrome)
Myocardial infarction
Central, crushing chest pain
Radiates to jaw/left arm
MONABASH
Management of acute heart failure
1) sit up
2) IV furosemide
3) high flow oxygen
4) nitrates if in pain (morphine if refractory)
Pulmonary embolism
Sharp, pleuritic chest pain
Haemoptysis
RF: OCP, long haul travel, recent immobility
Well’s criteria
Well’s criteria (7) for PE
Clinical signs and symptoms of PE (3) PE is most likely diagnosis (3) HR > 100 bpm (1.5) \+3/7 immobilisation or surgery within 4/52 (1.5) Previously PE or DVT (1.5) Malignancy with treatment in past 6/12 or palliative (1) Haemoptysis (1) >4: CTPA (pregnant: V/Q) <4: D-Dimer (+ve then CTPA)
Aortic coarctation
Interscapular murmur
Decreased femoral pulses
Turner’s syndrome
Stable angina
Exertional chest pain, radiating to jaw
CVD RF: smoking, hyperlipidaemia, obesity
Relieved by rest
Resting ECG: normal
Exercise ECG: ST depression and T wave inversion
Unstable angina
Episodic but progressing from stable angina
Chest pain at rest lasting longer
Prinzmetal/Variant angina
Cyclic ST elevation at rest
Female, 50yrs old
Vasospasmic (give CCB)
Syndrome X
ECG: ST depression
Normal angiogram
Hypertension, diabetes mellitus, obesity, hypercholesteraemia
Give nifedipine
Decubitus angina
Angina when lying down (at night before sleeping etc)
Dressler’s syndrome
Pleuritic chest pain
Low-grade fever
Pericarditis
2-10/52 post-MI
Cor pulmonale
Right heart failure
Pulmonary hypertension
Large A waves in JVP
Ventricular septal defect
Pulmonary hypertension + heart failure = shunt reversal
Harsh pansystolic murmur at left sternal edge
Left parasternal heave
Increased endocarditis risk
Atrial septal defect
Wide fixed split second heart sound
Ejection systolic murmur in 2nd/3rd ICS
ECG changes in STEMI
- anterior
- lateral
- inferior
- posterior
Anterior: V1-V4 (left anterior descending)
Lateral: lead I, aVL, V5-V6 (circumflex artery)
Inferior: lead II, III and aVF (right coronary artery)
Posterior: ST depression V1-V3, tall broad R waves, R dominance V2
JVP waveform changes
- SVC obstruction
- cardiac tamponade/constrictive pericarditis
- tricuspid regurgitation
- atrial fibrillation
- heart block/AV dissociation/ventricular arrhythmia
SVC obstruction: raised and fixed JVP
Cardiac tamponade/constrictive pericarditis: increased JVP on inspiration/Kussmaul’s sign (pulsus paradoxus)
Tricuspid regurgitation: large V waves
Atrial fibrillation: absent A waves
Heart block/AV dissociation/ventricular arrhythmia: cannon A waves
ECG changes
- left atrial hypertrophy
- right atrial hypertrophy
- pericarditis
- PE
- hyperkalaemia
- hypokalaemia
- hypocalcaemia
LAH: p mitrale (bifid p wave)
RAH: cor pulmonale (large a wave)
Pericarditis: widespread saddle-shaped ST elevation
PE: RBBB, right heart strain, S1Q3T3, sinus tachycardia
Hyperkalaemia: tall tented T waves, wide QRS, flat p waves
Hypokalaemia: inverted T waves, U waves, prolonged PR interval, tall p waves, ST depression
Hypocalcaemia: long QT interval
Management of pericarditis
Acute: analgesia and NSAIDs +/- antibiotics, antifungal
Chronic: colchicine or NSAIDS
Surgical: pericardiectomy (constrictive pericarditis)
Supraventricular tachycardia
AVNRT: SAN re-entry circuit
Narrow complex tachycardia (no delta wave) + absent p
AVRT: accessory pathway in ventricules
Short PR pathway, delta wave after termination, narrow complex QRS
Paroxysmal heart palpitations
Secondary cardiomyopathy: S3 gallop, RV heave, displaced apex
Management for SVT
Unstable: DC cardioversion
Stable:
1) vasovagal manoeuvres
2) adenosine 6mg then 12mg x2 every 2 mins *contraindicated in asthmatic patients (give verapamil 2.5mg/5mg)
3) step up (IV amiodarone, verapamil, DC cardioversion)
High output heart failure
NAP MEALS Nutritional (Beri-Beri) Anaemia Pregnancy Malignancy Endocrine AV malformations Liver cirrhosis Sepsis
Low output heart failure
Left: - valve dysfunction - cardiac (myositis, pericarditis) - drugs (alcohol/cocaine) - systemic (hypertension) Right: - valve dysfunction (tricuspid regurgitation) - pulmonary - cardiac
Myocarditis
Troponin-TIT