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CPSA - cardio Flashcards

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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)
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19
Q

What to offer at arms?

A

Blood pressure - sitting and standing, bilaterally

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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
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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

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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.

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23
Q

Sign? Interpretation?

A

Conjunctival haemorrhages

Infective endocarditis

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24
Q

Sign?

A

Conjunctival pallor on left

  • anaemia
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25
Sign?
Xanthelasma - hypercholesterolaemia
26
Sign? Cause?
Kayser-Fleischer ring - Brownish-yellow ring visible around the corneo-scleral junction (limbus) Characteristic of Wilson's disease
27
Sign? Cause?
Corneal arcus Hypercholesterolaemia
28
Sign? Cause?
Angular stomatitis - IDA
29
Sign? Cause? Meaning?
High arched palate Marfan's - increased risk of aortic/mitral prolapse or aortic dissection
30
Signs?
Pectus carinatum on left Pectus excavatum on right
31
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
32
VIVA: When should you surgically replace an aortic valve?
Refer for valve replacement if symptomatic or pressure > 40mmHg
33
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
34
VIVA: indications for CABG?
- Usually requires severe stenosis (>70%) with left main stem or triple vessel disease
35
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
36
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)
37
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
38
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
39
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
40
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
41
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)
42
VIVA: Should you stent with stable angina?
ORBITA trial - no evidence of benefit in placebo-control trial
43
Difference between NSTEMI and unstable angina?
NSTEMI has high troponin
44
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)
45
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
46
If valve disease suspected...
urgent specialist assessment (including echo) to adults with aortic stenosis and exertional syncope
47
When does valvular disease require specialist referral?
- moderate or severe - bicuspid aortic valve disease of any severity
48
Management of heart failure in people with valve disease
consider beta blocker for adults with moderate to severe mitral stenosis and HF
49
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
50
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.
51
If aortic stenosis severity uncertain?
- measure aortic valve calcium score on cardiac CT
52
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
53
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
54
Monitoring if asymptomatic severe valve disease and intervention suitable but not currently needed
Clinical review every 6-12 months
55
Monitoring for mild aortic or mitral stenosis
echocardiographic assessment every 3-5 years
56
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)
57
Mitral stenosis management
1st line: transcatheter valvotomy for adults with rheumatic severe mitral stenosis 2nd line: surgical mitral valve replacement if above unsuitable
58
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
59
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
60
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
61

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