CV (week 1) Flashcards
Prosthetic valves IE organisms
Staphylococcus epidermis (coagulase negative) until 2 months post surgery,
Native Valve IE organisms
Streptococcus viridans (classical), streptococcus mitis. In IVDU staphylococcus aureas
Less common IE organisms
Enterobacteriae, staphlococcus bovis (bowel malignancy), Culture negative (Brucella, bartonella, coxieta burneti, HACEK group)
Non infectious endocarditis?
SLE (libman Sack lesions)
Best investigation for IE
Transoesophageal echo (TOE), better than TTE
Classical IE features
Murmur, Anaemia, Janeway lesions, Osler’s nodes, Roth’s spots, Pyrexia, Emboli, Nail haemorrhages
Which IE features (/signs) are vascular and which are immune mediated?
Splinter haemorrhages and Janeway lesions are vascular
Osler’s nodes and Roth’s spots are immune complex mediated (can also cause glomerulonephrtis)
Dukes Criteria major/minor ratio?
2 Major 1 minor/ 1 major 3 minor/ 5 minor
Major Duke’s Criteria?
Atypical organisms from 2 separate/persistently positive BCs;
Echo findings
New valvular regurgitation (worsening/changing of pre-existing murmur isn’t enough)
Minor Duke’s criteria
Predisposition (heart condition/IVDU); fever; vascular phenomena; immunologic phenomina (Roth’s spot, osler node, glomerulonephritis); positive blood culture
Complications of IE
HF (sudden onset valve disease), perivavular abscess (e.g. aortic root abscess), septic emboli (e.g. stroke), metastatic abscess (e.g. to lung), mycotic aneurysm
Management of IE
Medical (ABx), surgical (valve replacemet/ abscess drain), social (manage predisposing factors).
Aortic stenosis murmur causes
Congenital, rheumatic fever (vegetations), age related calcification.
Aortic stenosis Signs
Angina (coronary arteries stem from aorta), arrhythmias, exertional syncope, left ventricular failure
syncope, exertional chest pain and exertional dyspnoea - > aortic stenosis triad
Aortic stenosis on examination
Pulse is small volume, slow rising, narrow pulse pressure (Sys/Dia BP equalises); hchest heaving, crescendo-decrescendo ejection systolic murmur. May radiate to carotids . Enhance by sitting foward and on expiration.
Aortic stenosis management
Acute by balloon valvuloplasty, chronically by aortic valve replacement
Aortic regurgitation causes
HT, aortic dissection tracking back to valve, weak connective tissue (Marfan’s) infection
Aortic regurgitation symptoms
SOB, fatigue, palpitations, chest pains, faint
Aortic regurgitation examination
Wide pulse volume. Collapsing pulse. Displaced apex. Auscultation will show early diastolic murmur at left sternal edge
Aortic regurgitation treatment
Acute is haemodynamic support, chronic is medical management (reduce BP to reduce pressure against valve and reduce heart contractility.) Surgical management needed in severe AR
Mitral stenosis causes
Classically through rheumatic fever, but also congenital, degenerative and SLE
Mitral stenosis Hx
SOB, fatigue, AF (atrium stretches), haemoptysis (backflow to pulmonary system)
Mitral stenosis examination
Malar flush, small volume pulse, parasternal heave, middiastolic murmur (loudest at apex, may radiate laterally where best heard with bell)
Mitral regurgitation causes
Left ventricular dilatation, cardiomyopathy, old age/degeneration, infection, autoimme
Mitral regurgitation History
SOB, fatigue, peripheral oedema, faint/dizzy
Mitral regurgitation examination
Pulse can have AF, parasternal heave, pan-systolic murmur
Mitral regurgitation Management
Acute is haemodynamic support, chronic is medical management (ACEi, Beta blockers) but can progress to surgical valve replacement
Cardiac output is…
HR x stroke volume
Ejection fraction is…
Volume of blood pumped by left ventricle in one contraction, expressed as percentage.
50-70% is normal, 40-50% is borderline, <40 is systolic HF and <355 is severe
Causes of HFrEF
Ischaemic heart disease, chronic HT, dilated cardiomyopathy, myocarditis
HFpEF
Diastolic dysfunction with preserved ejection fraction - insufficient filing of ventricle due to decreased compliance/impaired relaxation.
Causes are aging and HT mediated, fibrosis, amyloidosis, sarcoidosis, hypertrophic cardiomyopathy, constrictive pericarditis, restrictive cardiomyopathy
Left sided HF symptoms
Fatigue, restlessness, confusion, orthopnoea, tachycardia, exertional dyspnoea, cyanosis, paroxysmal noctural dyspnoea, elevated pulmonary capillary wedge pressure (est. LA pressure). Can also get back pressure into lungs (cough, crackles, wheeze, blood tonged sputum, tachypnoea)
Right sided HF symptoms
Can be through lung problem (cor pulmonale). Gives fatigue, increased peripheral venous pressure, ascites, hepatomegally, splenomegaly, distended jugular beins, anorexia/GI distress, weight gain, dependent oedema.
Clinical signs of Left sided HF
Fine inspiratory crackles (initially at bases, then spreads), gallop rhythm (3rd heart sound), laterally displaced apex beat, signs of right sided heart failure
Clinical signs of right sided HF
Lower limb and sacral pitting oedema, raised JVP, organomegaly (liver/spleen), ascites
Management of acute AF
Sit patient up, high flow oxygen, IV furosemide.
Consider IV nitrates (cation in hypotension and severe aortic stenosis), consider CPAP, consider ionotropic support (dobutamine), consider dervice therapy, consider referral for left ventricular assist device).
Balloon pump function?
Inflates to maintain pressure
Cardiac resynchronisation therapy
In HF, sometimes ventricles contract at different times and push away. Resynchronisation controls contraction to correct
Chronic HF management
Diuretics (symptomatic), ACEi (or ARB if ACEi not tolerated) and beta blockers (but not in acute decompensation or in pulmonary oedema).
Can add MRA, IF channel blockers (ivabridine) , ARNI, ISMN, mechnical therapies and consider transplant.
Ivibradine
Used for HFrEF<35% in patients with sinus rhythm and HR >70 (reduces HR). Used if Beta blockers CI or if max dose of Beta blockers already used. Acts on If channels, heavily expressed in SA node
