CV (week 1)

Question 1

Prosthetic valves IE organisms

Answer 1

Staphylococcus epidermis (coagulase negative) until 2 months post surgery,

Question 2

Native Valve IE organisms

Answer 2

Streptococcus viridans (classical), streptococcus mitis. In IVDU staphylococcus aureas

Question 3

Less common IE organisms

Answer 3

Enterobacteriae, staphlococcus bovis (bowel malignancy), Culture negative (Brucella, bartonella, coxieta burneti, HACEK group)

Question 4

Non infectious endocarditis?

Answer 4

SLE (libman Sack lesions)

Question 5

Best investigation for IE

Answer 5

Transoesophageal echo (TOE), better than TTE

Question 6

Classical IE features

Answer 6

Murmur, Anaemia, Janeway lesions, Osler’s nodes, Roth’s spots, Pyrexia, Emboli, Nail haemorrhages

Question 7

Which IE features (/signs) are vascular and which are immune mediated?

Answer 7

Splinter haemorrhages and Janeway lesions are vascular

Osler’s nodes and Roth’s spots are immune complex mediated (can also cause glomerulonephrtis)

Question 8

Dukes Criteria major/minor ratio?

Answer 8

2 Major 1 minor/ 1 major 3 minor/ 5 minor

Question 9

Major Duke’s Criteria?

Answer 9

Atypical organisms from 2 separate/persistently positive BCs;
Echo findings
New valvular regurgitation (worsening/changing of pre-existing murmur isn’t enough)

Question 10

Minor Duke’s criteria

Answer 10

Predisposition (heart condition/IVDU); fever; vascular phenomena; immunologic phenomina (Roth’s spot, osler node, glomerulonephritis); positive blood culture

Question 11

Complications of IE

Answer 11

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

Question 12

Management of IE

Answer 12

Medical (ABx), surgical (valve replacemet/ abscess drain), social (manage predisposing factors).

Question 13

Aortic stenosis murmur causes

Answer 13

Congenital, rheumatic fever (vegetations), age related calcification.

Question 14

Aortic stenosis Signs

Answer 14

Angina (coronary arteries stem from aorta), arrhythmias, exertional syncope, left ventricular failure

syncope, exertional chest pain and exertional dyspnoea - > aortic stenosis triad

Question 15

Aortic stenosis on examination

Answer 15

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.

Question 16

Aortic stenosis management

Answer 16

Acute by balloon valvuloplasty, chronically by aortic valve replacement

Question 17

Aortic regurgitation causes

Answer 17

HT, aortic dissection tracking back to valve, weak connective tissue (Marfan’s) infection

Question 18

Aortic regurgitation symptoms

Answer 18

SOB, fatigue, palpitations, chest pains, faint

Question 19

Aortic regurgitation examination

Answer 19

Wide pulse volume. Collapsing pulse. Displaced apex. Auscultation will show early diastolic murmur at left sternal edge

Question 20

Aortic regurgitation treatment

Answer 20

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

Question 21

Mitral stenosis causes

Answer 21

Classically through rheumatic fever, but also congenital, degenerative and SLE

Question 22

Mitral stenosis Hx

Answer 22

SOB, fatigue, AF (atrium stretches), haemoptysis (backflow to pulmonary system)

Question 23

Mitral stenosis examination

Answer 23

Malar flush, small volume pulse, parasternal heave, middiastolic murmur (loudest at apex, may radiate laterally where best heard with bell)

Question 24

Mitral regurgitation causes

Answer 24

Left ventricular dilatation, cardiomyopathy, old age/degeneration, infection, autoimme

Question 25

Mitral regurgitation History

Answer 25

SOB, fatigue, peripheral oedema, faint/dizzy

Question 26

Mitral regurgitation examination

Answer 26

Pulse can have AF, parasternal heave, pan-systolic murmur

Question 27

Mitral regurgitation Management

Answer 27

Acute is haemodynamic support, chronic is medical management (ACEi, Beta blockers) but can progress to surgical valve replacement

Question 28

Cardiac output is...

Answer 28

HR x stroke volume

Question 29

Ejection fraction is...

Answer 29

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

Question 30

Causes of HFrEF

Answer 30

Ischaemic heart disease, chronic HT, dilated cardiomyopathy, myocarditis

Question 31

HFpEF

Answer 31

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

Question 32

Left sided HF symptoms

Answer 32

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)

Question 33

Right sided HF symptoms

Answer 33

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.

Question 34

Clinical signs of Left sided HF

Answer 34

Fine inspiratory crackles (initially at bases, then spreads), gallop rhythm (3rd heart sound), laterally displaced apex beat, signs of right sided heart failure

Question 35

Clinical signs of right sided HF

Answer 35

Lower limb and sacral pitting oedema, raised JVP, organomegaly (liver/spleen), ascites

Question 36

Management of acute AF

Answer 36

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).

Question 37

Balloon pump function?

Answer 37

Inflates to maintain pressure

Question 38

Cardiac resynchronisation therapy

Answer 38

In HF, sometimes ventricles contract at different times and push away. Resynchronisation controls contraction to correct

Question 39

Chronic HF management

Answer 39

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.

Question 40

Ivibradine

Answer 40

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