Cardiovascular Flashcards
What type of murmur would aortic stenosis produce?
MRS ASS
Low pitched ejection systolic murmur best heard at aortic area, radiating to the neck
What type of murmur does aortic regurgitation produce?
High pitched (blowing) early diastolic murmur, best heard at the left sternal edge with the patient sitting forward in expiration
What type of murmur does mitral stenosis produce?
Low pitched (rumbling) mid-diastolic murmur best heard at the apex when the patient is lying on their left side
What type of murmur does mitral regurgitation produce?
MRS ASS High pitched (blowing) pan systolic murmur best heard at the apex radiating to the axilla
What is a mycotic aneurysm?
Dilation of an artery due to damage of the vessel wall by an infection such as staph aureus
In an AAA what are the indications for surgery?
> 5.5cm diameter in fit individuals
Rapidly increasing diameter on surveillance (>0.5cm in 6 months)
Symptomatic
Ruptured
What is the most common type of AAA?
Infrarenal - starts just below the level of the renal arteries
What is the AAA rupture triad?
Pulsatile abdominal mass
Abdominal/back pain
Hypotension
What has a mid-systolic click?
Mitral valve prolapse
Define heart failure.
Failure of the heart to pump oxygenated blood at a rate sufficient to meet the metabolic requirements of the tissue
What are some causes of heart failure?
Severe anaemia, Aortic stenosis, MI, restrictive cardiomyopathy, Renal failure, alcohol
What signs may be present in heart failure?
Elevated JVP 3rd heart sound Displaced apex beat Pulmonary oedema Pleural effusion Peripheral oedema
List some important diagnostic tests in HF.
Natriuretic peptides
Echo
What are the management options for chronic HF?
- ACEi / ARB + BB
- ACEi/ARB + BB + MRA
- BB + MRA + ARNI (sacubitril + Valsartan)
- ICD or Ivabradine
- Digoxin or isosorbide dinitrate
What are some complications of ACS?
Cardiogenic shock
Arrhythmias
Heart failure due to severe LV dysfunction
Myocardial rupture
Mitral regurgitation due to papillary muscle rupture
What signs may indicate a STEMI on ECG?
ST elevation
New LBBB
What is emergency repurfusion management in a STEMI?
Primary percutaneous coronary intervention - balloon and stenting - within 120min of ECG diagnosis
If can’t do above
Thrombolysis with Tenecteplase
What are the different types of MI?
I- coronary event (CA plaque rupture) II - increased oxygen demand or reduced oxygen supply II - sudden cardiac death IVa - PCI Ivb - Stent thrombosis V - cardiac surgery such as CABG
AF puts you at an increased risk for Stroke. What score can assess the thromboembolic risk?
CHA2DS2-VASc Cardiac failure Hypertension Age >75 (2 points) Diabetes Stroke/TIA (2 points) Vascular disease Age 65-74 Sex (female)
Define AF
An chaotic, irregular atrial rhythm at 300-600bpm
What are the types of AF?
Paroxysmal - lasts <48 hours and terminates spontaneously
Persistent - Remain in AF but sinus rhythm can be restored by cardioversion
Permanent - Chronic AF and can’t or its inappropriate to restore sinus rhythm
Define aortic stenosis
Obstruction to the outflow of blood from the LV into the aorta due to pathological narrowing of the aortic valve. usually due to calcification
What is the classic triad in AS?
Chest pain, heart failure and syncope
What are some signs of AS?
Low pitched ejection systolic murmur Murmur transmitted to carotid Narrow PP Pulsus parvus et tarsus - slow rising flat pulse Loud A2 Thrills at cardiac apex
What valve is most commonly affected in IE?
Mitral
What valve is most commonly affected in IE in IVDU?
Mitral but most Tricuspid valve endocarditis is due to IVDU
What organism usually causes native valve endocarditis>
Strep viridan
enterococcus
What organism usually causes endocarditis in IVDU?
S. aureus
What organism causes prothetic endocarditis?
CoNs - staph epidermis
What is the criteria to diagnose IE?
Dukes
2 major
1 major + 3 minor
5 minor
What is Dukes criteria
Major - typical organism in 2 positive culture and positive on Echo/ new valve regurgitation
Minor - Predisposition (IVDU/heart disease), fever >38, vascular phenomenon (septic emboli), immunological phenomenon (oslers nodes), positive culture
What are the signs of pericardial effusion?
Dyspnoea, raised JVP
Bronchial breathing at left base - Ewart’s sign (compression of left lower lung lobe due to large pericardial effusion)
What signs may indicate constrictive pericarditis?
Kussmaul’s sign (JVP rising paradoxically with inspiration)
Diastolic Pericardial knock, RHF, quiet heart sounds
What Triad may indicate cardiac tamponade?
Beck’s
Falling BP - (Hypotension)
Raised JVP
Muffled heart sounds
What is dilated cardiomyopathy?
A dilated heart causing ineffective systolic squeeze of blood due to thin, weak walls. Pump failure, reduced CO and reduced O2 to the body
What is the most common cause of sudden death in young people?
Hypertrophic cardiomyopathy
LV outflow obstruction due to asymmetric septal hypertrophy
How would you manage a haemodynamically unstable patient such as a cardiac arrest or SBP <90mmHg?
- Oxygen via face mask
- NBM t prevent aspiration
- Peripheral venous access
- IV atropine 1mg bolus
- If delay in pacing and patient still unstable - IV Isoprenaline 0.2mg
- Insert a temporary pacing wire
- Look for and treat reversible causes
How would you manage a Haemodynamically unstable tachycardic patient?
- External defibrillation
- Sedate for analgesia and have Naloxone ready incase of respiratory depression
- Propafol (if not fasted ETT to prevent aspiration)
- 200 Joules synchronised shock
- If Tachy unresponsive try correct acidosis or hypokalaemia. Mg and shock again. IV Amiodarone bolus
How do you usually treat a sinus tachycardia?
IV Adenosine 6mg
What makes up Virchows triad?
- Hypercoagulability
- Endothelial wall damage
- Satsis of blood/ slowed blood flow
How can you differentiate between ventricular arrhythmia and SV arrhythmia?
Narrow QRS - SV
Broad QRS - V
What is the P:QRS ratio in atrial flutter?
It can be 2:1, 3:1, 4:1 - there are more P waves due to the re-entrant circuit into the RA causing the atria to depolarise. Saw tooth
What might a Ventricular tachycardia look like?
~250bpm. No P waves as there is no atrial depolarisation. Broad QRS. Can be Monomorphic - QRS all look the same*
compromise to ventricular diastole - Coronary vessels - reduced blood supply - reduced CO
What is Torsades de pointes?
VT - Due to prolonged ventricular repolarisation - polymorphic QRS. looks like party streamer.
Can degenerate quickly into VF.
Give Amiodarone
What is VF?
Choatic, uncoordinated muscle fibre contraction. Ventricular fibres contract independently so NO QRS or P or T. - no cardiac output - Cardiac arrest
Direct current shock to break any disorganised electrical activity by depolarising ALL the heart cells
What is a junctional tachycardia or SVT?
Tachycardia due to re-entrance circuits
most common: AVNRT (no P, regular QRS, 200-300bpm)
What is Wolf Parkinsons White syndrome?
Heart beats abnormally fast our to AV re-entrant tachycardia. accessory pathway - bundle of Kent
Has a delta wave
How can you tell the difference form a BBB and a ventricular depolarisation?
Both have broad QRS
BBB HAS P WAVES (look closer at V1 and V6) as impulse generated in SA in atria
V - no p waves as impulse formed in ventricles
What is the J point?
the junction between QRS and ST segment
What type of narrow complex tachycardia is best reversed with a carotid massage or valsalva maenoveer?
AV nodal re-entrant tachycardia
these block the AV node, restoring sinus rhythm
What coronary vessel would be responsible for post- MI bradycardic?
RCA as it supplies 60% of the SA
Give some signs seen in aortic regurgitation.
De mussets sign - head bobbing in time with pulse
Durozier’s sign - Femoral artery murmur audible
Quinckes sign - Visible pulsation of the capillary nail bed
Corrigans sign - Visible carotid pulsation
What is an example of a narrow and broad complex tachycardia?
Narrow- SVT - AVNRT or AVRT
Broad - VT
How long is the normal PR interval?
120-200ms - 3-5 small sq
What is the normal size of QRS?
120ms - 3 small sq
What is a normal QT length?
<450ms
Varies with HR
Prolonged in electrolyte abnormalities and medications such as Amiodarone
>450 could lead to VT
What is an arrhythmia?
A depolarisation originating in another part if the heart
What causes atrial flutter?
Re-entrant circuit in usually the right atria near the tricuspid valve. up to 300bpm. saw tooth. Underlying ischaemic heart disease
What are some causes of AF?
Ischaemic heart disease, valvular heart disease, HTN, hyperthyroidism
What are some ECG findings of AF?
Irregularly irregular
No P wave as atria not properly depolarised and so only sometimes reaches AV node conduction (strong enough electrical activity) and so irregular QRS
Why is VT so dangerous?
No atrial contraction, broad QRS, V rate ~250bpm
Compromised ventricular diastole so blood to heart is reduced - ischaemia of heart muscle? and so reduced CO
Sx - chest pain, syncope, dizzy, SoB
What causes ventricle cells to fire faster than their intrinsic rate of 20-40 in VT?
Stress or damage to pacemaker cells/myocytes can cause re-entrant circuits
Drugs, illicit drugs, electrolyte imbalance, ischaemia
Give an example of a cause of torsades de pointe.
Hypoxia of pacemaker cells (extreme stress to them)
What are some causes of VF?
Mediciation, drugs, electrolyte imbalances, ischaemia, sepsis, cardiomyopathy
What is Wolf parkinsons white SYNDROME?
Wolf parkinson white pattern (bundle of kent - delta wave) PLUS Tachycardia
200-300bpm
What are escape rhythms?
Different parts of the heart that can create a depolarisation sequence if the SA node fails = bradycardia
Junctional and ventricular escape rhythms
What is a junctional escape rhythm?
Normal sinus rhythm initially then SA fails to generate impulse and so pacemaker cells around the AV node fire - no P waves but normal QRS
What is ventricular escape rhythm?
Sinus then SA fails. After a pause there is a single wide QRS
How might you tell if a BBB if from ischaemia?
LBBB - T wave inversion as well as BBB changes in V5 and V6, I, aVL
RBBB - T wave inversion in V1-V3 and BBB changes
What is the patten in RBBB?
MaRroW
RsR in V1
QRS in v6 - but key is the DEEP, wide S wave (may not be qrs)
What might a BBB and axis deviation indicate?
Fasicular block
Left axis deviation + RBBB = bifasicular block (as just RBBB should have a normal axis, so left anterior fascicle must also be involved)
What are some causes of BBB?
LBBB - AS, anterior MI, HTN, dilated cardiomyopathy
RBBB- atrial septal defect, PE, cor pulmonale, cardiomyopathy
How can you tell is the ST elevation is due to ischaemia or pericarditis?
Ischaemia - ST shape - convex, straight upsloping, straight horizontal, straight downslopinng
Pericarditis - Concave or saddle shape
What are some causes of an SVT causing a broad complex tachycardia (wide QRS)?
SVT + Aberrancy (BBB) - Past ECG shows BBB
SVT + Pre-excitation (from e.g. SA node - somewhere outwith the AV node)
SVT + Anti-arrhythmic Flecanidie - Class 1c
Antidromic AVRT - Retrograde conduction via AV node and anterograde via accessory pathway
What might a PE look like on ECG?
Sinus tachycardia
What are the causes of sinus bradycardia?
Sleep, young athlete - physiological
Chronic degeneration of the sinus or AV node or atria
Drugs - BB, morphine, Amiodarone, Ca channels, lithium
Cholestatic jaundice
MI or Ishcaemia of the SA node
Increased vagal tone - vasovagal attack, N&V
Hypothyrodism, hypothermia, raised ICP
What are some causes of heart/AV block?
Ischaemic heart disease, conduction system fibrosis (raging), calcific arotic stenosis, cardiomyopathy, hypothermia, infection, connective tissue disease, IE
List some clinical features seen in acute pericarditis?
Central chest pain that is worse on inspiration or lying flat and relieved by sitting forward
Pericardial friction rub, fever
May be pericardial effusion or cardiac tamponade
How would you manage acute pericarditis?
Analgesia - ibuprofen 400mg/8h
Treat cause (primary - idiopathic or 2ndary to RA, SLE, HIV, EBV, TB, Strep, uraemia, fungus, penicillin, isoniazid, trauma, radiotherapy)
Colchicine (inhibits neutrophil migration)
Steroids - if relapsing or continuing Sx
What are some signs of cardiac tamponade?
Becks Triad - raised JVP, muffled heart sounds, falling BP Thready pulse (rapid) Pulses paradoxus (drop in SBP >10mmHg on inspiration) Low O2 - SoB, restless, lightheaded, dizzy
What is restrictive cardiomyopathy and what are some causes?
When the myocardium is stiffened and so it cannot fill or stretch and so there is reduced CO and pump failure
HH, amyloidosis, sarcoidosis, scleroderma, idiopathic
Because there is reduced ventricular filling - diastolic dysfunction
What is the treatment for AF?
AF = BCD AF E
Beta blocker (cardioselective - atenolol, bisprolol)Or
Calcium channel (Verampamil, diltazem) And or 2nd line
Digoxin
Amiodarone or Flecanide
Electrical cardio version
List some non coronary causes of an elevated troponin.
Congestive heart failure Apical ballooning syndrome PE Anything that stresses the heart - critical illness Sepsis Tachyarrythmia
What is Brugada syndrome?
ECG abnormality with a high incidence of sudden cardiac death In structurally normal hearts. Mutation in cardiac Na channel. coved ST elevation in >1 of V1-V3 and >1 of:
Documented VF, polymorphic VT, FH of sudden cardiac death, coved ECG in family member, syncope, nocturnal agonal respiration
What drugs can affect wound healing?
Steroids and NSAIDs reduce skin healing
BB reduce peripheral blood flow
What is chronic venous insufficiency?
When venous valves are not working effectively and so there is pooling and stasis of blood
Pain worse on standing, varicose veins, pruritus, hyper pigmentation, oedema, venous ulceration
What are varicose veins?
Dilated and tortuous segments of vein due to valvular incompetence - SC veins >/= 3mm, with a demonstrable reflux
Give some features of a venous ulcer?
Between lower calf and medial malleolus
Shallow and flat margins with moderate to heavy exudate and slough at the base with granulation tissue
What is Acute Limb Ischaemia?
A sudden decrease in limb arterial perfusion compromising the viability of the limb. onset < 2 weeks
What are the signs and symptoms of Acute limb ischaemia?
6 Ps
Pulseless, pallor, perishingly cold, paralysis, painful, paraesthesia
When might surgical treatment be indicated for AAA?
Diameter >5.5cm in fit individuals Rapid increase in diameter on surveillance scans Ruptured Symptomatic Ascending thoracic aneurysm
What is a AAA?
Dilation of the abdominal aorta greater than 3cm
What are the 2 different types of aneurysms (not locations)?
True - Abnormal dilations involving all 3 layers
False - outer layer only
Treatment for acute limb ischaemia?
IV heparin
Thrombo-embolectomy - catheter-delivered lysis
Lysis and stenting
Amputation
What scoring tool is used in acute limb ischaemia?
Rutherford
I - viable, IIa - marginally threatened, IIb - Immediately threatened, III - Irreversible (major tissue loss and permanent nerve damage - paralysis and sensory loss)
What is chronic limb ischaemia?
Peripheral arterial disease that results in a symptomatic reduction in blood flow to the limbs.
What scoring tools can be used in chronic limb ischaemia?
Rutherford - grade 0-6
Fontaine - stage I - IV
Define intermittent claudication.
Reproducible ischaemic muscle pain on exertion caused by inadequate blood flow which is relieved by rest.
Should be on aspirin + statin
Define chronic limb threatening ischaemia.
A clinical syndrome defined by the presence of PAD combined with gangrene, rest pain or lower limb ulceration > 2weeks. Use Buergers test to distinguish from cellulitis (limb goes pale with CLTI)
What are the 3 ways in which critical limb ischameia can be clinically defined.
- ABPI < 0.5
- Ishcaemic rest pain for > 2 weeks requiring opiate analgesia
- Ischaemic lesions or gangrenen attributable to arterial occlusive disease
When does the external iliac become the femoral artery?
NAV Y VAN
Inguinal ligamant
From public tubercle and ASIS
You can feel the femoral pulse half way between the pubic symphysis and the ASIS
Where can the pulse be felt in the leg?
Dorsalis pedis - off ant tibial
posterior tibial
Femoral
Popliteal
How would you manage a patient in acute HF?
- sit them up
- Give O2
- diamorphine IV
- furosemide IV
- GTN
- Isosorbite dinitrate or more furosemide
- CPAP
When would you not give flecanide?
If the patient has underlying cardiac disease
Give amiodarone instead
