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y6 > CPSA - cardio > Flashcards

CPSA - cardio Flashcards

1
Q

Name of this scar? Start and end point? Indications?

A

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

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2
Q

Name of this scar? Indications? If this scar is not visible when you would expect it to be?

A
  • 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
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3
Q

Name of this scar? Indication?

A

mini sternotomy

  • substernal notch to 3rd or 4th intercostal space; typically appears as J shape to the right
  • aortic valve replacement
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4
Q

Name of this scar? location? Indication?

A

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.

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5
Q

Pacemaker structure

A

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.

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6
Q

Name of scar? Indication?

A

Left mid-axillary scar

this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD)

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7
Q

Finding? Interpretation?

A

Malar rash
- SLE
- polycythaemia vera

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8
Q

Finding? Interpretation?

A

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).

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9
Q

Finding? Interpretation?

A

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.

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10
Q

Finding? Causes?

A

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

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11
Q

Finding? Causes?

A

Splinter haemorrhage

  • local trauma
  • infective endocarditis
  • sepsis
  • vasculitis
  • psoriatic nail disease
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12
Q

Finding? Cause?

A

Janeway lesions (painless!)

  • infective endocarditis
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13
Q

Pulsating nail bed?

A

Quincke’s sign

pulsating capillaries - sign of widened pulse pressure ie aortic regurgitation

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14
Q

Finding? Cause?

A

Osler’s nodes

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15
Q

CRT technique? Normal? Abnormal? Causes? Next step?

A

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!

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16
Q

What to comment on with radial pulses? Then?

A
  • 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

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17
Q

Collapsing pulse cause?

A

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)
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18
Q

What to comment on with brachial pulse? Examples?

A

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)
19
Q

What to offer at arms?

A

Blood pressure - sitting and standing, bilaterally

20
Q

Blood pressure interpretation

A
  • 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
21
Q

How to measure JVP?

A

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

22
Q

Interpretation of JVP?

A

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.

23
Q

Sign? Interpretation?

A

Conjunctival haemorrhages

Infective endocarditis

24
Q

Sign?

A

Conjunctival pallor on left

  • anaemia
25
Q

Sign?

A

Xanthelasma - hypercholesterolaemia

26
Q

Sign? Cause?

A

Kayser-Fleischer ring
- Brownish-yellow ring visible around the corneo-scleral junction (limbus)

Characteristic of Wilson’s disease

27
Q

Sign? Cause?

A

Corneal arcus

Hypercholesterolaemia

28
Q

Sign? Cause?

A

Angular stomatitis - IDA

29
Q

Sign? Cause? Meaning?

A

High arched palate

Marfan’s - increased risk of aortic/mitral prolapse or aortic dissection

30
Q

Signs?

A

Pectus carinatum on left

Pectus excavatum on right

31
Q

General things to finish examination?

A

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

32
Q

VIVA:

When should you surgically replace an aortic valve?

A

Refer for valve replacement if symptomatic or pressure > 40mmHg

33
Q

VIVA:

Types of heart valve?

A

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

34
Q

VIVA: indications for CABG?

A
  • Usually requires severe stenosis (>70%) with left main stem or triple vessel disease
35
Q

VIVA: description of CABG procedure

A
  • 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
36
Q

VIVA: CABG complications?

A

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)

37
Q

VIVA: How can chest pain be classified?

A
  • 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

38
Q

VIVA: Management of stable angina

A
  • 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

39
Q

VIVA: Management of acute NSTEMI?

A

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

40
Q

VIVA: management of acute STEMI?

A

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

41
Q

VIVA: Secondary management for STEMI and NSTEMI?

A

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)

42
Q

VIVA: Should you stent with stable angina?

A

ORBITA trial - no evidence of benefit in placebo-control trial

43
Q

Difference between NSTEMI and unstable angina?

A

NSTEMI has high troponin

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