CPSA - cardio Flashcards
Name of this scar? Start and end point? Indications?
midline sternotomy scar
substernal notch to the xiphoid process
indications:
- open valve surgery (commonly left sided ie aortic or mitral)
- coronary artery bypass graft
- cardiac transplant
- congenital cardiac defect correction
Name of this scar? Indications? If this scar is not visible when you would expect it to be?
- great saphenous vein harvest scar
- CABG
- commonly the internal mammary arteries are utilised which means a patient won’t necessarily have harvesting scars. Remember that the internal mammary arteries branch from the subclavian artery to supply the anterior chest wall, so are easily accessible to be re-routed for the supply of coronary arteries distal to blockages
Name of this scar? Indication?
mini sternotomy
- substernal notch to 3rd or 4th intercostal space; typically appears as J shape to the right
- aortic valve replacement
Name of this scar? location? Indication?
4-5cm incision located in the left sub-clavicular region
- pacemaker insertion! pacemaker often palpable underneath
A pacemaker is inserted for the detection and correction of rhythm disturbances (e.g. atrial fibrillation, sick sinus syndrome, atrioventricular block and heart failure). Pacemakers may also have an additional defibrillator function for patients at risk of ventricular arrhythmias, in order to prevent sudden cardiac death.
Pacemaker structure
Pacemakers consist of a generator (a lithium battery encased in an inert titanium casing) that sits in the subcutaneous pocket beneath the incision site, which is connected to transvenous leads that are threaded through the subclavian vein and into one or more chambers of the heart.
There are three main types of pacemaker depending on which chambers are supplied – single chamber (one wire from the pacemaker to the right atrium (RA) or right ventricle (RV)), dual-chamber (2 wires from the pacemaker to the RA and RV) and triple chamber (3 wires from the pacemaker to RA, RV and LV). A CXR can be obtained to visualise the number of leads present.
Note that triple chamber pacemakers may also be known as biventricular pacemakers because there are leads to each ventricle.
These pacemakers are used for ‘cardiac resynchronisation therapy (CRT)’, a treatment indicated in certain patients with heart failure.
Name of scar? Indication?
Left mid-axillary scar
this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD)
Finding? Interpretation?
Malar rash
- SLE
- polycythaemia vera
Finding? Interpretation?
Xanthomata
- raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow
- Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Finding? Interpretation?
fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot.
Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.
Finding? Causes?
Clubbing
Cardiac causes:
- cyanotic heart disease
- infective endocarditis
- atrial myxoma
Pulmonary causes:
- bronchiectasis
- chronic interstitial lung disease
- chronic lung infection
- cystic fibrosis
- lung abscess
- lung cancer
Gastro causes:
- malnutrition - coeliac disease
- IBD
- cirrhosis
Finding? Causes?
Splinter haemorrhage
- local trauma
- infective endocarditis
- sepsis
- vasculitis
- psoriatic nail disease
Finding? Cause?
Janeway lesions (painless!)
- infective endocarditis
Pulsating nail bed?
Quincke’s sign
pulsating capillaries - sign of widened pulse pressure ie aortic regurgitation
Finding? Cause?
Osler’s nodes
CRT technique? Normal? Abnormal? Causes? Next step?
Press on distal phalynx for 5 seconds
Normal: return to original colour in <2s
Abnormal: >2s to return to original colour
- causes: hypovolaemia, congestive heart failure
Check central refill time!
What to comment on with radial pulses? Then?
- rate
- rhythm
if there’s any radio-radio delay:
causes -
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
Offer radio-femoral delay
Collapsing pulse cause?
Normal physiological states (e.g. fever, pregnancy)
Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus) High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
What to comment on with brachial pulse? Examples?
Character and volume
Types of character?
- Normal
- Slow-rising (associated with aortic stenosis)
- Bounding (associated with aortic regurgitation as well as CO2 retention)
- Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
What to offer at arms?
Blood pressure - sitting and standing, bilaterally
Blood pressure interpretation
- hypertension
- hypotention
- widened pulse pressure (more than 100mmHg between S and D): aortic dissection, aortic regurgitation,
- narrow pulse pressure (<25mmHg between S and D): aortic stenosis, congestive heart failure and cardiac tamponade
How to measure JVP?
Find top point of pulsation of internal jugular vein
- between medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
Measure upwards from sternal angle
Normal <3cm
Interpretation of JVP?
Venous hypertension:
Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
Sign? Interpretation?
Conjunctival haemorrhages
Infective endocarditis
Sign?
Conjunctival pallor on left
- anaemia
Sign?
Xanthelasma - hypercholesterolaemia
Sign? Cause?
Kayser-Fleischer ring
- Brownish-yellow ring visible around the corneo-scleral junction (limbus)
Characteristic of Wilson’s disease
Sign? Cause?
Corneal arcus
Hypercholesterolaemia
Sign? Cause?
Angular stomatitis - IDA
Sign? Cause? Meaning?
High arched palate
Marfan’s - increased risk of aortic/mitral prolapse or aortic dissection
Signs?
Pectus carinatum on left
Pectus excavatum on right
General things to finish examination?
bedside, bloods, imaging
bedside - observations, full history, ECG, respiratory examination, fundoscopy, urine dipstick
bloods - FBC, U&E, LFTs, CRP, capillary glucose. can consider ABG, blood cultures, BNP, troponin depending on findings
imaging - CXR, echo
VIVA:
When should you surgically replace an aortic valve?
Refer for valve replacement if symptomatic or pressure > 40mmHg
VIVA:
Types of heart valve?
manufactured mechanical
- long-lasting
donor human
- lasts 10-20 years
bioprosthetic
- Tissue valves can last 10 to 20 years and usually don’t require the long-term use of medication. For a young person with a tissue valve replacement, the need for additional surgery or another valve replacement later in life is highly likely.
Anticoagulation with warfarin:
Lifelong for mechanical, tissue valves may require anticoagulant treatment for up to 2 to 3 months after surgery only if recommended by surgeons post operatively
Aortic valve MECHANICAL replacement: same INR as when you give normally (2-3, 2.5) e.g. for DVT etc
Mitral valve MECHANICAL replacement: 2.5-3.5
- slower blood flow, higher risk of thrombus formation
VIVA: indications for CABG?
- Usually requires severe stenosis (>70%) with left main stem or triple vessel disease
VIVA: description of CABG procedure
- Chest is entered via a median sternotomy
- Left internal mammary artery (LIMA) is dissected
- Long saphenous vein can be harvested and prepared by second surgeon
- Heart is cannulated and patient is placed on bypass
- Aorta is cross clamped
- Injury to heart reduced by cardioplegic solutions
- Cardioplegia can be either warm (37 degrees) or cold (4 degrees)
- Recent advances include
Off-pump coronary artery surgery
Minimally invasive direct coronary artery surgery
Both can avoid either bypass or median sternotomy
VIVA: CABG complications?
Bleeding
Pericardial tamponade
Graft failure (e.g. kinking, disconnection)
Atrial fibrillation
Wound infection
Poor cardiac function
Stroke
subclavian-coronary steal (if LIMA graft and proxinal left subclavian artery stenosis)
VIVA: How can chest pain be classified?
- relieved by rest & GTN
- brought on by exertion
- crushing retrosternal
All 3: typical chest pain
2: atypical chest pain
0 or 1: non-angina chest pain
VIVA: Management of stable angina
- Aspirin + statin (in absence of any contraindication)
- Sublingual glyceryl trinitrate to abort angina attacks
- 1st line: beta blocker OR calcium channel blocker (e.g. amlodipine) - bisoprolol associated with sexual dysfunction incl loss of libido and erectile dysfunction
○ If CCB monotherapy, non-dihydropyridine e.g. verapamil or diltiazem
○ If used with beta blocker, then dihydropyridine/longer-acting e.g. amlodipine or modified release nifedipine - If poor response, initial treatment to be increases to maximum tolerated dose
- If symptomatic on monotherapy, add whichever of beta blocker or CCB hasn’t been added
- If monotherapy and cannot tolerate addition of CCB or beta blocker:
○ Long-acting nitrate e.g. isosorbide mononitrate - associated with tolerance and reduced therapeutic effects
○ Ivabradine
○ Nicorandil - associated with ulcers in GI tract, refractory to treatment
○ Ranolazine - Only add 3rd drug if patient taking beta blocker and CCB, if patient awaiting assessment for PCI
Nitrate tolerance
* Patients who take standard-release isosorbide mononitrate should use asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimse nitrate tolerance
VIVA: Management of acute NSTEMI?
1) Antiplatelet - 300mg loading dose aspirin
2) Antithrombin - fondaparinux unless high bleeding risk or immediate angiography
○ If creatinine > 265, consider unfractionated heparin
Calculate GRACE score to predict 6 month mortality and risk of cardiovascular events
If < 3% (ie low risk):
- consider conservative management w/o angiography
- no bleeding risk: ticagrelor + aspirin
- bleeding risk: clopidogrel + aspirin or aspirin alone
Ischaemia testing before discharge
If > 3% (ie high risk)
- if clinical condition unstable: immediate angiography
- otherwise angiography + PCI if indicated within 72 hours (if no contraindications ie comorbidities, active bleeding)
- if no separate indication for anticoag & PCI intended: prasugrel + aspirin. If PCI not intended, ticagrelor + aspirin
- if separate indication for oral anticoagulation, clopidogrel + aspirin
if having PCI, offer unfractionated heparin on top
VIVA: management of acute STEMI?
Morphine + antiemetic + laxative
Oxygen if hypoxic (<94%)
Nitrate - sublingual GTN
Aspirin loading dose
Assess eligibility for reperfusion therapy ie are they presenting within 12 hours of symptoms AND PCI available in 12 hours
If eligibile for PCI:
- angiography + PCI
Medical on top:
if not already taking anticoag, prasugrel + aspirin
if already taking anticoag, clopidogrel + aspirin
If presenting within 12 hours but PCI not available in 120 minutes:
- fibrinolysis with alteplase
- offer ECG 60-90 minutes after
Additional drugs:
- antithrombin
- no high bleeding risk: ticagrelor + aspirin
- high bleeding risk: clopidogrel + aspirin
If NOT eligible for reperfusion therapy:
low bleeding risk: ticagrelor + aspirin
high bleeding risk: clopidogrel + aspirin
VIVA: Secondary management for STEMI and NSTEMI?
Cardiac rehabilitation
Lifestyle advice - exercise, diet, alcohol, smoking
Drug therapy (ABCD):
- ACEi (or ARB if cannot tolerate)
- beta blocker OR rate-limiting calcium channel blocker (e.g. verapamil or diltiazem)
- cholesterol (statin)
- dual antiplatelet therapy (aspirin + second antiplatelet)
VIVA: Should you stent with stable angina?
ORBITA trial - no evidence of benefit in placebo-control trial
Difference between NSTEMI and unstable angina?
NSTEMI has high troponin
Consider an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on…
- nature of murmur
- age (>75)
- family history
- medical history (e.g. AF)
Offer an echocardiogram if valve disease suspected (based on age, nature of murmur, family history, and medical history) and…
- signs (peripheral oedema)
- symptoms (breathless, ECG)
- ejection systolic murmur with a reduced heart sound and no other signs or symptoms
If valve disease suspected…
urgent specialist assessment (including echo) to adults with aortic stenosis and exertional syncope
When does valvular disease require specialist referral?
- moderate or severe
- bicuspid aortic valve disease of any severity
Management of heart failure in people with valve disease
consider beta blocker for adults with moderate to severe mitral stenosis and HF
When should people with asymptomatic AS get referral for intervention?
VALVE
Vmax > 5m/s
Aortic valve area <0.6
LV EF < 55%
Very high BNP or NT-BNP (2x normal)
Exercise testing unmasks symptoms
Consider referring adults with symptomatic low-gradient aortic stenosis with LVEF less than 50% for intervention if during dobutamine stress echocardiography the aortic stenosis is shown to be severe by
- a mean gradient across the aortic valve that increases to more than 40 mmHg and
- an aortic valve area that remains less than 1 cm2.
If aortic stenosis severity uncertain?
- measure aortic valve calcium score on cardiac CT
When should people with asymptomatic severe aortic regurg be referred for intervention?
LV EF < 55%
OR
End systolic diameter > 55mm or end systolic diameter index > 24mm/m2 on echocardiography
When should people with asymptomatic severe primary mitral regurgitation be referred for intervention?
- LV EF < 60%
- ESD > 45 or ESDI > 22mm/m2
- increase of systolic pulmonary artery pressure to more than 60mmHg on exercise testing
Monitoring if asymptomatic severe valve disease and intervention suitable but not currently needed
Clinical review every 6-12 months
Monitoring for mild aortic or mitral stenosis
echocardiographic assessment every 3-5 years
Aortic valve disease management
low risk: surgery (median sternotomy or minimally invasive surgery) for severe aortic stenosis, aortic regurgitation, or mixed aortic valvwe disease
high risk: TAVI
- anticoagulate with aspirin (or second line: clopidogrel)
Mitral stenosis management
1st line: transcatheter valvotomy for adults with rheumatic severe mitral stenosis
2nd line: surgical mitral valve replacement if above unsuitable
Primary mitral regurgitation management
1st line: surgical mitral valve repair (median sternotomy or minimally invasive surgery)
2nd line: surgical valve replacement
3rd line: transcatheter edge to edge repair
Secondary mitral regurgitation management
1st line: surgical mitral valve repair
2nd line: surgical mitral valve replacement
If HF and severe secondary mitral regurgitation, medical treatment
If still symptomatic after medical treatment, transcatheter mitral edge to edge repair
Chronic heart failure management
First line: ACEi + beta blocker
* One drug to be started at a time
Second line: aldosterone antagonist (aka mineralocorticoid receptor antagonist)
* E.g. spironolactone or eplerenone
ACEi and aldosterone antagonists cause hyperkalaemia so monitor potassium!!
Increasing role for SGLT-2 inhibitors in management of heart failure with reduced ejection fraction
Third line:
* To be started by specialist
Options: * ADD Ivabradine ○ Criteria: sinus rhythm > 75/min and left ventricular fraction < 35% * Sacubritil-valsartan (replacing ACEi with this) ○ Criteria: left ventricular fraction < 35% ○ Considered in heart failure with reduced ejection fraction & symptomatic on ACE inhibitors or ARBs ○ Should be initiated following ACEi or ARB wash-out period * Digoxin ○ Strongly indicated with co-existent atrial fibrillation * ADD Hydralazine + nitrate ○ Especially in Afro-Caribbean patients * Cardiac resynchronisation therapy ○ Include widened QRS complex on ECG
Other:
* Annual influenza
* One-off pneumococcal
